Approaches To The Rehabilitation Process
REHABILITATION OF PATIENTS
After hospitalization, rehabilitation is where many patients get discharged to. Basics of care in rehabilitation are short-term or long-term. Short-term is usually for a stay of less than a month and the goal is for functional recovery along with enhanced community participation while the goal for long-term is the maintenance of functional ability (Castle, McDonald, & Wagner, 2013).
Patients have different reactions when going to rehabilitation, however it allows them to have a greater quality of life. There are many components of rehabilitation which include: the role of the nurse, the promotion of independence, the reaction of decreased functional mobility, the promotion of safety and wellbeing, trends in care, the role of the physical therapist (PT) and occupational therapist (OT), and methods to increase collaboration amongst the rehabilitation team. Nurses play an integral role in patients that have functional mobility interferences. They act as a caregiver, educator, counselor, patient advocate, case manager, consultant, and care coordinator (Cheever & Hinkle, 2013).
The nurse develops a therapeutic and supportive nurse-patient relationship that features: positive reinforcement, emphasis on strengths, sharing of patient successes and active listening. With the maintenance of a good nurse-patient relationship, the nurse promotes self-care, manages skin integrity along with bowel and bladder function, identifies mobility deficiencies, and assists with coping (Cheever & Hinkle, 2013).
In addition, the nurse coordinates a holistic evidenced based plan of care alongside the patient, family, and health care team. Essentially the nurse is at the core of the patient’s care starting with an assessment. An assessment consists of assessing the patients cardiovascular, neurologic, and musculoskeletal system, secondary conditions related to the disability, personal factors, and observation of the patient’s ability to perform activities of daily living along with instrumental activities of daily living. These systems play an important role due to the dependence of functional ability on muscle and joint strength, cardiovascular reserve, and neurologic function (Cheever & Hinkle, 2013).
Secondary conditions related to the disability can be related to: muscle deconditioning or atrophy, bowel and bladder control, sexual function, and skin integrity (Cheever & Hinkle, 2013). Personal factors to consider that have the ability to impact the rehabilitation process include: physical, mental, social, spiritual, emotional, and economic status along with cultural and familial environment (Cheever & Hinkle, 2013).
In addition, in relation to activities, the nurse’s assessment focuses on: degree of independence, time taken, mobility, coordination, endurance, and amount of assistance needed (Cheever & Hinkle, 2013). Also. a commonly used tool that displays the level independence of a patient is, the Functional Independence Measure (FIM). The FIM measures 18 self-care items, addresses mobility, communication, and social cognition. Tools such as FIM are standardized assessment parameters to make known the patient’s ability to all members of the rehabilitation team.
The promotion of independence in patients with decreased functional mobility can be achieved by: assessments, education, and performance of the task by the patient. Self-care with ADL’s can be encouraged by defining the goal of the activity and then creating an individualized approach to accomplish the goal once an assessment identifying the functional limitations of the patient is completed (Cheever & Hinkle, 2015).
Coaching and limiting maladaptive behaviors are beneficial as well. In regards to transferring and ambulation, the nurse assesses the patient’s ability to perform those tasks and works with PT and OT to determine assistive devices and gait necessary to promote independence and safety (Cheever & Hinkle, 2015). The patient is shown and instructed on how to perform the task. The patient is continuously monitored for stability, safety, and compliance with weighting bearing restrictions. Consistency in education, assistance, and ingenuity by the healthcare team facilitate self-care (Cheever & Hinkle, 2015).
These measures serve as a foundation to independence in care, however care fundamentals are also essential to recovery for the patient. Patients with decreased functional mobility can exhibit physiological and psychological responses that include: maladaptive behaviors and substance abuse. The inability to perform activities of daily living independently can lead to ineffective coping in patients with impaired functional mobility. Patients can exhibit behaviors such as social isolation, a dependence on caregivers, and depression (Cheever & Hinkle, 2015).
Maladaptive coping mechanisms can lead to substance abuse. Substance abuse is two to four times higher in those with disabilities compared to the normal population due to lack of resources, health problems, and societal enabling (Cheever & Hinkle, 2015).
