Rehabilitation of Patients with Neurological Disorders
Joanne V. Hickey
Emily C. Bonvillain
This chapter provides basic information about the principles and concepts of rehabilitation as they apply to patients with neurological disorders. Rehabilitation nursing is a specialty area of nursing practice with published standards and a scope of practice. However, rehabilitation principles and concepts are fundamental components of nursing practice, and transcend all practice areas. Understanding of the comprehensive rehabilitation process by nurses caring for patients with neurological disorders will facilitate a seamless continuum of care for patients. A number of published resources can assist the nurse in expanding knowledge about rehabilitation.1, 2, 3
FRAMEWORK FOR DISABILITY
The restoration to health or improvement of function is the main focus of rehabilitation. Most definitions of rehabilitation are based on the International Classification of Functioning, Disability and Health (ICF) published by the World Health Organization (WHO).4 The ICF provides a comprehensive description of how people live with their health conditions through a classification of health and health-related domains that describe body functions and structures, activities, and participation. It provides a way to measure the impact disability has on health and how to optimize the ability to remain engaged and functional. The ICF consists of two parts, each of which is divided into two components.
Functioning and disability
Body functions and body structures
Activities and participation
Contextual factors
Environmental factors
Personal factors
Body functions include the physiology of body systems (including psychological function), whereas body structures include the anatomic parts of the body such as organs, limbs, and their components. Activity is defined as the execution of a task or action by an individual; participation is involvement in life situations. Environmental factors are the physical, social, and attitudinal environment in which an individual lives and conducts his or her life; personal factors are the internal influences on functioning and disability unique to the person. This conceptualization of rehabilitation is holistic and recognizes the influence of environmental and personal factors on rehabilitation outcomes.
Disease and health conditions are comparable regardless of cause. This view places mental disorders and physical illness on equal footing in that both can affect the ability to function optimally. Disease refers to intrinsic pathology that may or may not be evident clinically. Impairment is an abnormality of a psychological, physiologic, or anatomic structure and function; it represents disturbance on the organ level. Disability is the consequence of impairment as it relates to individual functional performance and activity; it represents disturbance on the person level.
CONCEPTS OF REHABILITATION
Rehabilitation is a dynamic process through which a person is assisted to achieve optimal physical, emotional, psychological, social, and vocational potential, and to maintain dignity, self-respect, and a quality of life that is as self-fulfilling and satisfying as possible. The major goals of rehabilitation are optimizing function; promoting independence, satisfaction, and quality of life; and preserving self-esteem. To be effective, rehabilitation should be a philosophy of care and is an integral part of health care delivery.
Rehabilitation is a continuum of functional restoration. In some situations, complete functional restoration is possible, as in the situation of a patient who sustains a mild cerebral concussion. In this instance, complete recovery is the rule. However, when complete recovery of function is not possible and permanent disability is likely, the patient needs help to accept, adjust to, and compensate for the existing deficit and to establish an optimal level of function. An example is a patient with paraplegia who has sustained a severed spinal cord injury resulting in permanent paralysis. Present medical therapies cannot restore the severed cord to its premorbid condition, although this may be a future possibility. However, a comprehensive rehabilitation program helps the person live a useful, relatively independent life from a wheelchair.
Another aspect of rehabilitation addresses chronic health problems and degenerative diseases, such as multiple sclerosis (MS). Although currently no cure exists for MS, a rehabilitation program can improve quality of life through health promotion, symptom management, prevention of complications, and patient education to promote optimal independence for the longest possible time. As the disease progresses, rehabilitation offers alternate ways of conducting activities of daily living (ADLs) with adaptive devices and alternate methods of performing skilled acts.
A PHILOSOPHY OF REHABILITATION
A philosophy is a set of broad statements about fundamental beliefs and values. The philosophy of rehabilitation offers a framework to shape the overall rehabilitation process. It often includes the following premises.
A person with a disability has intrinsic value that transcends the disability; each person is a unique holistic being who has the right and the responsibility to make informed personal choices regarding health and lifestyle. Patient-centered care focuses on the patient as the primary focus of care. Restoring an individual’s capacity to the highest level possible assists the person to resume roles such as homemaking, parenting, and gainful employment, thus offering many social, emotional, psychological, and financial returns to society.
Rehabilitation is an integral component of all care administered by all health care providers. Rehabilitation begins the moment a person seeks health care so that prevention is incorporated into the rehabilitation process. A major goal in educating all health care providers is to prepare them to “think rehab” from the moment of initial contact with the patient.
