Table 8-1 summarizes the nurse’s role as part of the rehabilitation team. Because of an increase in the need for older adult rehabilitation, some nurses specialize in gerontologic rehabilitation (Association of Rehabilitation Nurses, 2008b). Nurses and other health care professionals may be designated as rehabilitation case managers in the home or in acute care settings. Case management is described in Chapter 1.

TABLE 8-1 NURSE’S ROLE IN THE REHABILITATION TEAM

• Advocates for the patient and family

• Creates a therapeutic rehabilitation milieu

• Provides and coordinates holistic 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 having 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 interdisciplinary plan of care for the patient and family

Adapted from Association of Rehabilitation Nurses. (2008). Standards and scope of rehabilitation nursing practice, Glenview, IL: Author.

Physical therapists intervene to help the patient achieve self-management by focusing on gross mobility skills (e.g., by facilitating ambulation and teaching the patient to use a walker) (Fig. 8-1). They may also teach techniques for performing certain ADLs, such as transferring (e.g., moving into and out of bed), ambulating, and toileting, and can assist with cognitive retraining (often for patients with TBI). Physical therapy assistants (PTAs) may be employed to help the PT.

FIG. 8-1 A physical therapist helping a patient ambulate with a walker.

Occupational therapists work to develop the patient’s fine motor skills used for ADL self-management, such as those required for eating, hygiene, and dressing. OTs also teach patients how to perform independent living skills, such as cooking and shopping. Many inpatient rehabilitation facilities have fully furnished and equipped apartments where patients can practice independent living skills in a mock setting under supervision. To accomplish these outcomes, OTs teach skills related to coordination (e.g., hand movements) and cognitive retraining (Fig. 8-2). Occupational therapy assistants (OTAs) may be available to help the OT.

FIG. 8-2 A registered occupational therapist working with a patient on improving hand strength.

Speech-language pathologists (SLPs) evaluate and retrain patients with speech, language, or swallowing problems. Speech is the ability to say words, and language is the ability to understand and put words together in a meaningful way. Some patients, especially those who have experienced a head injury or stroke, have difficulty with both speech and language. Those who have had a stroke also may have dysphagia (difficulty with swallowing). SLPs provide screening and testing for dysphagia. If the patient has this problem, the SLP recommends appropriate foods and feeding techniques. Speech-language pathology assistants (SLPAs) may be employed to help the SLP.

PTs, OTs, and SLPs are collectively referred to as rehabilitation therapists. Assistants to PTs, OTs, and SLPs are called rehabilitation assistants. Restorative aides, usually in the nursing department, continue the rehabilitation therapy plan of care when therapists are not available. This model of care is common in long-term care settings, such as nursing homes.

Recreational or activity therapists work to help patients continue or develop hobbies or interests. These therapists often coordinate their efforts with those of the OT.

Cognitive therapists, usually neuropsychologists, work primarily with patients who have experienced head injuries with cognitive impairments. These therapists often use computers to assist with cognitive retraining.

Registered dietitians (RDs) may be needed to ensure that patients meet their nutritional needs. For example, for patients who need weight reduction, a restricted calorie diet can be planned. For patients who need additional calories or other nutrients, including vitamins, nutritionists can plan a patient-specific diet.

As their name implies, nursing assistants or nursing technicians assist in the care of patients. These members of the rehabilitation team are under the direct supervision of the registered nurse (RN) or licensed practical or vocational nurse (LPN or LVN).

Various counselors are helpful in promoting community reintegration of the patient and acceptance of the disability or chronic illness. Social workers help patients identify support services and resources, including financial assistance, and coordinate transfers to or discharges from the rehabilitation setting. Clinical psychologists also counsel patients and families on their psychological problems and on strategies to cope with disability. They may also perform a battery of cognitive assessments. Spiritual counselors, usually members of the clergy, specialize in spiritual assessments and care.

Vocational counselors assist with job placement, training, or further education. Work-related skills are taught if the patient needs to change careers because of the disability. If the patient has not yet completed high school, tutors may help with completion of the requirements for graduation.

Depending on the patient’s health care needs, additional team members may be included in the rehabilitation program, such as the geriatrician, respiratory therapist, pharmacist, and prosthetist. Interdisciplinary team conferences for planning care and evaluating the patient’s progress are held regularly with the patient, family members and significant others, and health care providers. The interdisciplinary patient record is shared and read by all team members.

Patient-centered Collaborative Care

Assessment

History

Collect the history of the patient’s present condition, any current drug therapy, and any treatment programs in progress. Begin by obtaining general background data about the patient and family. This information includes cultural practices and the patient’s home situation. In collaboration with the occupational therapist, the nurse or case manager addresses the layout of the home. Together they discuss whether the physical layout at home, such as stairs or the width of doorways, will present a problem to the patient after discharge.

Assess the patient’s usual daily schedule and habits of everyday living. These include hygiene practices, eating, elimination, sexual activity, and sleep. Ask about the patient’s preferred method and time of bathing and hygiene activity. In assessing dietary patterns, note food likes and dislikes. Also, obtain information about bowel and bladder function and the normal pattern of elimination.

In assessing sexuality patterns, ask about changes in sexual function since the onset of the disability. The patient’s current and previous sleep habits, patterns, usual number of hours of sleep, and use of hypnotics are also assessed. Question whether the patient feels well rested after sleep. Sleep patterns have a significant impact on activity patterns. The assessment of activity patterns focuses on work, exercise, and recreational activities.

Considerations for Older Adults

Older adults who need rehabilitation often have other chronic diseases that need to be managed, including diabetes mellitus, coronary artery disease, osteoporosis, and arthritis. These health problems added to the normal physiologic changes associated with aging predispose the older adult to falls, pressure ulcers, and pneumonia. When discharged from a hospital setting, some older patients are undernourished, which causes weakness and fatigue. The longer the hospital stay, the more debilitated the older adult can become.

Health teaching may be challenging because some older patients may have beginning cognitive changes, including short-term memory loss. Sensory losses, like vision and hearing, also affect their ability to give an accurate history or grasp new information.

Physical Assessment/Clinical Manifestations

Upon admission for baseline and every day thereafter according agency policy and type of setting, collect the physical assessment data systematically according to major body systems (Table 8-2). The focus of the assessment related to rehabilitation and chronic disease is on the functional abilities of the patient.

TABLE 8-2 ASSESSMENT OF PATIENTS IN REHABILITATION SETTINGS

BODY SYSTEM	RELEVANT DATA
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