Chapter 6 Flashcards
Rehabilitation
is a philosophy of practice and an attitude toward caring for people with disabilities and chronic health problems
disabling health condition
is any physical or mental health/behavioral health problem that can cause disability.
chronic health condition
is one that has existed for at least 3 months.
purpose of rehabilitation
to prevent further disability, maintain function, and restore individuals to optimal functioning in their community.
common chronic diseases that can result in varying degrees of disability
Stroke, coronary artery disease, cancer, chronic obstructive pulmonary disease (COPD), asthma, and arthritis
results from advanced technology that save people from accidents:
often faced with chronic, disabling neurologic conditions such as traumatic brain injury (TBI) and spinal cord injury (SCI)
common veteran health problems
TBI, single or multiple limb amputations, and post-traumatic stress disorder (PTSD)
HEALTH CARE ORGANIZATIONS
seeks to maximize the function of the individual impacted by the injury or chronic condition
HEALTH CARE ORGANIZATIONS examples
acute inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term acute care (LTAC) facility, or home health agency (HHA)
PAC level (best health care organization)
based on the individual’s biopsychosocial and ecological assessment
must be matched to the patients’ needs.
Rehab for older adults
rehabilitation services for the first 100 days of inpatient care are paid by Medicare A.
Skilled nursing facilities (SNFs)
are part of either a hospital or long-term care (nursing home) setting
Rehabilitation care continuum.
The intensity of services decreases across the continuum from the inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) to home health to comprehensive ambulatory care (outpatient) programs.
resident
implies that the person lives in the facility and has all the rights of anyone living in his or her home.
Home for older adults is often:
in senior citizens’ housing units, their family’s home, or assisted-living facilities.
Group homes
are facilities in which individuals live independently together with other people with disabilities.
Alternative living settings include:
a board-and-care facility or transitional living apartment.
The desired outcome of rehabilitation
is that the patient will return to the best possible physical, mental, social, vocational, and economic capacity.
It also includes education and therapy for any chronic conditions characterized by a change in a body system function or body structure
health care team in the rehabilitation setting may include:
- Nurses and nursing assistants
- Rehabilitation nurse case managers
- Physicians and physicians assistants
- Advanced practice nursing (APNs) such as nurse practitioners and clinical nurse specialists
- Physical therapists and assistants
- Occupational therapists and assistants
- Speech-language pathologists and assistants
- Rehabilitation assistants/restorative aides
- Recreational or activity therapists
- Cognitive therapists or neuropsychologists
- Social workers
- Clinical psychologists
- Vocational counselors
- Spiritual care counselors
- Registered dietitians (RDs)
- Pharmacists
Rehabilitation nurses in the inpatient setting:
coordinate the collaborative plan of care and therefore function as the patient’s case manager.
rehabilitation milieu
- Allowing time for patients to practice self-management skills
- Encouraging patients and providing emotional support
- Protecting patients from embarrassment (e.g., bowel training)
- Making the inpatient unit a more homelike environment
Advanced practice nurses (APNs)
are masters- and doctorate-prepared nurses who function independently or under the supervision of a physician, depending on the rules and regulations of the state or province.
Nurse’s Role in the Rehabilitation Team
- Advocates for the patient and family
- Creates a therapeutic rehabilitation milieu
- Provides and coordinates whole-person patient care in a variety of health care settings, including the home
- Collaborates with the rehabilitation team to establish expected patient outcomes to develop a plan of care
- Coordinates rehabilitation team activities to ensure implementation of the plan of care
- Acts as a resource to the rehabilitation team who has specialized knowledge and clinical skills needed to care for patient with chronic and disabling health problems
- Communicates effectively with all members of the rehabilitation team, including the patient and family
- Plans continuity of care when the patient is discharged from the health care facility
- Evaluates the effectiveness of the interprofessional plan of care for the patient and family
nursing assistants or nursing technicians
assist in the physical care of patients
physiatrist
A physician who specializes in rehabilitative medicine
oversee the rehabilitation medical plan of care from the emergency department, intensive care unit, telemetry unit, and medical surgical unit into the community
Physician assistants (PAs)
work under the supervision of the physician
Physical therapists (PTs), also called physiotherapists
intervene to help the patient achieve self-management by focusing on gross MOBILITY skills
Physical therapy assistants (PTAs)
may be employed to help the PT.
