Rehabilitation Concepts for Chronic

and Disabling Health Problems

Chronic & Disabling Health Problems
Complications account for majority of deaths
Younger adults living longer with potentially
disabling congenital/genetic disorders
Accidents are leading cause of death among young
and middle-aged adults
Rehabilitation Definition & Goals
Continuous process of learning to live with/manage
chronic and disabling conditions
Helps patients return to best possible physical,
mental, social, vocational, economic state
Returns function in post-traumatic situation
Education/therapy for chronic illnesses
characterized by change in body system, function,
or body structure
Rehabilitation
Needed for chronic and disabling health problems
Continuous process to improve:
Physical state
Mental state
Social state
Vocational state
Economic state
Rehabilitation Team
Physicians
Nurses and nursing assistants
Physical therapists and assistants
Occupational/vocational therapists and assistants
Speech-language pathologists and assistants
Rehabilitation Team (contd)
Rehabilitation assistants/restorative aides
Recreational or activity therapists
Social workers
Spiritual counselors
Cognitive therapists or neuropsychologists
Clinical psychologists
History
Information on patients present condition, current
drug therapy/treatments
General background data
Usual daily schedule
Dietary patterns
Sleep habits
Assessment
History
Cardiovascular and respiratory
Gastrointestinal and nutritional
Renal and urinary
Neurologic and musculoskeletal
Skin
Cardiovascular & Respiratory
Assessment
Assess for decrease in cardiac output
Shortness of breath
Chest pain
Severe weakness and fatigue
Plan care to maximize limited energy resources
Frequent rest periods
Energy levels often higher in the morning
GI & Nutritional Assessment
Assess:
Height and weight
Oral intake
Pattern of eating
Anorexia, dysphagia, nausea/vomiting, or discomfort
Hemoglobin/hematocrit
Serum prealbumin
Blood glucose levels
Constipation most common problem
Renal & Urinary Assessment
Assess:
Baseline urinary patterns
Frequent concerns:
Nocturia
Urinary incontinence or retention
Monitor for UTI:
Urinalysis
Culture and sensitivity
Neurological & Musculoskeletal
Assessment
Assess:
Motor function
Paresis (weakness) or paralysis (absence of movement)
Sensation
Response to touch, temperature and position change
Cognition
Gait patterns
Sensory changes
Visual acuity
ROM and endurance level
Mobility Assistive Devices
Standard Walker Walking with cane
Tripod
Position
Tool for
Assessing
Mobility
Proper Use of Gait Belt
Must be used when
ambulating patient who
is assessed as contact
guard assist (CGA) or
stand by assist (SBA).

When in doubt, always

use gait belt for safety,
both the patients and
yours.
Skin Assessment
Assess skin integrity
Skin assessment tools
Braden Scale

Marks, J. & Miller, J. (2006). Lookingbill and Marks Principles of Dermatology. 4th Ed. St. Louis: Saunders.
Skin Assessment
Actual or potential interruptions in skin integrity
Iatrogenic wound
Fixator wound
Ingrown rope
Ingrown rope
Macerated heel
Heel
Ulcers
Why we tape catheters
Urethral Slit Caused by Tension from Foley
Catheter
Functional Assessment
Ability to perform ADLs
Instrumental activities of daily living (IADLs)
phone use, shopping, preparing food,
housekeeping
Functional independence measure (FIM)
Levels of Function (FIM Score)
Independent another person is not required for the
activity (NO HELPER).
IND or I 7 Complete Independence
Mod I 6 Modified Independence
Dependent Patient requires another person for
either supervision or physical assistance in order to
perform the activity, or it is not performed (REQUIRES
HELPER).
Levels of Function (FIM Score), cont.
Modified Dependence the patient expends half
(50%) or more of the effort.
Supv. 5 Supervision or Set-up (stand by, cueing,
coaxing, etc.)
Min PA 4 Minimal Contact Assistance (75%) or more
of the effort
Mod PA 3 Moderate Contact Assistance (between 50
and 74%) effort
Levels of Function (FIM Score), cont.
Complete Dependence the patient expends less than
half of the effort. Maximal or total assistance is
required.
Max PA 2 Maximal assistance expends 24 to 49%
effort
Total 1 Total assistance expends less than 25% effort.
Psychosocial Assessment
Body image and self-esteem
Use of defense mechanisms
Response to loss
Presence of stress-related physical problems
Availability of support systems
Vocational Assessment
Vocational counselors can help find meaningful
training education or employment after discharge
Job analysis
Job modifications
Americans with Disabilities Act, 1991 Prevents
employer discrimination against disabled people
Workers compensation
Improving Physical Mobility
Transfer techniques
Gait training
Wheelchair mobility skills
ROM techniques
Proper Use of Gait Belt
Must be used when
ambulating patient who
is assessed as contact
guard assist (CGA) or
stand by assist (SBA).
When in doubt, always
use gait belt for safety,
both the patients and
yours.
Transfers from Bed to Wheelchair
Safe Patient Handling Practices

