Rehabilitation and Restorative services

INTRODUCTION TO REHABILITATION AND RESTORATIVE CARERehabilitation and restorative care are provided to improve and maintain the patients physical abilities. This may include mobility skills (Figure 1) and the ability to carry out activities of daily living (ADLs). Activities of daily living are the tasks that we learn as children and do throughout life. These tasks include bathing, oral care, hair and nail care, dressing and undressing, eating, toileting, and mobility. Being independent with daily care promotespositive self-esteem.Figure 1Rehabilitation is a process in which the person is assisted to reach an optimal level of physical, mental, and emotional health. Rehabilitation and restorative care are similar,but there are some differences. http://www.youtube.com/watch?v=deB3Zx_NEG8

How Rehabilitation and Restorative Nursing are Alike

Assists patient to attain optimum level of physical, mental, and psychosocial function in light of condition Considers how one weak area of function can affect the whole person Helps patient adapt to limitations imposed by illnessor injury Helps patient regain lost skills or learn a new way of doing skills lost because of illness or injury Requires physician orderTABLE 1 COMPARISON OF REHABILITATION AND RESTORATIVE NURSING

Rehabilitation Restorative NursingAggressive and Slower paceIntensive

Scheduled 14 hours Not scheduled, given 24 hoursa day, 7 days a week a day, whenever needed

A separate and Approaches integrated intodistinct service regular nursing care

Goal is to improve Goal is to maintain; improvement is desirable, but not required

Patient makes rapid, Patient may or may notsignificant progress progress, but does not decline

Planned and Planned and implemented byimplemented by nursingtherapists

Must have potential May participate even if nofor improvement potential for improvement

Provided in any Required in long-term care;setting, but not usually provided in homerequired health care, long-term care facilities, subacute care, and long-term acute care hospitals

Licensed personnel Licensed and unlicensedprovide most personnel provide services;services unlicensed personnel are primary caregivers

Paid by Medicare, Inconsistently paid byMedicaid, private Medicare and Medicaid inInsurance some situations; usually not paid by private insurance Requires initial evaluation and periodic re-evaluation Must be verified by documentation Documentation must be measurable Safety an important factor Patient teaching is part of program; staff and family teaching may also be done May use services of others outside the department Assists with activities of daily living Works toward goals Patient benefits from service Provides a necessary service; not given as an activity or to keep the patient occupied Prevents complications Maintains current abilities Improves quality of lifeThe information in this unit applies to both rehabilitation and restorative care. These services complement each other. They do not compete. A restorative program established by the therapist to complement the rehabilitation program reinforces what the therapists are teaching, and the patient masters the skill more quickly. When you follow the program developed by the licensed nurse, you are helping the atient master skills for which nursing is responsible, suchas bowel and bladder management. Regardless of whether the service is planned and provided by therapy or nursing, it is a functional service for the patient. For example: The speech therapist works with a patient who is recovering from a stroke to communicate the need for basic services that are essential to daily life, such as hunger, thirst, pain, and elimination. The therapist would not work with the patient to teach words that the patient is not likely to use, such as aardvark or kumquat. The physical therapist works with a patient who recently had a hip replacement to relearn safe ambulation. On the nursing unit, personnel follow a safe ambulation program to complement rehabilitation rather than applying restraints to prevent falls. A restorative nursing program may establish a goal for a patient to walk 150 feet with a walker, gait belt, and one assistant. The purpose of the program is to walk to the dining room, which is 150 feet from the patients room. The patient would not walk back and forth in the hallway until the 150-foot goal is reached. As you can see, both rehabilitation and restorative nursing work with functional skills that the patient needs each day. This process is called restoration.REASONS FOR -REHABILITATION/RESTORATIVE CAREA person may need rehabilitation because of a disability. A disability exists when the person has an impairment that affects the ability to perform an activity that a person of that age would normally be able to do. Adults, for example, are able to dress and undress independently. If a person is unable to do this because of a disease or injury, a disability exists. A disability may be temporary or permanent. Impairments or disabilities result from trauma or disease. Disorders of the musculoskeletal system, such as amputation (Figure 2) of an extremity or arthritis, may require rehabilitation.