Occupational therapists (OTs)
work to develop the patient’s fine motor skills used for ADL self-management such as those required for eating, hygiene, grooming, and dressing.
Occupational therapy assistants (OTAs)
may be available to help the OT.
Speech-language pathologists (SLPs)
evaluate and retrain patients with speech, language, or swallowing problems.
rehabilitation therapists`
PTs, OTs, and SLPs
rehabilitation assistants.
Assistants to PTs, OTs, and SLPs
Recreational or activity therapists
work to help patients continue or develop hobbies or interests.
Cognitive therapists,
usually neuropsychologists, work primarily with patients who have experienced a stroke, brain injury, brain tumor, or other condition resulting in cognitive impairment.
social workers
help patients identify support services and resources, including financial assistance
Clinical psychologists
assess and diagnose mental health/behavioral health or COGNITION issues resulting from the disability or chronic condition and help both the patient and family identify strategies to foster coping.
Spiritual counselors
specialize in spiritual assessments and care and are able to address the needs of a wide array of patient preferences and beliefs.
Vocational counselors
help with job placement, training, or further education.
Registered dietitians (RDs)
help ensure that patients meet their needs for NUTRITION.
Pharmacists
collaborate with the other members of the health care team to ensure that the patient receives the most appropriate drug therapy, if required.
For some patients severe undernutrition results in decreased serum albumin and prealbumin, causing third spacing:
Assess the older adult for generalized edema, especially in the lower extremities. Be sure to collaborate with the RD to improve the patient’s nutritional status, with a focus on increasing protein intake that is needed for healing and decreasing edema.
Assessment steps
history- interview and PAMS BM
physical assessment
Cardiovascular system
Chest pain
Fatigue
Fear of heart failure
Respiratory system
Shortness of breath or dyspnea
Activity tolerance
Fear of inability to breathe
Gastrointestinal system and nutrition
Oral intake, eating pattern
Anorexia, nausea, and vomiting
Dysphagia
Laboratory data (e.g., serum prealbumin level)
Weight loss or gain
Bowel elimination pattern or habits
Change in stool (constipation or diarrhea)
Ability to get to toilet
Renal-urinary system
Urinary pattern
Fluid intake
Urinary incontinence or retention
Urine culture and urinalysis
Neurologic system
Motor function
Sensation
Perceptual ability
Cognitive abilities
Musculoskeletal system
Functional ability
Range of motion
Endurance
Muscle strength
Integumentary system
Risk for skin breakdown
Presence of skin lesions
nocturia
routinely awakens during the night to empty the bladder
UTIs in older adults
Urinary tract infections (UTIs) among older adults are often missed because acute confusion may be the only indicator of the infection.
dysphasia
slurred speech
aphasia
(inability to speak or comprehend)
paresis
weakness
paralysis
(absence of movement)
activities of daily living (ADLs)
such as bathing, dressing, eating, using the toilet, and ambulating.
Instrumental activities of daily living (IADLs)
refer to activities necessary for living in the community such as using the telephone, shopping, preparing food, and housekeeping.
Assessment Components of the Minimum Data Set (MDS)
- Hearing, Speech, and Vision
- Cognitive Patterns
- Mood
- Behavior
- Preferences for Customary Routines and Activities
- Functional Status
- Bowel and Bladder
- Active Disease Diagnoses
- Health Conditions (e.g., pain, fall history)
- Swallowing and Nutritional Status
- Oral/Dental Status
- Skin Condition
- Medications
- Special Treatments and Procedures
- Restraints
- Participation in Assessment and Goal Setting
- Supplemental Therapies
Psychosocial Assessment.
body image and self-esteem through verbal indicators and descriptions of self-care.
patient’s use of defense mechanisms and manifestations of anxiety
presence of any stress-related physical problem
depression
priority collaborative problems for patients with chronic and disabling health conditions typically include:
- Decreased mobility due to neuromuscular impairment, sensory-perceptual impairment, and/or chronic pain
- Decreased functional ability due to neuromuscular impairment and/or impairment in perception or cognition
- Risk for pressure injury due to altered sensation and/or altered nutritional state
- Urinary incontinence or urinary retention due to neurologic dysfunction and/or trauma or disease affecting spinal cord nerves
- Constipation due to neurologic impairment, inadequate nutrition, or decreased mobility
SPHM practices
- Maintain a wide, stable base with your feet
- Put the bed at the correct height—waist level while providing direct care and hip level when moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
- Keep the patient as close to your body as possible to prevent reaching
Orthostatic hypotension
is indicated by a drop of more than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure between positions.