Heavy lifting and dependent transfers by staff

result in very high incidence of work-related
musculoskeletal disorders (MSDs)
Most facilities have policies and procedures
addressing this problem.
Maintaining Skin Integrity
Best intervention frequent position changes with
adequate skin care, sufficient nutritional intake
All patients should be turned/repositioned at least
every 1 to 2 hours
Monitor patients in wheelchairs
Lateral Position
Correct
Position To
Relieve
Pressure
Shear and Friction
Areas
Susceptible to
Pressure Ulcers
Wheelchair
Push-Up
Maintaining Skin Integrity (contd)
Pressure-relieving devices
Specialty beds
Establishing Urinary Continence
Spastic or reflex (upper motor neuron) bladder
incontinence with sudden gushing voids
Flaccid or areflexic (lower motor neuron)
bladderurinary retention and overflow
(dribbling)
Uninhibited bladdersimilar to reflex; neurologic
problem affects brains bladder center in the frontal
lobe
Bladder Retraining
Re-training or re-patterning voiding
Facilitating or triggering techniques (Valsalva, Cred
maneuvers)
Intermittent catheterization
Consistent scheduling of toileting routines
Drug therapy (cholinergics, antispasmodics, skeletal
muscle relaxants)
Fluid intake
Urinary Assessment

Post-void residual assessment (PVR)

Amount of urine remaining in bladder within 20
minutes of voiding
Can use Bladder Scanner to determine volume
Constipation
Reflex (spastic) bowel
Upper motor neuron disease/injury
Defecation occurs suddenly without warning
Flaccid bowel
Lower motor neuron disease/injury
Defecation occurs infrequently and in small amounts
Uninhibited bowel
Brain injury
Frequent defecation
Urgency
Hard stool
Bowel Training
Combination of suppository use, consistent
toileting schedule
Bisacodyl (Dulcolax)
Fluids
Fiber
Bedside commode
Metamucil
Community-Based Care
Home care management
Teaching for self-management
Health care resources
Audience Response System Questions

54
Question 1
Which statement confirms that the patient
understands the rehabilitation treatment goals?

A. With rehabilitation Ill be my old self again.

B. This place will keep me until my nursing home
room is ready.
C. I will work hard to learn to use my left hand to do
everything now.
D. The plan is to see how well I can function with my
new disability before I can go home.
Question 2
The nurse is conducting an interview with a patient who
is experiencing a chronic illness. The patient is reluctant
to discuss his resulting disability. What should the nurse
do?

A. Interview the patients family to obtain needed information.

B. Observe the patient closely for evidence of suicidal thoughts.
C. Assess the patients self-esteem and body image through his
description of self-care.
D. Assume that the patient is experiencing a symptom of
depression.
Question 3
Which nursing intervention is appropriate to assist a
patient to manage overactive bladder incontinence?

A. Establish a toileting routine.

B. Provide a bedside commode.
C. Encourage use of incontinence pads.
D. Instruct unlicensed assistive personnel to check on
the patient every 2 hours.
Question 4
The nurse is assessing a patient who has been newly
admitted to a rehabilitation unit after recovering from a
stroke. The patient reports, when asked, that he usually has
a bowel movement every third day. What should the nurse
do next?

A. The nurse concludes that the patient is constipated.

B. The nurse asks if this pattern is normal for him.
C. The nurse offers him a laxative.
D. The nurse assesses the patients bowel sounds.
Question 5
The nurse is assisting a patient with ambulation. The patient has
general weakness but is able to walk. Which measure will best
prevent potential falls due to orthostatic hypotension?

A. Administer the patients antihypertensive medications 1 hour before

ambulation.
B. Hold the patients antihypertensive medication until after the
ambulation session.
C. Have the patient move from a lying to standing position slowly.
D. Teach the patient to first sit on the side of the bed for a few minutes
before standing slowly.