figure 2A handicap exists if the disability limits or prevents the person from fulfilling a role that is normal for that person. This might include such functions as holding a job, managinga household, and raising a family. If a disability is permanent, such as tetraplegia (paralysisfrom the neck down) from a spinal cord injury, it is unrealistic to expect that rehabilitation will enable the patient to walk again. In these situations, the goals will be to teach the patient to: Adapt to the present circumstances. Use adaptive devices to increase independence. Learn new ways of doing routine tasks, such as dressing or bathing. Become as independent as possible in light of the disability. Patients with severely limiting conditions, such as tetraplegia, are taught to assume responsibility for personal well-being, including verbally directing caregivers to accomplish the results the patient wants.THE INTERDISCIPLINARY -HEALTH CARE TEAMPhysicians who specialize in rehabilitation are called physiatrists. Nurses and nursing assistants who work in rehabilitation receive specialized education. Many other disciplines may be involved in the rehabilitation process. For instance, a person who has had a stroke may receive: Physical therapy to learn how to walk again Occupational therapy to relearn the activities of daily living Speech therapy to learn new communication or swallowing methods Nursing services for bowel and bladder management, prevention of pressure ulcers, and other complications Dietitian services to help the patient learn to manage new dietary restrictions for a low-sodium diet (to reduce blood pressure), and to plan and prepare meals Psychological support to adapt to the sudden changes brought about by the stroke Social services to plan for the impending discharge http://www.youtube.com/watch?v=sKygX-BbiLs

All disciplines work together with the patient and family to solve problems and plan care. There are many subspecialties in rehabilitation. Health care professionals may choose to work in geriatric (care of the elderly) or pediatric rehabilitation. Others may specialize in the care of patients with strokes, spinal cord injuries, brain injuries, amputations, burns, or arthritis.http://www.youtube.com/watch?v=vU0jJoo05vI

THE ROLE OF THE NURSING ASSISTANTThe nursing assistant who works in the rehabilitation and restorative nursing unit will assist the nurses with: Procedures to prevent complications Mobility skills (transfers and ambulation) Bathing and personal care procedures Bowel and bladder management programs Maintaining the patients nutritional status Programs to increase the patients independence

PRINCIPLES OF REHABILITATION

Four principles form the foundation of successful rehabilitation or restorative care.1. Treatment begins as soon as possible.This means that services begin as soon as the patients condition is stable. For example, if a patient has had a stroke, passive exercises and positioning techniques are initiated in the critical care unit to prevent contractures, pressure ulcers, and other complications that would prohibit or delay rehabilitation.2. Stress the persons ability, not the disability. Workers must think in terms of what the patient can do, not what he or she cannot do. The patients strengths are used to help in adapting to limitations. A strength refers to anything the patient can do. Perhaps a patient whose dominant hand is paralyzed cannot use that hand to feed himselfbut instead of having nursing staff feed him, he can be taught to use the other, stronger hand. Use the restorative philosophy when communicating with patients. Avoid statements such as, You cant use your right hand. Instead, say, You can use your left hand. Allow the patient to struggle a little, but avoid letting him progress to the point of frustration before you step in to assist.3. Activity strengthens and inactivity weakens. Complications result from physical and mentalinactivity. These can cause further disability or even be life-threatening. A rehabilitation or restorative plan of care always includes approaches and goals for physical and mental activity.4. Treat the whole person.When we give care to patients, we are concerned with the whole person (Figure 41-4). We must also work with the patients families. They directly influence the emotional and mental health of the patients. Keys to success in rehabilitation and restorative nursing programs are: Teamwork. All staff cooperate with each other and other departments involved in care of the patient. Use of the care plan. All staff are familiar with the patients problems, goals, and approaches. Consistency of care. All staff use the same approaches (as listed on the care plan) when caring for the patient. Continuity of care. There is a smooth progression and flow between caregivers and between shifts. Good communication among all caregivers, the patient, and interested family members.COMPLICATIONS FROM INACTIVITYPeople with disabilities may be unable to move about at will. The inactivity or immobility can result in numerous complications affecting body systems, as shown in Table 2.

TABLE 2 COMPLICATIONS OF IMMOBILITY

System Complication

IntegumentaryPressure ulcers may develop in a short time from lack of oxygen to the tissues. Pressure ulcers may worsen quickly and be dif ficult or impossible to reverse.

MuscularWeakness and atrophy from lack of use. Contractures develop because of the patients position, freezing the muscle in a permanent state of flexion. Contractures arepainful and difficult or impossible to reverse.

SkeletalCalcium drains from the bones when they are inactive. This contributes to fractures, lack ofhealing, osteoporosis, and other complications.

RespiratoryFluid and secretions collect in the lungs. The patient has more difficulty expanding the lungs,increasing the risk of pneumonia and other lung infections.

CirculatoryBlood clots caused by pooling of blood and pressure on the legs . Edema may be caused by lack of movement. The heart must work har der to pump blood through thebody. Changes in the blood vessels may cause dizziness and fainting when the patient isplaced in the upright position.