Holistic care is essential to the success of patients in rehabilitation, so measures should be taken to facilitate physiological and psychological safety, wellbeing and comfort. The following interventions promote safety as well as comfort and wellbeing: correct positioning, sturdy well-fitting shoes, tracking of performance, and ingenuity. Correct positioning aides to prevent deformities allowing for increased activity tolerance, independence, safety, and success. Additionally, well-fitting shoes reduces the chance of falls, fostering comfort and safety. Also, the healthcare team can increase morale, motivation, and safety by showing the patient a record of improvement in performance from start to present by the patient (Cheever & Hinkle, 2015).
Furthermore, ingenuity by the rehabilitation team creates an individualized approach to self-care tasks promoting independence, safety and wellbeing (Cheever & Hinkle, 2015). Trends in the care of patients with decreased functional mobility include animal therapy, music therapy, and art therapy. Animal therapy can help reduce mental and physical strain that patients experience in acute rehabilitation (Beck, Burres, Edwards & Richards, 2016). Additionally, evidence showed improvements in cardiovascular, mental, and physical health (Beck et al., 2016).
Music therapy is another therapy that can help reduce anxiety therefore improving mood and enhancing the environment (Crow, Danseur, Olson, Stutzman, & Villarreal, 2017). It can be used as an adjunct tool during medical procedures and the benefit maximized by the patient choosing the genre (Crow et al., 2017).
Moreover, art therapy allows the patient to gain autonomy and can provide as a distraction from the presence of illness. Patients have the opportunity to return to normalcy while taking part in art therapy (Atkan, Celik, & Kurtuncu, 2017). During rehabilitation, it is important that other therapies such as animal art, and music therapy be utilized to help increase patient outcomes by tending to their psychosocial needs. PT in the acute setting focuses on improved mobility while the community setting promotes increased control and greater improvement in their health. In the acute setting, PT works with patients to improve gait, therapeutic exercise, and transitional movements based off of their assessment (Barrett, et al., 2015).
PT in the community, discusses with patient’s how to safely incorporate physical activities in their day to day life, how to cope with fatigue, how to adapt to their home and work environments, and how to tap community support groups (Ries, 2018). PT in both settings works alongside OT to increase patients function.
Acute care and community based OT have similar goals in terms of function but community based care is more individualized because the focus is based on the patient’s life at home. In an acute care setting, their role is to provide training in self-care activities, address cognitive and perceptual deficits, develop home programs, provide assistive devices, and contribute to safe discharge planning (Alexander, H., Bondoc, S., Frost, L., Hermann, V., Lashgari, D., 2018).
Community based healthcare varies from acute care by focusing on self-perception, interpersonal relationships, independent living, social integration, and productivity as well as function and mobility (Nadeau, 2016). The focus is placed on the individual’s life, instrumental activities of daily living (ADL’s) and ADL’s. Instrumental ADL’s include sleep habits, work demands, play, leisure, socialization, and home management (Nadeau, 2016).
Collaboration by OT and the rehabilitation team in acute care and community based settings are essential to the reintegration of patients back into the community. Methods that can be taken to maximize interdisciplinary collaboration include shared values, shared view of ones’ roles, and staff continuity. Team work doesn’t consist of multiple people working on a task together. It is identifying and working towards shared values and learning from each other’s experiences (Brämberg, 2016).
Staff continuity is important because the new team member may not be included. Utilizing these methods can increase collaboration therefore increasing patient outcomes. While at the acute rehabilitation center, they displayed collaboration between the rehab team with the nurse and doctor discussing patient plan of care. Although, the nurse and PT displayed a lack of communication with patients being taken early for PT. Additionally, there was a lot of education taking place as the nurse went along. Also, the center had patients that had been there for months, so it was nice to get to know them and associate what was taught in a Medical-Surgical course to the patients’ conditions. In addition, to see PT was very interesting because of the exercises that they had the patients perform. Overall, it was a great experience and eye-opening.