Comprehensive rehabilitation requires the active participation and collaboration of all members of the interprofessional team through ongoing communication, common patient-centered goals, and coordinated/timely treatment. Scheduled team conferences, informal discussion, a documented plan of care, and progress notes provide a means of communication. Multidisciplinary collaboration and management mean that all health team members collaborate to achieve specific, identified, mutual goals.
Patient-centered rehabilitation requires the active participation of the patient and family to achieve optimal rehabilitative potential. The patient must be motivated and actively involved in the rehabilitation process to achieve optimal outcomes.
Rehabilitation actively involves the patient’s family or significant others; they are the patient’s potential support systems and assist with the transition back to the home and community. Family members should be reached at their individual levels of understanding, taking into consideration their educational, socioeconomic, and cultural backgrounds to understand the rehabilitative goals and methods selected to meet these goals. The nurse usually interprets this information for the family, helping them to understand how they can best participate. In addition, the family is a rich source of information about the patient’s personality and lifestyle that will be helpful in the transition back to the community.
An individual patient and family evaluation is the basis to determine their ability to contribute to the rehabilitation process. All families cannot contribute in the same way or to the same degree. Because each family and patient present different strengths and needs, individual evaluation is necessary.
The patient experiences illness and disability within the context of his or her previous adjustment patterns. The strengths and weaknesses of the patient’s personality are essentially the same during illness. Team members must recognize the social and cultural influences that affect the patient’s adjustment patterns and acceptance of care.
Rehabilitation takes place within the context of the patient’s whole life: the sociocultural aspects of life, his or her job or vocation, family, home, place in the community, religion, and relationship to self. When illness strikes, family life is abruptly interrupted and altered. Illness affects not only the patient, but also the family. Therefore, rehabilitation includes the needs of the family.
Rehabilitation is a dynamic process with progress, plateaus, and setbacks. In relation to the rapid change in the acute care setting, rehabilitation progresses at a slower pace often with challenges along the way. Only through ongoing assessment and problem solving is achievement of patient goals possible.
Transitions in care include plans for continued rehabilitation services and care coordination. Options include acute or subacute inpatient rehabilitation, community re-entry, outpatient rehabilitation, or home health therapies. The patient and family are presented with various care alternatives and helped to evaluate the implications of each choice, including cost and health insurance issues. The patient and family actively participate in the decision-making process of discharge planning to the degree that they are able and willing to participate for a relatively smooth transition and adjustment.
Terminology of Rehabilitation
The following terms are used consistently in rehabilitative health care.
Rehabilitative potential: dormant power for rehabilitation within a person that exists as a possibility that can eventually become actualized
Short-term goals: goals to be achieved in the immediate future (usually set for 1 week); discrete units or steps involved in the learning of a skill that must be achieved before more complex skilled acts can be accomplished; the steps through which long-term goals are achieved
Long-term goals: goals projected for completion in the distant future; can be considered the ultimate objectives of a rehabilitation program
Optimal goals: the rehabilitation goals that may be expected barring significant setbacks or complications
Realistic goals: goals that reflect a grounded and reasonable appraisal of the person and achievable outcome
Acute disability: a disability that has a finite duration and is completely resolved in a short period of time; reversible; temporary
Chronic disability: an ongoing disability that limits the person in some way; permanent; irreversible
Interdisciplinary practice model: health professionals working together to achieve measurable functional outcomes for people with disabilities
Multidisciplinary team rounds: activity in which the health professionals round together to assess and monitor progress, functional level, problems, and concerns on some scheduled daily or weekly basis; it provides data for further discussion at team meetings or patient care conferences
Family meetings: planned meetings with one or more health care professionals and family members to discuss patient progress, needs, and planning; recognizes the importance of the family in the rehabilitation of the patient, and helps to maintain open communication
Framework for Rehabilitation Decisions
Initial decisions related to rehabilitation are based primarily on information gathered during a screening examination. The goal is to determine the best match between the patient needs and available
resources. In this complex health care environment, utilization of health care and cost are scrutinized. A key initial decision is whether the person can benefit from rehabilitation. Figure 11-1 summarizes the process of rehabilitation decision making. This information and figure are taken from the Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines, Post-Stroke Rehabilitation (1995), but they are applicable to all initial and subsequent transitional rehabilitation decisions.5
resources. In this complex health care environment, utilization of health care and cost are scrutinized. A key initial decision is whether the person can benefit from rehabilitation. Figure 11-1 summarizes the process of rehabilitation decision making. This information and figure are taken from the Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines, Post-Stroke Rehabilitation (1995), but they are applicable to all initial and subsequent transitional rehabilitation decisions.5
 Figure 11-1 ▪ Framework for rehabilitation decisions. (Gresham, G. E., Duncan, P. W., Stason, W. B., … Trombley, C. A. (1995). Post-stroke rehabilitation. Clinical practice guideline, No. 16. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. 95-0662. May.) |
Interprofessional Team and Outcomes
Depending on patient needs, several health care disciplines may participate in an interprofessional collaborative model of practice to provide a comprehensive rehabilitation program. The focus of care is patient centered and includes the family or significant other. Each team member works with the patient and family to achieve optimal outcomes as defined by the patient, family, and health team. Although all patients will not require the services of every discipline, they are available for consultation as necessary.