GenitourinaryThe extra calcium in the system from the bones promotes the development of kidney stones.Retention of urine is common, and is often caused by the patients position in bed. Overflowof a full bladder leads to incontinence. The patient is at high risk of urinary tract infection.

GastrointestinalIndigestion and heartburn may result if the patient is not positioned properly for meals. Lossof appetite may occur from lack of activity, illness, and boredom. Constipation and fecalimpaction result from immobility.

NervousWeakness and limited mobility. Insomnia may result from sleeping too much during the day,then being unable to sleep at night.

Mental changesIrritability, boredom, lethargy, and depression result from the patients frustration andfeelings of helplessness. Lack of social contact and sensory stimulation result in disorientation .

ACTIVITIES OF DAILY LIVINGOne purpose of restorative care is to increase the persons physical abilities. Healthy adults do ADLs automatically. If a person cannot complete any or all of the ADLs, a self-care deficit exists. Deficits are caused by problems that limit the ability to do self-care, such as decreased strength, lack of endurance, or disorientation. Patients with self-care deficits are evaluated by therapists and nurses. The results of the evaluations will determine whether the patients functional (physical) abilities can be increased. In other words, can the interdisciplinary team help this patient to relearn an activity of daily living? This is discussed with the patient and the family.

FIGURE 3

Restorative ProgramsIf the patient has the potential to relearn an ADL and is motivated to try, a restorative program is planned. These programs are sometimes called retraining programs or ADL programs.

Approaches Used in Restorative ProgramsThe approaches to use will be listed on the care plan. It is important that the same approach be used consistently. Setup. Patients with self-care deficits are not able to set up or prepare for activities of daily living. You may need to provide the setup (Figure 4). Verbal cues. The care provider uses short, simple phrases to prompt the patient. Example: Give the patient a prepared washcloth and then say, Please wash your face (Figure 5). Hand-over-hand techniques. Example for eating program: Place a glass in the patients hand. Place your hand over the patients hand. Guide the glass to the patients mouth(Figure 6). Demonstration. Act out what you want the patient to do. Example: Before giving the patient a toothbrush, make the motions of brushing your teeth with the toothbrush

Adaptive DevicesAdaptive devices are sometimes used to simplify an ADL. Adaptive devices are ordinary items that have been modified for use by patients with various types of problems. A person with a disability may be unable to perform certainADLs. Adding a device that changes the way the task is done may enable the person to perform it independently.The person is taught to use the device for everyday tasks

FIGURE 4 This patient is able to feed herself if thenursing assistant sets up the tray

FIGURE 5 The nursing assistant uses verbal cues toassist the patient with ADLs.

(Figure 6). Your role as a nursing assistant is to makesure the device is clean, available, and used by the patient.You may need to work on the skill with the patient whileshe is learning to use the device. The care plan will provideinstructions on the types of devices the patient uses.

Adaptive devices for eating The most common adaptive devices are used to enable patients to feed themselves. Many individual devices are available to meet patients needs. The most common devices are adaptive silverware (Figures 7A and 7B), plates and plateguards (Figure 7C), and cups (Figure 7D). Other items, such as a straw holder (Figure 7E), may also be necessary.

Adaptive devices for dressing Dressing aids are also commonly used. These devices make it easier for patients to dress themselves. Using these adaptive devices may appear awkward to you, but being able to dress independently is important to a patients self-esteem.Adaptive devices for grooming and hygieneBeing able to bathe and groom oneself are important skills. Everyone has a personal hygienic routine. Grooming and hygiene are very private activities. Using adaptive devices permits the patient to perform these skills and increases self-esteem and comfort.ABCDEFIGURE 7 A. Many types of adaptive utensils ar e available to meet individual needs and enable patients to feedthemselves. B. The wrist cuf f enables the patient to hold silverwar e and eat independently. C. Adaptive plates and bowlshave raised edges so patients can scoop food easily. D. An adaptive cup. E. The straw holder centers the straw and holdsit in place. http://www.youtube.com/watch?v=69xC7j0HmiMTHE RESTORATIVE ENVIRONMENTAll patients benefit from living in an environment that promotes quality of life. The interdisciplinary team helps promote this environment. Give the patient a sense of control and opportunities to make decisions. Remember that mental and physical activity are essential to well-being. Provide cues for orientation. Create an environment that is safe, serene, and colorful.