Notify the health care provider and the therapists about this change.
help the patient change positions slowly, with frequent pauses to allow the blood pressure to stabilize. If needed, measure blood pressure with the patient in the lying, sitting, and standing positions to examine the differences.
Weight gain
is another potential problem when rehabilitation patients have decreased MOBILITY.
ambulatory aids
walkers, canes, ect.
Walker-Assisted Procedure
- Apply a transfer belt around the patient’s waist.
- Guide the patient to a standing position.
- Remind the patient to place both hands on the walker.
- Ensure that the patient’s body is well balanced.
- Teach the patient repeatedly to perform this sequence:
- Lift the walker.
- Move the walker about 2 feet forward and set it down on all legs.
- While resting on the walker, take small steps.
- Check balance.
- Repeat the sequence.
Cane-Assisted Procedure
- Apply a transfer belt around the patient’s waist.
- Guide the patient to a standing position.
- Be sure the cane is at the height of the patient’s wrist when the arm is placed at his or her side. (Many canes can be adjusted to the required height.)
- Remind the patient to place his or her strong hand on the cane.
- Ensure that the patient’s body is well balanced.
- Teach the patient to perform this sequence repeatedly:
- Move the cane and weaker leg forward at the same time.
- Move the stronger leg one step forward.
- Check balance and repeat the sequence.
ROM techniques
beneficial for any patient with decreased mobility.
how to promote independence
Encourage the patient to perform as much self-care as possible. Allow time to complete the task as independently as possible.
assistive/adaptive device
is any item that enables the patient to perform all or part of an activity independently and safely.
Buttonhook
Threaded through the buttonhole to enable patients with weak finger mobility to button shirts
Alternative uses include serving as pencil holder or cigarette holder
Extended shoehorn
Assists in the application of shoes for patients with decreased mobility
Alternative uses include turning light switches off or on while patient is in a wheelchair
Plate guard and spork (spoon and fork in one utensil)
Applied to a plate to assist patients with weak hand and arm mobility to feed themselves; spork allows one utensil to serve two purposes
Gel pad
Placed under a plate or glass to prevent dishes from slipping and moving
Alternative uses include placement under bathing and grooming items to prevent them from moving
Foam buildups
Applied to eating utensils to help patients with weak hand grasps feed themselves
Alternative uses include application to pens and pencils to assist with writing or over a buttonhook to assist with grasping the device
Hook and loop fastener (Velcro) straps
Applied to utensils, a buttonhook, or a pencil to slip over the hand and provide a method of stabilizing the device when the patient’s hand grasp is weak
Long-handled reacher
Assists in obtaining items located on high shelves or at ground level for patients who are unable to change positions easily
Elastic shoelaces or Velcro shoe closure
Eliminates the need for tying shoes
Assistive technology
has further increased the ability for people with disabilities to care for themselves.
Robotic technology
provides mechanical parts for the extremities when they are not functional or have been amputated.
Fatigue
often occurs with chronic and disabling conditions. Therefore collaborate with the OT to assess the patient’s self-care abilities and determine possible ways of conserving energy.
best intervention to prevent pressure injury and maintain TISSUE INTEGRITY
frequent position changes (at least every 2 hours) in combination with adequate skin care and sufficient nutritional intake.
pre–pressure injury areas, or stage I pressure areas
If reddened areas do not fade within 30 minutes after pressure relief or do not blanch
wheelchair push-ups
pressure relief by using their arms to lift their buttocks off the wheelchair seat for 20 seconds or longer every hour or more often if needed
neurologic problems and pressure
decreased or absent sensation and may not be able to feel the discomfort of increased pressure.