The rehabilitation process begins with a comprehensive functional assessment. The functional independence measure (FIM) is the most widely used standardized instrument to measure severity of disability based on a functional assessment. The FIM assesses self-care, sphincter control, transfers, locomotion, communication, and social cognition. In addition, each health care team member can further assess the patient using other instruments specific to the particular discipline.
After a database has been compiled, a comprehensive rehabilitation plan is developed with identified functional outcome goals and measures. Team member communications is vital to achieving well-coordinated and timely care. Team conferences are one example of a formal communication mode. Informal communications between and among team members are ongoing. These interactions reinforce interprofessional collaboration among team members by
promoting continuity of care and moving the plan forward. Because of the complexity of care and the numbers of people involved, it is easy for communications to break down. Therefore, planned, formal, patient-centered conferences are essential for the vitality of the process. Patient outcomes are measured using the FIM, Barthel Index, and other specific instruments.
promoting continuity of care and moving the plan forward. Because of the complexity of care and the numbers of people involved, it is easy for communications to break down. Therefore, planned, formal, patient-centered conferences are essential for the vitality of the process. Patient outcomes are measured using the FIM, Barthel Index, and other specific instruments.
CHART 11-1 Principles of Learning and Teaching | ||
|---|---|---|
|
ASSESSMENT OF ACTIVITIES OF DAILY LIVING
ADLs are activities performed by an individual focused on self-care and interaction with the environment on a daily basis. A number of instruments are available to measure independence in ADLs. Independence can be measured by the degree of ability a patient has for successful functioning at home, at work, and in social situations.
ADLs can be divided into two main groups.6
Basic or personal ADLs (BADLs or PADLs): these are activities focused on self-care. They include bathing/showering, bowel and bladder management, dressing, eating (ability to chew and swallow), feeding (process of bringing food/drink to the mouth for consumption) functional mobility personal device care (e.g., hearing aids, glasses), personal hygiene and grooming, sexual activity, sleep/rest, and toilet hygiene. The ability to perform these activities vastly contributes to independent self-care.
Instrumental ADLs (IADLs): these are activities focused on interaction with the environment. These are activities that can be performed by another person on behalf of the individual if necessary. These activities include caring for others including pets, child rearing, communication device use, community mobility, financial management and maintenance, home establishment and management, meal preparation and cleanup, safety procedures and emergency responses, and shopping. Independence in these activities is a key marker for independence outside the home.
Other important areas of life are education, work, play, leisure, and social participation. The skills required to engage in these areas of life are also assessed by the occupational therapist (OT), family counselor, and/or vocational counselor.6 Helping the patient relearn ADLs begins with an assessment of the skills that remain intact, those that are lost, and those that can be used with help. The major barriers to relearning ADL skills in patients with neurological disorders are deficits affecting perception, motor activity, communication, vision, and cognitive functions.
A teaching plan is developed based on the individual patient needs and the principles of learning and teaching. For example, an OT helps in making suggestions for teaching the patient ADLs such as self-feeding. If the patient is being seen by the OT, the nurse coordinates nursing activities with those of the OT so that the patient is given the same instructions by both providers; this prevents confusion and frustration.
Each activity that must be relearned is analyzed to identify the critical components involved in the overall task. Use of adaptive devices may be necessary to compensate for neurological deficits and to allow the patient to perform ADLs independently. Simple remedies may provide great self-care benefits. For example, a spoon with a bulky stem may allow the patient with hand contractures to grasp the spoon and feed himself or herself, an unachievable act with a regular spoon. Chart 11-1 details the principles of learning and teaching. The information in Chart 11-2 applies specifically to patients with cerebral injury.
