Concepts Related to Rehabilitation

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					 Concepts Related to
   Rehabilitation

Northern New Mexico College Nursing
            N228 Integrated Nursing
1. Explain the purpose and goals of rehabilitation.
                    Objectives
2. Distinguish between impairment, disability, and
    handicap.
3. Describe community based settings for client
    rehabilitation.
4. Examine the roles of individual members of the
    rehabilitation team.
5. Analyze the nurse’s role in the collaborative
    management of the client in rehabilitation.
6. Interpret assessment findings for the client in a
    rehabilitation program.
7. Develop a teaching plan for the client with impaired
    physical mobility.
8. Explain the collaborative management of
    rehabilitation clients with self-care deficits.
9. Discriminate between bladder training techniques for
    clients with impaired urinary elimination.
10. Prioritize nursing care for the client in rehabilitation.
   Explain the Purpose and
    Goals of Rehabilitation



Rehabilitation Nursing
• Definition
  – Rehabilitation is a treatment or treatments designed
    to facilitate the process of recovery from injury,
    illness, or disease to as normal a condition as
    possible.
• Purpose
  – The purpose of rehabilitation is to restore some or all
    of the patient's physical, sensory, and mental
    capabilities that were lost due to injury, illness, or
    disease. Rehabilitation includes assisting the patient
    to compensate for deficits that cannot be reversed
    medically. It is prescribed after many types of injury,
    illness, or disease, including amputations, arthritis,
    cancer, cardiac disease, neurological problems,
    orthopedic injuries, spinal cord injuries, stroke, and
    traumatic & Purpose
 Definitionbrain injuries. of Rehabilitation
  – The Institute of Medicine has estimated that as many
    as 14% of all Americans may be disabled at any
    given time.
       Rehabilitation Nursing

“ A specialty practice area of professional
  nursing. Rehabilitation nursing is the
  diagnosis and treatment of human
  responses of individuals and groups to
  actual or potential health problems
  relative to altered functional ability and
  lifestyle” [Association of Rehabilitation
  Nurses (ARN), 2000].
• Rehabilitation nurses are experts in
                               Nursing
        Rehabilitation and averting
  preventing complications
  further disability in their patients.
• Chronic conditions, associated with reduced
  lifestyle satisfaction and limited functional
  abilities, are often precursors to disability.
• Rehabilitation nurses assist persons with
  disabilities or chronic conditions with
  attaining or maintaining maximum functional
  abilities, optimal health and well-being, and
  effective coping with changes or alterations
  in their lives.
• Rehabilitation nurses require unique
       Rehabilitation Nursing
  expertise in educating patients and their
  families and in enabling them to become
  authorities on their own condition and
  situation.
• They assist patients with negotiating
  mutually acceptable, lifelong goals, including
  patients who have developmental disabilities
  or unique and persistent problems not
  defined by medical diagnosis and those who
  have different cultural perceptions.
• Rehabilitation is an active intervention to
  achieve maximum function and to improve
  quality of life; it is not a third stage of health
  care, a kind of final resort.
  Levels of Prevention as Interventions Over the Natural Course                                 of a
                       Chronic Disease or Disability

Level of       Types of Interventions                  Applications
Prevention

Primary        Interventions: health promotion,        Conducted before a condition or problem is
               education, and specific protections     clinically evident or at any stage to improve
                                                       the situation and prevent further disability or
                                                       complications



Secondary      Interventions for early diagnosis       Screening on surveys, curative actions or
               and treatment to limit disability and   treatments, halting of the disease process,
               impairments or control the disease      and prevention of spread or complications
               processes                               after the disease has shown early signs or
                                                       advanced



Tertiary       Interventions for restoration or        Community, education, or vocation planning;
               rehabilitation toward optimal           self-care and ADL education; minimizing
               independence and function with          disability; primary prevention for whole
               quality of life, convalescence from     person, not a focus on disease or disablement
               acute or injury problems, and
               adaptation to impairments
     Distinguish Between
   Impairment, Disability, and
           Handicap

 Definitions are defined according to the
      International Classification of
Impairments, Disabilities and Handicaps
  (World Health Organization, 1980).
                         (p. 119 in Textbook)

