REHABILITATION NURSING

Chapter 46 REHABILITATION NURSING



OBJECTIVES



• Define the key terms/concepts

• Recognise the terminology used in rehabilitation nursing to describe the client’s level of functioning

• Explain the philosophy of rehabilitation

• Outline the functions of each member of the rehabilitation team

• Describe the process of adjustment to disability

• Assist in planning and implementing care for clients who require rehabilitation


KEY TERMS/CONCEPTS


adaptation

choices

client-centred goals

community

decision making

education

empowerment

independence

problem solving

team



CHAPTER FOCUS


Rehabilitation is a dynamic process which, to be effective, must occur as a collaborative process involving all members of the rehabilitation team, of which the client is the most important. Effective rehabilitation enables the individual to achieve optimal physical, emotional, psychological, social and vocational potential, to maintain dignity and self-respect. Rehabilitation empowers the individual to make informed choices about health care and achieve a level of wellness that is acceptable to that individual. The focus of this chapter is to introduce the nurse to the processes of rehabilitation and the many facets of rehabilitation that can be practised in any care setting.




LIVED EXPERIENCE




Denise had experienced a cerebrovascular accident. When the rehabilitation team sat down with her to set some client goals, what Denise wanted most was to get back to ballroom dancing. The team were a bit perplexed as to what to do, as Denise’s stroke had been a very severe one and she had become quite despondent and depressed. Rob, her husband, was also experiencing depression and hopelessness. However, each team member was able to work toward this goal little by little. Short-term goals were set with Denise and Rob achieving small tasks first, which, altogether, would build toward the main goal. This empowered both Denise and Rob. Each small achievement was celebrated — first just standing, then taking a few steps, then walking the length of the ward corridor. Their moods lifted and progress was enhanced. Denise went home to continue her rehabilitation with the Rehabilitation in the Home Program and then as a Community Care client. Denise and Rob came back after only a few months to show the in-client rehabilitation program team that they had achieved the major goal and gave a demonstration of their ballroom dancing.


Isabella, Enrolled Nurse, rehabilitation unit


Rehabilitation is a complex process with a range of dimensions including: motivation; adaptation to change; coping with stress; adjustment to altered circumstances; body capabilities and/or appearance; and regaining independence and wellness.



AIMS AND CHARACTERISTICS OF REHABILITATION


The basic aim of rehabilitation nursing is to limit the effects of disability and handicap in clients with particular impairments. It begins with immediate care to minimise the effects of damage and to prevent complications in the stage immediately after an accident or the onset of illness. It continues through the time clients are receiving restorative care and it often necessitates helping clients to adapt to a permanently changed situation and a new kind of life. Rehabilitation nursing includes a wide range of activities that include working collaboratively with other members of a rehabilitation team to:


• Retrain physically damaged clients to walk again

• Retrain cognitively damaged clients to communicate effectively orally or in writing

• Help clients adapt to impairment in a way that enables them to care for their own needs, such as showering, dressing and eating and using ordinary toilet facilities

• Promote client abilities to manage ordinary everyday modes of travel

• Teach clients how to put on, remove and care for different types of prosthetic appliances, e.g., an artificial limb or eye (Hoeman 2008; Jester 2007).

Rehabilitation also takes place in the area of mental health nursing and includes minimising impairment in functioning and preventing relapse in clients who experience recurrent problems with mental ill-health. This can be achieved through an approach that includes community-based programs such as educational groups, vocational and skills training and halfway houses (Collins & Diego 2000). Clinical Interest Box 46.1 indicates the main characteristics of rehabilitation.



CLINICAL INTEREST BOX 46.1 Main characteristics of rehabilitation



• Reduction of disability and handicap

• Self-sufficiency and independence

• Empowerment

• Problem solving

• Client centred

• Holistic approach

• Educational process

(Smith 1999)



CATEGORIES OF INDIVIDUALS REQUIRING REHABILITATION


A person may experience a disability of acute or chronic onset at any stage of the life span. Rehabilitation programs may be developed and implemented in hospitals, other health care settings, and in the home, for an individual who is experiencing:


• Disturbance of musculoskeletal function as a result of injury, illness or surgical intervention (e.g. fractured femur, arthritis, amputation, joint replacement)

• Brain damage (e.g. following a cerebrovascular accident or head injury)

• Nervous system impairment (e.g. as a result of a spinal cord injury or disease such as multiple sclerosis)

• Impaired skin integrity (e.g. as a result of burns)

• Removal of a body part (e.g. a limb, mastectomy, laryngectomy, or hemicolectomy with subsequent colostomy)

• Cardiac impairment (e.g. after a myocardial infarction)

• Impaired renal function (e.g. renal failure requiring dialysis)

• Impaired bladder control (e.g. as a result of neurogenic bladder disorder)

• Respiratory impairment (e.g. as a result of obstructive disorders of the airways such as asthma or pulmonary emphysema)

• Impaired vision or hearing

• Chronic pain

• Substance abuse

• A psychiatric or emotional disorder (e.g. schizophrenia, depression, anxiety).