PRINCIPLES OF REHABILITATION NURSING
Principles of rehabilitation are an integral component of independent nursing practice and include the major elements of prevention, maintenance, and restoration. Many nursing protocols and procedures contain elements of all three components. Preventive measures include special skin care, proper positioning and realignment, frequent turning, and range-of-motion (ROM) exercises. The maintenance of intact skills and functions is supported by activities such as getting the patient out of bed to a chair and
encouraging the patient to be as independent as possible in ADLs. Instituting exercise programs designed to increase ROM, teaching ADLs to a patient with a paralyzed limb, and helping a patient to relearn names of common objects are examples of restorative nursing activities. This framework can be kept in mind when planning and administering nursing care to address particular deficits.
encouraging the patient to be as independent as possible in ADLs. Instituting exercise programs designed to increase ROM, teaching ADLs to a patient with a paralyzed limb, and helping a patient to relearn names of common objects are examples of restorative nursing activities. This framework can be kept in mind when planning and administering nursing care to address particular deficits.
CHART 11-2 Teaching the Patient with Cerebral Injury | ||
|---|---|---|
|
A fundamental concept of rehabilitation is to do with the patient and not do for or to the patient. According to the American Nurses Association and the Association of Rehabilitation Nurses, the goal of rehabilitation nursing is to assist people who have disability and chronic illness to attain maximum functional ability, maintain optimal health, and adapt to an altered lifestyle.7 Rehabilitation nurses assist patients to identify goals that are realistic and attainable and consider the patient’s continuing accountability for optimal wellness. After a skill has been mastered, it is expected to be maintained, and also to become a building block for the next functional level. A patient is assisted to do any part of a task even if it is not the complete task. For example, the nurse may soap and squeeze a washcloth, and the patient may be able to wash one side of the face with this assistance. This begins the cycle to develop complete skill in the future. Unlike other aspects of nursing, rehabilitation is often a very slow process requiring ongoing perseverance and effort. The long-lasting reward is that a human being has been helped to achieve maximal potential.
Rehabilitation is a collaborative interdisciplinary process involving health care professionals working together to achieve mutual goals. As the member of the rehabilitation team who spends the most time with the patient on a daily basis, the nurse supports continuity of care through coordination. The nurse coordinates and manipulates the patient’s daily schedule so that optimal benefit will be derived from therapy. For example, the patient needs a high energy level for the strenuous activity of mat work or ambulation in physical therapy. Scheduling these activities when the patient is fatigued is counterproductive to the goals of physical therapy. The nurse also assesses and addresses the patient’s physical, emotional, and psychological responses to various therapeutic regimens.
The family often approaches the nurse with questions and concerns about the overall plan of care. In some instances, information and clarification are provided. In other instances, referral of questions to other team members for a one-on-one basis or initiation of a family-team meeting is most appropriate. Keeping the lines of communication open is a tedious and difficult job that is compounded by the large number of people involved in the patient’s care. The nurse often becomes the clearinghouse for information, concerns, and confrontations.
Patient and family education is key to optimal recovery. Community resources are available through various agencies such as the American Stroke Association. Stroke rehabilitation information can be accessed by telephone or website. The patient and family need to be aware of these resources; they may need assistance in making contact.
Nursing Management of Patients with Impaired Physical Mobility
Assessment
The nurse assesses mobility by conducting a motor function examination and reviewing the data from the FIM. Independence is closely correlated to a person’s ability to move individual body parts or the body as a whole. Loss of mobility imposes severe constraints on the individual’s freedom and independence.
Nursing management depends on identifying patient and collaborative problems. The following are possible patient problems and nursing diagnoses.
Impaired physical mobility
Risk for injury (from falls)
Risk for altered skin integrity
Fatigue
Activity intolerance
Depression
The following are possible collaborative problems, although many more preventive focused problems can be cited.
Pathologic fractures
Joint dislocation
Falls
The major patient problem of Impaired Physical Mobility is exemplified by a patient with limited physical movement including bed mobility, transfers, and ambulation. When considering altered mobility, interventions directed at preventing edema of the extremities, skin breakdown, contractures, subluxation, deconditioning of muscles, pneumonia, and deep vein thrombosis are common collaborative problems in which the nurse plays an important role.
Patients with concurrent cerebral injury and impaired physical mobility may not have sufficient cognitive ability to fully comprehend the extent and implications of their disability or the relationship of prescribed treatment to the maintenance, prevention, and restoration of functional loss. They will need direct supervision. They are at high risk for injury due to falls.
Fatigue and Activity Intolerance are related to bed rest deconditioning. Endurance for activity must be developed. As a rule, one day for every day in bed is necessary to build endurance; in elderly patients, it is longer. The nurse deals with these patient problems to help the patient achieve an optimal level of independence.
Interventions
As a member of the multidisciplinary team, the nurse works collaboratively with other team members to assist the patient to regain function. The philosophy of rehabilitation nursing is an integral part of care. The specifics of care depend on the patient’s functional deficits and needs as well as expected outcomes.