skin care:
cleaning soiled areas, drying carefully, and applying a moisturizer
patient is incontinent, use topical barrier creams or ointments to help protect the skin from moisture, which can contribute to skin breakdown.
teach UAP to avoid rubbing reddened areas.
patient’s weight and serum prealbumin levels- If either of these indices decreases significantly:
high-protein, high-carbohydrate food supplements
Pressure-relieving or pressure-reducing devices
waterbeds, gel mattresses or pads, air mattresses, low–air loss overlays or beds, air-fluidized beds, and Mattress overlays
normal patterns of urinary ELIMINATION
without retention, infection, or incontinence.
spastic (upper motor neuron) bladder
causes incontinence with sudden voiding
flaccid or areflexic (lower motor neuron) bladder
results in urinary retention and overflow (dribbling).
Post-void residual (PVR)
amount of urine remaining in the bladder after voiding.
Long-term urinary catheters cause:
urinary tract infections that are often chronic.
bladder management teaching:
- Facilitating, or triggering, techniques
- Intermittent catheterization
- Consistent scheduling of toileting routines (“timed void”)
Facilitating (triggering) techniques
stroking the medial aspect of the thigh, pinching the area above the groin, massaging the peno-scrotal area, pinching the posterior aspect of the glans penis, and providing digital anal stimulation.
Credé maneuver
placing his or her hand in a cupped position directly over the bladder area. Then instruct him or her to push inward and downward gently as if massaging the bladder to empty.
Valsalva maneuver
teach the patient to hold his or her breath and bear down as if trying to defecate
Intermittent catheterization
may be needed for a flaccid or spastic bladder.
The patient should not go beyond 8 hours between catheterizations
chronic bacteriuria
bacteria in the urine with a positive culture common in pt that need intermittent cath
bladder capacity
may range from 100 to 500 mL
Mild overactive bladder problems drug therapy
antispasmodics
urinary antispasmodic drugs are used in older adults
observe for, document, and report hallucinations, delirium, or other acute cognitive changes caused by the anticholinergic effects of the drugs.
symptomatic UTIs treatment
short-term antibiotics such as trimethoprim (Trimpex) or trimethoprim/sulfamethoxazole (Septra, Bactrim)
frequent UTIs treatment
placed on pulse antibiotic therapy in which they alternate 1 week of antibiotic therapy with 3 weeks without antibiotics.
Bowel retraining programs
designed for each patient to best meet the expected outcomes
enhance the quality of life for patients
reflex (spastic) bowel pattern
with defecation occurring suddenly and without warning
Upper motor neuron diseases and injuries
digital stimulation
use a lubricated glove or finger cot and massage the anus in a circular motion for no less than 1 full minute.
digital stimulation: when not to use
Do not use digital stimulation for patients with cardiac disease because of the risk for inducing a vagal nerve response. This response causes a rapid decrease in heart rate (bradycardia).
flaccid bowel pattern
with defecation occurring infrequently and in small amounts.
Lower motor neuron diseases and injuries
flaccid bowel pattern treatment
manual disimpaction may get the best results. Some patients also need oral laxatives and/or stool softeners.
uninhibited bowel patterns management
consistent toileting schedule, a high-fiber diet, and the use of stool softeners.
Bowel retraining
programs for patients with neurologic problems are often designed to include a combination of methods
Bisacodyl (Dulcolax)
laxative
rectally or orally
Suppositories
placed against the bowel wall to stimulate the sacral reflex arc (if intact) and promote rectal emptying. Results occur in 15 to 30 minutes. Administer the suppository when the patient expects to defecate
to avoid constipation
Encourage fluids (at least eight glasses a day) and 20 to 35 g of fiber in the diet. Teach patients to eat two to three daily servings of whole grains, legumes, and bran cereals and five daily servings of fruits and vegetables.
Expected outcomes of rehab:
- Reach a level of mobility that allows him or her to function independently with or without assistive devices
- Prevent complications of decreased MOBILITY
- Perform self-care and other self-management skills independently or with minimal assistance, possibly using assistive/adaptive devices
- Have intact skin and underlying tissues.
- Establish urinary ELIMINATION without infection, incontinence, or retention
- Have regular evacuation of stool without constipation or incontinence