(Derstine & Drayton-Hargrove 2001; Flannery 2004; Hoeman 2008)


In many situations complete rehabilitation is achieved but in others complete recovery of function is not possible and the individual faces a permanent disability or impairment (see Chapter 47 for definitions of these terms). When this happens, individuals must be helped to accept, adapt to, and compensate for the existing impairment to establish an optimal level of independence and quality of life. Clinical Interest Box 46.2 provides an explanation of the term adaptation.



CLINICAL INTEREST BOX 46.2 Explanation of adaptation


Adaptation implies the ability to adapt oneself or to modify behaviour and expectations in line with changing circumstances. Adaptation is a mechanism that affects the whole being, physically, socially and psychologically, and is a necessary process of normal life. However, in times of trauma or when facing disability, individuals may find it beyond their capabilities to adapt to circumstances without professional assistance. For a clearer understanding of adaptation it is recommended that the reader refer to Sister Callista Roy’s work The Roy Adaptation Model first published in 1984.



THE MEANING OF HABILITATION AND REHABILITATION


Habilitation, rather than rehabilitation, is a term that refers to the process in which a person who is born with an impairment is helped to achieve optimal independence and function by learning new skills that empower them to make choices and have degrees of control. Long-term habilitation programs are necessary for individuals born with conditions such as spina bifida, Down syndrome, or intellectual or physical impairment.


One aspect of rehabilitation addresses chronic health problems and degenerative diseases. Although there may be no cure for such conditions, a rehabilitation program can improve the quality of life. In this sense rehabilitation is directed towards the maintenance of optimal function and prevention of complications, or towards retaining the greatest amount of function and independence that the client desires for as long as possible.


Rehabilitation begins at the onset of illness or accident and continues until it is decided by the client, in consultation with the rehabilitation team, that the optimal level for that particular individual has been attained. The rehabilitation process may extend over a period ranging from a few weeks to several months or years. Rehabilitation programs are conducted in a variety of settings, including acute care hospitals, specific rehabilitation institutions, day clinics, the home, and in the community (Pryor 2000).



PHILOSOPHY OF REHABILITATION


A philosophy is a broad statement of basic related principles, concepts and beliefs. A philosophy of rehabilitation offers a framework from which the rehabilitation process can be developed. Although rehabilitation teams devise their own philosophy, philosophies of rehabilitation are generally based on the premise that rehabilitation recognises the worth and uniqueness of the person as a valuable human resource, and that rehabilitation programs must be a major integral component of care offered by health services. Rehabilitation necessitates the participation and coordination of all health team members through constant communication with the client and significant others to develop a comprehensive rehabilitation plan acceptable to and agreed to by the client. The individual receiving rehabilitation must be viewed as an active team member, and the process must actively involve the family and significant others in the individual’s life.


Rehabilitation is concerned with the whole person and includes the sociocultural aspects of the person’s life, sexuality, family and home, job, vocation, religion and community role. Rehabilitation aims to achieve the highest level of empowerment and independence possible for the individual and is client and goal focused (Derstine & Drayton-Hargroves 2001; Hoeman 2008).



CLIENT-CENTRED GOALS AND EMPOWERMENT


Goal setting can be seen as a way to give control back to clients and make empowerment real. It is seen as a move away from the traditional medical model in which nurses tended to tell clients what to do, to one that focuses on health promotion, clients’ abilities rather than disabilities, and wellness rather than illness. Empowerment is a process that enables groups or individuals to change after being given the skills, resources, opportunities and authority to do so (Rodwell 1996). Empowerment:


• Is a helping process

• Is a partnership that values self and others

• Involves mutual decision making using resources, opportunities and authority

• Confers freedom to make choices and accept responsibility (Rodwell 1996).

A partnership between team members and the client transfers power and builds on the client’s self-esteem and self-worth. Often clients in rehabilitation experience feelings of poor self-esteem and a sense of worthlessness. They can be grieving for what they perceive as a loss of independence and lifestyle. Client-centred goals can assist in identifying what is important to that individual. The client may not always set the goals at the level the team believes they should be able to achieve. It is not effective use of resources if therapists aim for the client to walk 100 metres if the client only wants to walk around the house or only wants to be able to walk to the letterbox. The goals must be realistic and the client must have a desire to reach them.