Rehabilitation Nursing
               Impairment

• Impairment is an abnormality of a body
  structure or structures or an alteration in a
  body system function resulting from any
  cause; it represents a disturbance at the
  organ level. Impairments can be
  temporary or permanent and may or may
  not be associated with an active
  pathologic condition.
                Disability

• Disability is the consequence of an
  impairment and is usually described in
  terms of a client’s altered functional
  ability; it represents a disturbance at the
  personal level. A variety of diseases or
  traumas impair mobility and may result in
  a decreased ability to function.
                Handicap

• A Handicap is the disadvantage that a
  person feels as a result of impairments
  and disabilities. This disadvantage is
  base on interactions that the client
  experiences in society. Although
  impairments and the disabilities that result
  from pathologic changes in a body organ
  are often unpreventable or irreversible,
  handicaps are both preventable and
  reversible.
 Practice Settings In Rehabilitation
• Acute Inpatient Rehabilitation Care-
  – Developed afterNursing
                   WWII to provide intensive
    rehabilitation for patients with disabling
    conditions.
  – Units can be part of a larger tertiary hospital or
    can be free standing hospitals.
  – Patients admitted to these units must be able to
    tolerate several hours of therapy each day, and
    families are encourage to participate in therapy
    sessions.
  – Recent focus on cost containment has caused
    shorter LOS and lower reimbursement for acute
    inpatient rehabilitation facilities. The design of
    acute rehab units will continue to change.
 Rancho Los Amigos Hospital
• Rancho Los Amigos
Clinical Programs
Rehabilitation is a treatment and education process that helps you return to
  your home or community to enjoy a more active and satisfying life. Rancho
  Los Amigos National Rehabilitation Center has been America's leader for
  more than half a century.
Our teams of highly qualified rehabilitation experts blend their unmatched
  experience with the latest advanced technology and the creative spirit that
  has led to many important advances in rehabilitation. Rancho's more than
  20 Centers of Excellence provide unmatched care to individuals with
  catastrophic injury and illness.
                                          •   Orthotics and Prosthetics
• Services Include:                       •   Model Home
    –   Spinal Cord injury                •   Language and Culture Resource
    –   Stroke                                Center
    –   Adult Brain Injury                •   Vocational Services
    –   Neurologic Disorders              •   Drivers Training
    –   Pediatrics                        •   Center for Applied Rehabilitation
    –   Alzheimer's Disease Research          Technology
        Center                            •   Dentistry for People with
    –   Diabetes/Limb Preservation            Disabilities
        and Amputation                    •   Environmental Health
    –   Pathokinesiology                  •   Pressure Ulcer Management
    –   Arthritis and Rheumatology        •   Post-polio Program
    –   Gerontology Program               •   Audiology
    –   Adult Day Services
 Practice Settings In Rehabilitation
• Subacute and Long-Term Care-
               Nursing
  – Emerged as a potentially lower-cost option
    serving patients who require skilled medical
    and nursing care but not diagnostic or
    invasive procedures.
  – Many subacute units admit persons whose
    medical treatment makes their participation
    in an acute rehab program difficult or for
    those who cannot tolerate the intensive
    therapy provided in acute rehab programs.
 Describe Community Based
Settings for Client Rehabilitation


Rehabilitation Nursing
 Practice Settings In Rehabilitation
• Community Settings-
                 Nursing
  – The community, rather than the hospital or
    inpatient setting, has become a primary
    treatment setting in which many persons with
    disabilities manage their care and daily activities.
  – The term community-based rehabilitation
    (CBR) has been broadly defined and applied to
    a variety of programs and settings in which
    patients receive rehabilitation services.
  – CBR services may include outpatient care, home
    health care, independent living centers, senior
    citizen centers, community reentry programs,
    rural outreach, and mobile rehabilitation teams.
Practice Settings In Rehabilitation
             Nursing
• Community Settings- (cont)
  – Residents in rural areas have more
    difficulty accessing rehabilitation services.
  – Problems include limited access to the
    variety of services needed, and limited
    transportation and money to travel to
    receive services.
  – In addition there is a shortage of health
    care providers.
Practice Settings In Rehabilitation
             Nursing
• Home Health Care-
  – Home rehabilitation is generally viewed as a
    continuation of rehabilitation programs initiated in
    other settings, such as acute, out-patient, or
    long-term care settings.
  – Returning home is often one of the strongest
    desires for patients.
  – A measure of successful rehabilitation is the
    conversion of skills to the home setting.
  – Home rehabilitation promotes patient autonomy,
    independence, and community integration.
 Practice Settings In Rehabilitation
• Telerehabilitation-
                  Nursing
  – Videoconferencing and computer-based
    support groups
    • Applications of telerehabilitation include providing
      the following:
    1. Comprehensive rehabilitation services to patients for
       whom transportation and disability limit access
    2. Alternatives to on-site home evaluations
    3. A link between providers at remote sites and real-time
       consultation at a specialty hub
    4. Support for patients and families transitioning to home
    5. Education programs for patients as well as staff
       Examine the Roles of
    Individual Members of the
       Rehabilitation Team
               (p 119-120 in Textbook)