THE BASIS OF MOVEMENT AND TREATMENT OF MOVEMENT DISORDERS
Normal movement patterns originate in genetically programmed configurations of neurons. Maturation of the central nervous system follows a predetermined pattern of elaboration and refinement of movement. Reflex and voluntary control proceeds in cephalic to caudal and proximal to distal directions. For example, voluntary head movement is learned before voluntary trunk movement. Most motor systems are modifiable within limits, thus providing the basis for developing acquired motor skills.
The maturation and concurrent development of movement and posture follow a deliberate pattern for learning skilled acts. Mobility develops from synchronized co-activated flexor and extensor muscles that provide the stabilizing forces for posture. Hand and finger control develops from visually directed grasping and releasing of objects. Understanding the underlying physiology and pathophysiology of movement patterns is the basis of treatment.
Neurophysiological and Developmental Treatment Approaches
There are at least five recognized rehabilitation treatment approaches for people with motor control deficits related to cerebral injury: the Rood approach; the Bobath neurodevelopmental treatment (NDT) approach; the Brunnstrom (Movement Therapy) approach; proprioceptive neuromuscular facilitation (PNF); and Carr and Shepard motor relearning. Because the Bobath NDT approach is used by many nurses, it is discussed here in greater detail.
Bobath Neurodevelopmental Treatment Approach
The Bobath NDT approach is used primarily for patients with hemiplegia caused by stroke, brain injury, and cerebral palsy. The major goal is normalization of muscle tone, inhibition of primitive reflexes, and facilitation of normal postural reactions. Underlying premises include the following.7, 8, 9, 10
The sensation of movement is learned and not the movement itself.
Every skilled activity takes place against a backdrop of basic patterns of postural control, righting, equilibrium, and other protective reactions.
When cerebral injury occurs, abnormal patterns of posture and movement develops that interfere with the performance of ADLs.
Abnormal patterns develop because sensation is diverted into the abnormal patterns; this diversion must be stopped to reinstitute control over the motor output in developmental sequence.
Eliciting the basic patterns of postural control, righting, and equilibrium is necessary, thus providing the normal stimuli while inhibiting abnormal patterns.
People are allowed to feel, and thus relearn, normal movement patterns and postures.
Nurses can incorporate major principles of treatment into positioning, turning, transferring, and ADLs. These principles include the following.7
Reintegration of function of the two sides of the body is emphasized during movement, ADLs, and bed or chair positioning so that bilateral segmental movement will occur.
Proximal to distal positioning is recommended (tone in the limbs can be reduced from proximal points, such as the head, shoulder, or pelvic girdle).
Weight bearing is provided on the affected side to normalize tone. This includes its role in sitting, lying, or rising.
Tasks should begin from a symmetric midline position with equal weight bearing on the affected and unaffected sides.
Movement toward the affected side is encouraged.
Straightening of the trunk and neck is encouraged to promote symmetry and normalization of tone and posture.
Patients with hemiplegia should be positioned in opposition to the spastic patterns of flexion and adduction in the upper extremity and extension in the lower extremity.
Positioning
Positioning the patient in proper body alignment is necessary to prevent development of musculoskeletal deformities, such as contracture and ankylosis; pressure ulcers; and decreased vascular supply, thrombosis, and edema. Positioning of the patient with a neurological disorder may be complicated by nuchal rigidity, spasticity, abnormal posturing (e.g., decerebration), presence of a cast, position restriction secondary to surgery, and lacerations or abrasions associated with multiple trauma. These specific problems encountered in positioning change as the muscles undergo the various phases of recovery (Table 11-1).
A few basic principles are guides for positioning the patient in bed.11
The unconscious patient should be repositioned every few (e.g., 2 hours) hours around the clock. As consciousness is regained, independent movement in bed and participation in self-care activities are encouraged to maintain muscle strength and tone. Proper positioning should be taught to the patient if he or she has the cognitive ability to participate.
TABLE 11-1 PATTERNS OF MUSCLE RECOVERY IN HEMIPLEGIA
STAGE
NAME
ONSET
DESCRIPTION
I
Flaccidity
From the time of injury to 2 or 3 days after
No tendon reflexes or resistance to passive movement
II
Spasticity (late onset of spasticity indicates a poorer prognosis)
2 days-5 wks
Hyperactive tendon reflexes and exaggerated response to minimal stimuli
III
Synergy (flexion, then extension)
2-3 wks
Simultaneous flexion of muscle groups in response to flexion of a single muscle (e.g., an attempt to flex the elbow results in contraction of the fingers, elbow, and shoulder)
IV
Near normal, possible weakness, or slight incoordination may still be present (late return of tendon reflexes indicates a poor prognosis)
1 wk-6 mos
Control of voluntary movement; recovery occurs predictably from the proximal muscles of the extremity to the distal muscles (i.e., voluntary movement of the hand and foot is last to recover and tends to be weaker)
If spasticity is present, frequent repositioning is necessary. Splinting and casting to inhibit tone may be ordered and applied by a physical therapist (PT).