The importance of the client feeling in control of what is happening, what is being planned and of decisions that affect their life cannot be emphasised strongly enough. This sense of control is facilitated when the client is involved in determining their own rehabilitation goals. Clinical Interest Box 46.3 provides an example of a formula for setting client-centred goals. It is important for nurses working in the area of rehabilitation to keep in mind that throughout the process of rehabilitation the client and the family are often facing markedly changed circumstances and may be struggling to adapt to what has happened.



CLINICAL INTEREST BOX 46.3 Client-centred goal setting



• Subject — client is assumed subject unless otherwise stated

• Verb — desired behaviour

• Condition — environmental context/assistance/aids/strategies

• Criteria — measurable outcome; for example, 90% degree of accuracy, within a stated time limit, over a set distance

• Time frame — aim date

Example: Mrs Johnson will walk independently for 50 metres, using a four-point stick, from her front door to her letterbox safely by 15.7.04.


(MacPhail 1998)



ADJUSTMENT TO DISABILITY


The process of adjustment as it relates to disability is similar to that in dying (see Chapter 14 for further information on loss, grief and dying). Disability involves loss and is accompanied by an adjustment process as the individual and significant others learn to come to terms with the disability and its implications. The individual may experience loss of:


• Sensation

• Skin integrity

• A body part

• Ability to walk

• Use of an arm

• Bowel and/or bladder control

• Sexual function

• Ability to speak, read, write and comprehend

• Memory

• Ability to relate to other people and the environment

• Self-image, sense of self-worth, self-esteem, sexuality

• Independence.

The person whose disability has only occurred recently generally experiences four stages in adjustment during the rehabilitation process:


1. Acute disorganisation. The individual may express feelings of extreme anxiety, fear and disbelief that such an event has occurred

2. Assessment. The individual begins to assess what has happened and begins to recognise and identify changes in function and ability. The client may experience anger, depression, denial and bargaining. The individual may hope for a spontaneous recovery or a medical miracle, and tends to resist activities designed to help regain function with an impairment

3. Mourning. The individual continues to experience anger and depression; however, there is generally a new awareness of the losses involved. The individual begins to accept the changed probable future and no longer denies or ignores the disability. Eventually the client begins to participate more fully in the rehabilitation program.

4. Re-entry. The individual resolves the depression of the mourning process and begins to experience more positive feelings about self and the future. They recognise that the disability does in fact exist and are keen to find means to adapt their personal lifestyle to the disability.

It is important for nurses to understand that each client will have an individual timetable for adjusting and adapting to living with a disability. Thus, while some people adjust in a relatively short time, others will take much longer. There is no normal period of time before a person finally accepts and adjusts to a disability. It must not be forgotten that the family also goes through a process of grieving and adjustment. The rehabilitation team plays an important role as it supports the individual and family during the process of adjustment and adaptation (see Chapter 13 for information on adaptation to stress).



THE REHABILITATION TEAM


Effective rehabilitation involves client-centred care planning with the individual, family or significant others, and the whole health care team. The special needs of the individual determine the fields of expertise that are represented in the rehabilitation team. A multidisciplinary team is required and consists of members from various disciplines, each with a vital role to play. Clinical Interest Box 46.4 identifies some of the people who might be included in a multidisciplinary rehabilitation team. Who is included depends on the specific needs of individual clients; for example, a non-English speaking client would need an interpreter to be included.



CLINICAL INTEREST BOX 46.4 Members of a multidisciplinary rehabilitation team



• The client

• The client’s family/friend(s) or significant other(s)

• Nurse

• Case manager

• Counsellor (possibly an expert in grief and loss counselling)

• Physiotherapist

• Occupational therapist

• Speech therapist

• Social worker

• Dietitian

• Podiatrist

• Prosthetist/orthotist

• Psychiatrist

• Psychologist

• Chaplain or other religious/spiritual support person

• Teacher/educator (essential for children undergoing long-term rehabilitation)

• Medical officer (often the team’s clinical director)

The team most often works to an interdisciplinary model, which means that there is an integrated and collaborative approach to identifying goals, which reduces duplication (particularly in goal setting) and conflict. There is some blending of roles and building of knowledge that goes beyond the original discipline. The interdisciplinary team involves members who are engaged in problem solving beyond the confines of their particular knowledge base. This particular model of a rehabilitation team broadens the capacity of the team to obtain the outcomes that the client wants (Hoeman 2002).

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Feb 12, 2017 | Posted by in NURSING | Comments Off on REHABILITATION NURSING

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