Rehabilitation Nursing
• Interdisciplinary
   Collaboration        Rehabilitation Team
   replaces
   communication
   as the key to
   successful
   interdisciplinary
   teams.
• Team members
   are involved in
   problem solving
   beyond the
   confines of their
   discipline.
• Members strive
   to reduce
   duplication or
   conflict in goals.
           Team
• Physiatrist            Members
 •   A physician who specializes in rehabilitation
     medicine.
• Rehabilitation Nurse
     • Coordinate the efforts of the team members
     • Often the Rehabilitation Case Manager
• Physical Therapists(PTs)
     •  Intervene to help the client achieve mobility.
     • May also teach techniques for performing certain
       ADLs such as transferring, ambulating, and
       toileting.
• Occupational Therapists (OTs)
                    Members
           Team the client’s fine motor skills
  – Work to develop
    used for ADLs, such as eating, maintaining
    hygiene, dressing.
• Speech-Language Pathologists (SLPs)
  – Evaluate and retrain clients with speech,
    language, or swallowing problems:
     • Head injury, stroke, dysphagia
• Recreational or Activity Therapists
  – Work with clients to continue or develop
    hobbies or interests.
  – Often coordinate with OT
• Cognitive Therapists
             Team Members
  – Work with patients, (usually with head injuries), who
    have cognitive impairments to assist with retraining.
• Nursing or Therapy Assistants
  – Assist in the care of clients
  – Under the direct supervision of a registered nurse or
    therapist.
• Social Workers
  – Help clients to identify support services or resources,
    including financial assistance
  – Usually coordinate transfers to or discharges from
    the rehab setting.
• Vocational Counselors
  – Assist with job training, placement, or further
    education
  – Work-related skills are taught if the client needs to
    change careers because of the disability.
     Analyze the Nurse’s Role
                in the
     Collaborative Management
                of the
      Client in Rehabilitation


Rehabilitation Nursing
     The Rehabilitation Nurse
• Nursing theory is based on the holistic model.
  They understand the impact that social and
  physical environments have on patients.
• In addition, nurse work from a wellness model,
  with a focus on empowering clients to stay well
  and care for themselves.
• Nurses have established their roles on the
  rehabilitation team, frequently directing efforts.
• Fitting roles for nurses in rehab are:
   – Coordinator, Educator, Researcher, Consultant,
     Case Manager, Advocate, Enabler/Facilitator, Expert
     Practitioner and Team Member.
     Interpret Assessment
  Findings for the Client in a
    Rehabilitation Program



Rehabilitation Nursing
       Assessment Findings
• Collect the physical assessment data
  systematically according to major body
  systems on admission for baseline, and
  frequently to monitor changes.