Any restrictions of position are posted conspicuously at the head of the patient’s bed and included in the nursing care plan (paper or electronic site).
A sufficient number of pillows are available to maintain body alignment.
Trochanter rolls and other positioning devices are useful.
If an arm is weak or paralyzed, the shoulder is positioned to approximate the joint space in the glenoid cavity. The affected arm should not be pulled. A pillow or small wedge in the axillary region helps prevent adduction of the shoulder.
Special resting hand splints may be ordered by the OT to prevent contracture. These should be removed periodically to assess the skin for pressure ulcers.
Edema of the extremities, particularly of the hands, is controlled by positioning and elevating the hand higher than the elbow.
An elastic glove may be ordered by the OT to control hand edema.
Prevention of footdrop is critical. Foot positioning devices, such as high-top sneakers or special splints, may be ordered by the PT.
Heels are kept off the bed to prevent pressure ulcers from developing. A pillow placed crosswise to elevate the lower legs or heel guards may be applied. (In many instances, the patient will already be wearing elastic stockings and air boots.)
Supine Position
The supine position is commonly utilized in the hospital setting. This position allows for optimal interaction with the patient’s environment. The patient can be positioned flat in supine or with some degree of elevation of the head of the bed into a semi-reclined position. There are a few important guidelines to remember when positioning a patient in supine.
The head should be supported in a neutral position through use of pillows or a soft collar or brace. This is especially important with patients with poor head control.
The upper extremities should also be supported with pillows. For patients with hemiplegia, the affected extremity should be positioned in a manner that the shoulder is supported with joint approximation to prevent subluxation.
Towel rolls can be utilized along the outer aspect of the thighs to keep the hips in neutral rotation.
The lower extremities should be supported under the knees and lower legs. Positioning a pillow under the lower legs elevates the heels off the bed to prevent pressure ulcers.
Side-Lying Position
An unconscious patient, or one with a diminished or absent swallowing or gag reflex, is not positioned supine because of the possible aspiration of secretions or occlusion of the airway by the tongue. Therefore, positioning in the true supine position is reserved only for the conscious patient. The side-lying position with the head of the bed elevated 10 to 30 degrees facilitates drainage of secretions from the mouth. The head should be placed in a neutral position. A soft collar or towel roll is useful to maintain the neutral position and prevent hyperflexion, which can partially obstruct the airway and impede venous drainage from the brain. Proper body alignment is maintained through the use of pillows and positioners. With a patient on long-term bed rest, a modified position halfway between the supine and side-lying position may be necessary to relieve pressure on body surfaces. This patient can be positioned in good body alignment with the head turned slightly to facilitate drainage of oral secretions and to maintain a patent airway.
Exercise Programs
Voluntary muscles will lose tone and strength if they are not used. Patients with neurological deficits involving paresis and paralysis and those confined to prolonged bed rest are subject to these deleterious muscle effects of immobility (Table 11-2). Because the flexor and adductor muscles are stronger than the extensors and abductors, contractures of the flexor and adductor muscles will develop quickly if preventive measures are not instituted. An exercise program is followed aggressively to maintain muscle tone and function, prevent additional disability, and aid in the restoration of motor function.
ROM exercises include the full range of movement that each joint of the body can normally perform. A patient who cannot carry out independent ROM exercises should be assisted by the nurse. After radiographic studies rule out fractures and the presence of other medical problems or medical treatments or contraindications are verified, ROM exercises begin. Exercises can be classified into the following categories.
Passive: ROM is provided to a body joint by another person or outside force.
TABLE 11-2 EFFECTS OF IMMOBILIZATION ON THE MUSCULOSKELETAL SYSTEM
STRUCTURE
INITIAL CHANGES
ADVANCED CHANGES
Bones
Skeletal malalignment
Decreased bone mineral density
Skeletal deformities
Generalized osteoporosis
Fractures
Joints
Joint stiffness
Changes in periarticular and cartilaginous joint
Osteoarthritis structure
Fibrotic changes of ligaments and tendons
Shortening or stretching of ligaments
Decreased range of motion
Ankylosis
Contractures
Muscles
Decreased muscle mass
Decreased muscle strength
Muscle shortening
Muscle atrophy
Active: voluntary ROM to a body joint is independently executed by the individual.