Safety ConcernsSafety is a primary concern when there is a loss of function. If a patients condition changes, evaluate his or her awareness. If the level of consciousness or mental status has changed, report to your supervisor. Changes in consciousness and mental status may indicate serious problems. Other important observations that should be reported are: Whether the patient is aware of the change Whether the patient denies that there has been a change Whether the patient asks for assistance when needed The patients desire to remain independent despite the increased safety risk Any falls that you know of Changes in vision Changes in bowel and bladder control The patients ability to ambulate Problems with standing, balance, or coordinationIf you observe any of these changes, notify your supervisor immediately. A licensed health care professional will assess the patient. He or she makes other team members aware of the changes. They will reevaluate the care plan and write new approaches, if necessary. The restorative program will be designed with the changes in mind. The overall goal is keeping the patient safe. If the patient has been on bedrest for a long time, he or she must gradually increase activity. Inactivity and bedrest cause changes in blood pressure and balance. Your supervisorwill develop a schedule to gradually increase the length of time that the patient will be up.

Restorative CareG U I D E L I N E S for Become familiar with the patients condition. Provide restorative care at the usual time of day for the activity. Make sure that the treatment area is ready, equipment is gathered, and the patients physical needs are met before beginning. Follow the instructions on the care plan. Check frequently for changes to the plan. Provide privacy. The patient will make mistakes and become frustrated. Avoid embarrassing the patient in front of others. Eliminate as many distractions as possible. Apply orthotic and prosthetic devices as ordered. These will be listed on the care plan. Orthoticdevices improve function and prevent deformities. Prosthetic devices are replacements for body parts, such as the eye, breast, hand, leg, or foot. Modify the environment to promote independence, if necessary. Practice good body mechanics for yourself and the patient. Practice safety, and teach the patient safety measures. Remember that all ADLs have many steps. If the patient cannot complete one step, he or she will not be able to complete the activity. Treat the patient with dignity. Be positive and encouraging. Stress what the patient can do. Give the patient as much control as possible by allowing him or her to make choices and decisions. Allow enough time for the activity. Be patient and avoid rushing the patient. Work on one step at a time. When the patient masters one step, move to the next. Remember that the patients progress may be inconsistent from one day to the next. Provide frequent, positive feedback during the procedure. Be patient. Provide simple, clear directions. Keep directions as clear and simple as possible. If the patient does not understand, demonstrate. Give verbal cues, whenever necessary , to describe what you want the patient to do. If the patient does not respond to verbal cues, use hand-over-hand technique. Place your hand on top of the patients hand and guide him or her to begin the activity. If the patient does not respond, replace your hand and guide the patient through the activity. Allow the patient to do as much self-care as possible. Show the patient that you are confident in his or her ability. Use adaptive devices, if necessary. If the patient cannot complete an ADL, praise his or her accomplishment. Complete the task without comment or complaint. Report your observations to your supervisor. Notify the proper person if you feel that the patients condition requires evaluation. Document care immediately after providing it. Never document in advance.

MONITORING THE PATIENTS RESPONSE TO CAREYou must observe how the restorative program affects the patient. This is particularly true in the early stages of an illness. The patient may become easily frustrated. Allow the patient to struggle a little. Intervene before the patient reaches the point of frustration. Remind him orher that learning takes time. Practice empathy. Tell the patient you understand how frustrated he or she feels. Be aware of the patients fears. A fear of falling or spilling may prevent the patient from participating in an activity or attempting to do a task. Early in the restorative program, the patient may have an unexpected physical response. You have learned that even a short period of bedrest has a negative effect on the body. Any physical activity may cause a change in the physical condition. Monitor for signs of fatigue. Be alert for changes, and report them to your supervisor. A good practice is to take the patients pulse before beginning, then perform theactivity. Monitor the pulse every five minutes during the activity. Normally, the pulse increases slightly with activity.Assuming the pulse is under 100 during the activity, continue. If the rate is more than 100, or if the patient develops other problems, such as pain, shortness of breath, nausea,or perspiration, stop the activity. If the patient is standing, assist him or her to sit down. Notify your supervisor or a nurse immediately. Pull the call signal, or send someone else to get help. Do not leave the patient alone. After you complete the activity, check the pulse again. It should return to within 10 beats of the resting pulse rate within 5 minutes.

Precautions and Special SituationsPatients with certain conditions require special care and handling. Avoid exercising extremities that have fractures or dislocations. The bones of patients with osteoporosis or bone cancer break easily. Osteoporosis is a condition in which bone mass decreases, leading to fractures with little or no trauma. Check with your supervisor and the care plan before continuing. Notify a nurse if the patient has a wound, red, or open area on the joint you are exercising. Inquire if exercise will be harmful before continuing. If a patient is combative or resists care, explain why it is important. Try to coax him or her into participating. Try singinga song with the patient for distraction. Avoid forcing a patient to accept care. Notify your supervisor if the patient continues to refuse.