• The focus of the assessment related to
  rehabilitation and chronic disease is
  on the functional abilities of the client.
• History
                        Assessment
   – Obtain info on client’s present condition, current medications, and any
     treatment programs in progress.
   – Background data such as financial status, occupation, educational level,
     cultural background, and home situation.
• Physical Assessment
   – Body system & relevant data:
   – Cardiovascular
       • Chest pain, fatigue, fear of cardiac failure
   – Respiratory
       • SOB or dyspnea, activity tolerance, fear of inability to breathe
   – Gastrointestinal & Nutritional
       • Oral intake, eating pattern, anorexia, N&V, dysphagia, lab data (serum albumin
         level), weight loss, elimination pattern, ability to get to toilet
   – Renal & Urinary
       • Urinary pattern, fluid intake, incontinence or retention, Urine C&S, or UA
   – Neurologic
       • Motor function, sensation, cognitive abilities
   – Musculoskeletal
       • Functional ability, ROM, Muscle strength
   – Skin
       • Risk of breakdown, presence of skin lesions
• Functional Assessment
                 Assessment
  – Ability to perform Activities of Daily Living
    (ADLs), such as bathing, dressing, feeding, and
    ambulating as well as independent skills such as
    cooking and shopping.
  – Functional assessment tools are used to assess
    a client’s abilities. The most common tool used is
    the     Functional Independence Measure
    (FIM).
  – Areas assessed using this tool are:
     • Eating, grooming, bathing, dressing/undressing (upper
       body), dressing/undressing (lower body), toileting
       bladder-level of assistance, bladder-frequency of
       accidents, bowel-level of assistance, bowel-frequency
       of accidents, bed/chair/wheelchair transfer, toilet
       transfer, tub/shower transfer, walk, wheelchair, stairs,
       comprehension, expression, social interaction,
       problem solving, and memory.
• Psychosocial Assessment
  – To assess the client’s psychosocial needs, the nurse
    must understand the theories of body image and self-
    esteem.
  – Assess the use of defense mechanisms and presence
    of anxiety by observing facial expressions and
    communication patterns.
  – Assess the client’s response to loss, and the presence
    of depression and powerlessness.
  – Assess for the presence of support systems.
• Vocational Assessment
  – The rehab nurse should be aware of the appropriate
    resources for each client to assist in maximizing
                Assessment
    functional status.
  – Clients should be aware of the American’s Disabilities
    Act (ADA), passed in 1991, to prevent employer
    discrimination against disabled people.
     Develop a Teaching Plan
        for the Client with
    Impaired Physical Mobility



Rehabilitation Nursing
• Henry & Sara Smith own a small upholstery
       Case Study- Sara Smith
  shop. Mr. Smith bids out work and supervises
  their small staff; Mrs. Smith does all the skilled
  finish sewing. Eight days ago, Mrs. Smith had a
  left hemisphere stroke, leaving her aphasic and
  with right extremity weakness. Mrs. Smith’s
  insurance pays for a limited amount of inpatient
  rehabilitation. The entire family is concerned
  about how they will meet her care needs when
  she returns home.

  1. How do you plan to teach the Smith family what they
     need to know about Mrs. Smith’s post-hospital care?
  2. What are the teaching priorities for this family?
        Explain the
Collaborative Management
 of Rehabilitation Clients
  with Self-Care Deficits



Rehabilitation Nursing
•Managementoccupational therapist
  The nurse and of Self-Care Deficits
  collaborate to identify ways in which self-
  care activities can be modified so that the
  client can perform them independently.
• The occupational therapist teaches
  techniques for self care such as dressing,
  and the nurse reinforces these skills and
  encourages the client to practice.
• A variety of assistive/adaptive devices are
  available for clients. (Table 10-4, page 127)
Intervention Activities for the Client
in Rehabilitation       (Chart 10-3, page 127)

Self-Care Assistance: Assisting another to perform
activities of daily living
• Monitor client’s ability for independent self-care.

• Monitor client’s need for adaptive devices for personal hygiene,
dressing, grooming, toileting, and eating.
• Provide assistance until the client is fully able to assume self-care.

• Use consistent repetition of health routines as a means of establishing
them.
• Encourage client to perform normal activities of daily living to level of
ability.
• Teach family to encourage independence, to intervene only when the
client is unable to perform.
• Establish a routine for self-care activities.
    Discriminate Between
 Bladder Training Techniques
       for Clients with
Impaired Urinary Elimination