Active assistive: ROM to a body joint is accomplished by the patient with the assistance of another person.
Active resistive: ROM is voluntarily provided to a body joint against resistance.
Isometric or muscle setting: exercises are accomplished by alternately tightening and relaxing the muscle without joint movement.
The exercise program prescribed depends on the stage of illness and the particular disabilities. In the acute stages of illness, a PT comes to the bedside once or twice daily to administer specific exercises. If only ROM exercises are prescribed, nurses will be the care provider administering these exercises. After the patient’s condition improves, he or she is taken to the physical medicine department where equipment is available for a more sophisticated, aggressive rehabilitation program. The nurse can reinforce and integrate the skills gained into other aspects of care. In addition, the patient’s family is taught how to carry out the prescribed exercises.
Passive Range-of-Motion Exercises
When passive ROM exercises are administered, two factors are considered: the joint being exercised and the placement of the caregiver’s hands when administering the exercise properly. One hand is placed above the joint to provide support against gravity and any unwanted movement. The other hand gently moves the joint through its normal ROM.
Passive ROM exercises are usually administered at least four times daily and may be incorporated, in part, with other procedures, such as bathing or repositioning.
Choose a time when the patient is rested, comfortable, and pain free for optimal cooperation.
Explain the procedure, even if the patient is apparently unconscious.
Position in proper body alignment, and drape, as necessary, to avoid undue exposure. Drawing the curtains offers privacy and excludes environmental stimuli in the instance of an easily distracted patient.
Provide a comfortable room temperature to prevent chilling, shivering, and unwanted muscle contractions.
Maintain good posture to ensure efficient body movement; face the patient to observe facial reaction to the exercises.
Movements are slow, smooth, and rhythmical.
Move the body part to the point of resistance and stop.
Move the body part to the point of pain and stop.
If the patient becomes excessively fatigued, discontinue the exercises.
Although the PT may move a body part beyond the point of pain or resistance for selected patients, this is not within the scope of nursing practice and is avoided unless specifically prescribed. As the patient’s condition improves, self-care is encouraged for as many activities as possible. Because return of motor function is a slow process, the patient is encouraged to carry out the exercises and be reminded of the need to continue with these activities as part of the rehabilitation program.
Other Exercises
Specific exercises, such as lifting hand weights, may be ordered to strengthen a weakened arm. Encourage the patient to engage in these activities. Be sure that the necessary equipment is present. Adapt activities to provide movement for specific muscle groups. For example, providing a ball of yarn for a female patient who enjoys knitting can improve motor function of a weakened hand while providing sensory stimulation.
Balancing and Sitting Activities
After the patient’s condition has stabilized and ROM exercises have begun, the next skills to acquire are balancing and sitting. Deconditioning develops rapidly. Patients who have been confined to bed for a long period of time will progress more slowly. The head of the bed is raised gradually over a period of days to overcome orthostatic hypotension. Monitor the physiologic response by assessing the blood pressure, pulse, and skin color and asking the patient whether he or she is experiencing dizziness or lightheadedness. Record baseline signs and symptoms. After the head of the bed is raised the prescribed number of degrees, again assess for a drop in blood pressure; a thready, rapid pulse; paleness; diaphoresis; dizziness; or lightheadedness. If these signs quickly reverse, no action is necessary. Sustained symptoms require lowering the head of the bed slightly until symptoms subside. Although many neurological patients are placed at a 30-degree angle while confined to bed, they will still need a period of adaptation to tolerate the vertical position. For those maintained in a flat position or at a 10-degree angle, the adjustment will take longer.
For patients with paraplegia or quadriplegia, orthostatic hypotension can be a stubborn problem to manage, because extensive vasomotor paralysis results in a subsequent drop in blood pressure when the vertical position is assumed. Wearing an abdominal binder or thigh-high elastic stockings and elevating the leg rests of the wheelchair help to combat hypotension. These patients, particularly patients with quadriplegia, may require a special PT program in which a tilt table is used to raise the patient gradually over several days.
Balancing. Balancing, the ability to sit or stand erect, is achieved through consciously using both sides of the body, focusing on the symmetric midline point, and using support devices that help to steady the center of gravity. Use of a back or neck brace for a spinal
cord injury patient can make the difference between success and failure. The patient with hemiplegia is placed in the sitting position and instructed to support himself or herself with the unaffected arm and hand. The hand is placed flat on the bed slightly behind or at the side as a means of support. The affected arm and hand should also be placed in a weight-bearing position with or without the external support of the therapist or a brace such as an air splint. Weight bearing in the affected extremity can provide the sensory-motor feedback necessary to help normalize tone. Because there is a tendency to slouch to the affected side, the patient is reminded to sit straight and erect, focused on a balanced midline. Some conscious patients who have difficulty balancing while sitting in bed do well when they are helped to sit at the side of the bed or in a chair with their feet flat on the floor.
cord injury patient can make the difference between success and failure. The patient with hemiplegia is placed in the sitting position and instructed to support himself or herself with the unaffected arm and hand. The hand is placed flat on the bed slightly behind or at the side as a means of support. The affected arm and hand should also be placed in a weight-bearing position with or without the external support of the therapist or a brace such as an air splint. Weight bearing in the affected extremity can provide the sensory-motor feedback necessary to help normalize tone. Because there is a tendency to slouch to the affected side, the patient is reminded to sit straight and erect, focused on a balanced midline. Some conscious patients who have difficulty balancing while sitting in bed do well when they are helped to sit at the side of the bed or in a chair with their feet flat on the floor.
In unconscious patients, the same process for overcoming orthostatic hypotension is used; however, information regarding the adjustment of these patients is derived from objective signs. Ability to balance is not possible until the level of consciousness improves; however, the patient can be propped to the required position. Conditioning reflexes can be maintained by simply sitting in a chair for 1 to 2 hours.12
After balance in the sitting position has been mastered, the patient is ready to begin balancing in the standing position at the bedside.
Sitting. Both conscious and unconscious patients can sit in a chair, although the unconscious patient is not positioned in the sitting position on the side of the bed for obvious safety concerns. The conscious patient may sit on the side of the bed, using the overbed table and pillows for support. The chair selected should provide firm support and have a high back and arms, especially if the patient has motor weakness or paralysis. For the weak, debilitated patient who cannot hold up the head or neck, a high-back chair that extends to the top of the head is most effective. If the patient has a neck brace, it should be applied for sitting.
A lapboard, pillows, and the overbed table, rolled down to a comfortable height, are helpful for providing added support while positioning a patient in a chair. Pillows or rolls support the arms in the desired position. The feet are positioned flat on the floor. The pressure on the bottom of the feet assists in stretching the heel cord. Footdrop may develop if stretching of the heel cord is not provided. The head is positioned carefully so that the airway or tracheostomy (if present) is not obstructed. Any equipment that is in place, such as a urinary catheter or feeding tube, is checked to ensure patency and freedom from traction.
If the patient has some intact motor function, necessary equipment is placed nearby, possibly on an overbed table that has been lowered and placed in front of the patient’s chair. The call bell should be accessible to the patient. Observe the patient to monitor tolerance of the activity. Do not allow the patient to become overtired. It is best to plan a schedule that allows for periods of bed rest and out-of-bed activity based on an individual patient’s tolerance and fatigue.
Mobility: Transfer and Ambulation
When considering a patient’s mobility, the type(s) of transfer used reflect(s) a continuum from complete dependency to complete independence. For a completely dependent patient two options are possible for transfers.
Two-person lift: physical transfer by at least two nursing staff members; no active patient participation
Mechanical lift: transfer using a lifting device that is operated by nursing staff members; no active patient participation
After the patient is able to balance and sit, he or she is ready for transfer activities.
The patient, with assistance from one or more nursing staff members, stands and pivots on the unaffected leg; moderate patient participation is required. A transfer belt is worn around the patient’s waist to allow the nurse to grasp it to support the patient. Inspect the transfer belt to be sure it is not worn or defective.
With the assistance of a slide board, the patient is able to transfer from the bed to the chair with or without assistance. Sliding board transfers are typically for patients with lower extremity weight-bearing restrictions or inability to bear weight through the lower extremities as with patients with paraplegia or quadriplegia.
Independent transfer is the patient’s ability to transfer without assistance.
The degree of assistance necessary for transfer and ambulating is classified as follows.13
Independent: patient does not require any supervision or physical assistance to safely perform the activity.
Modified independent: patient does not require any supervision or physical assistance to safely perform the activity, but the task has been modified or increased time is given to complete the task. Use of an assistive device classifies a patient as modified independent.
Supervision or standby assistance: patient requires supervision, verbal cuing or setup of items required to complete the task.
Physical assistance is not required.
Contact guard assistance: patient is able to complete the task with an assistant close by with hands on the patient or transfer belt for protection if the patient should experience loss of balance.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