Rehabilitation Nursing
• Reflex or Spastic Bladder
   – Incontinence that is characterized by sudden, gushing voids.
     Neurologic problems affecting the upper motor neuron typically occur
     with injuries above T-12. The injury results in a failure of impulse
     transmission from the lower spinal cord to the brain.
   – When the bladder fills and transmits impulses to the spinal cord, the
     client is not conscious of the filling sensation.
   – Because there is no injury to the lower cord, and the voiding reflex arc
     is intact, the efferent(motor) impulse is relayed and the bladder
     contracts.
• Flaccid Bladder
   – Results in urinary retention and overflow (dribbling). Injuries that
     cause damage to the lower motor neuron at S2-4 (MS and SCI below
     T-12) may directly interfere with the reflex arc. The bladder fills and
     afferent (sensory) impulses conduct the message via the spinal cord to
     the cortical region of the brain. There is a failure to respond with a
     message for the bladder to contract.
• Uninhibited Bladder
   – May occur when the client has a neurologic problem that affects the
   Three Functional Types of Neurogenic
     cortical bladder center of the brain (frontal lobe), such as stroke or
     brain injury.
                 Bladder
   – The client has little sensorimotor control. The client is incontinent, but
     the bladder may not completely empty.
•   Facilitating or Triggering Techniques
     – Used to stimulate voiding
          • Upper motor neuron problem
              – Techniques include stroking the medial aspect of the thigh, pinching the
                area above the groin, pulling pubic hair, and providing digital stimulation.
          • Lower motor neuron problem
              – Valsalva maneuver- client is instructed to hold their breath and bear down
              – Crede’ maneuver- client places hand in a cupped position directly over the
                bladder area and pushes inward and downward, massaging bladder to
                empty

•   Intermittent Catheterization
     – Often used for flaccid or spastic bladder
     – Catheterization is performed after the patient attempts to empty their bladder
     – If the residual is >150ml, catheterizations are performed every 2-3 hours; if
       <150ml, the time between catheterizations is increased to every 4-6 hours. The
       client should not be allowed to go beyond 8 hours between catheterizations.
     – Bedside bladder ultrasound may also be used by the nurse to determine
       residuals.

•   Toileting Schedule
     – Used as a way to re-establish voiding continence in clients who may have
    Three Techniques for Bladder Training
       uninhibited bladder such as those with brain injury.
     – Patients are regularly assisted with voiding at regular intervals; (every 2 hours
       during the day, and every 4 hours at night). Typical times are upon awakening,
       before & after meals, before & after activities, and at bedtime.
TABLE 10-5 MANAGEMENT OF IMPAIRED URINARY ELIMINATION
(Page 129)
Functional    Neurologic       Clinical             Re-Establishing Voiding
Type          Disability       Manifestations       Patterns
Reflex        Upper motor      Urinary frequency,   •Triggering or facilitating
(spastic)     neuron spinal    incontinence         techniques
              cord injury                           •Medications
              above T-12                            •Bedside bladder ultrasound
                                                    •Intermittent catheterization
                                                    •Consistent toileting schedule


Flaccid       Lower motor      Urinary retention,   •Valsalva and Crede’
              neuron spinal    overflow             maneuvers
              cord injury                           •Medications
              below T-12
              (affects S2-4
              reflex arc)
Uninhibited   Brain damage     Frequency,           •Intermittent catheterization
              from injury or   urgency,             •Consistent toileting schedule
              stroke           incontinence,        •Regulation of fluid intake
                               voiding in small
                               amounts
         Prioritize Nursing Care
                  for the
         Client in Rehabilitation



Rehabilitation Nursing
Maslow’s            • First-level priority problems
Hierarchy              Care
         Prioritizing ABCS
              of
Needs                 Airway
                               Breathing
                               Circulation
                               Signs for Vital Sign concerns
                               Second-level priority problems
                               MAA-U-AR
                               Mental Status change
                               Acute pain
                               Acute Urinary/Elimination problems
                               Untreated Medical problems requiring
                               immediate attention (Diabetic who
                               needs insulin)
                               Abnormal lab values
                               Risks of infection ,safety, or security
                               Third-level priority problems
                               Things lower in priority than above
                               (lack of knowledge, coping, family
                               coping, activity, rest)
            Prioritizing Care
• What is the priority Nursing Diagnosis for
  a client in a rehabilitation program after a
  stroke that caused extensive right sided
  weakness?

  – Self care deficit-partial
  – Risk for impaired skin integrity
  – Constipation
  – Impaired physical mobility
           Prioritizing Care

• Answer: B

  – The client already has a self care deficit and
    impaired physical mobility related to the
    stroke. These problems greatly increase the
    risk for the client to experience skin
    breakdown, complicating or interfering with
    the recovery and rehabilitation efforts.
             References:

• Hoeman, S., (2008). Rehabilitation
    Nursing: Prevention, Intervention,
    & Outcomes.(4th Ed.) St Louis:
    Mosby

• Ignatavicius D. & Workman M., (2006).
     Medical-Surgical Nursing: Critical
     Thinking in Collaborative Care.(5th
     Ed.) St. Louis: Saunders