Chapter 10
Chronic illness, disability and rehabilitation
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exercise, supportive counselling and vocational
evaluation.
•
Comprehensive burn rehabilitation programs
may serve as
step-down units from intensive care burn units. Although
rehabilitation strategies are implemented immediately
in acute care, a program focused on progressive joint
mobility, self-care and ongoing counselling is imperative
for burn patients.
•
Paediatric rehabilitation programs
meet the needs of
children with developmental and acquired disabilities,
including cerebral palsy, spina bifida, traumatic brain
injuries and spinal cord injuries.
As in all areas of nursing practice, nurses practising in the
area of rehabilitation must be skilled and knowledgeable about
the care of patients with substance abuse. For all people with
disabilities, including adolescents, nurses must assess actual
or potential substance abuse. There is a strong correlation
between disability, substance abuse and homelessness (Taylor
& Sharpe, 2008). Substance abuse is a risk factor for homeless
ness (AIHW, 2012) and a large proportion of homeless people
are affected by mental illness and experience higher rates of
disability and chronic illness than the general population
(Lynch, 2005).
Substance abuse is a critical issue in rehabilitation, espe
cially for people with disabilities who are attempting to gain
employment via vocational rehabilitation. This increased
abuse is associated with a number of risks that may have an
adverse impact. These risks include medication and health
problems, societal enabling (i.e. acceptance and tolerance of
substance abuse by key social and cultural groups), a lack of
identification of potential problems, and a lack of accessible
and appropriate prevention and treatment services. Treatment
for alcoholism and drug dependencies includes thorough
physical and psychosocial evaluations; detoxification; counsel
ling; medical treatment; psychological assistance for patients
and families; treatment of any coexisting psychiatric illness;
and referral to community resources for social, legal, spiritual
or vocational assistance.
The length of treatment and the rehabilitation process
depends on the patient’s needs. Self-help groups are also
encouraged, although attendance at meetings of such groups
(e.g. Alcoholics Anonymous, Narcotics Anonymous) poses
various challenges for people who have neurological disorders,
are permanent wheelchair users, or must adapt to encoun
ters with non-disabled attendees who may not understand
disability.
Teaching patients self-care
In the same way as self-management teaching for chronic
illness involves significant expenditures of time and resources,
rehabilitation involves enabling patients to gain the skills
and confidence to manage their care and health effectively
after discharge from the hospital. It is also important to
consider the effect of a pre-existing disability or a disability
associated with recurrence of a chronic condition on the
patient’s ability to manage ADLs, self-care and the therapeu
tic regimen.
Formal programs provide patients with effective strategies
for interpreting and managing illness-specific issues and
skills needed for problem solving, as well as building and
maintaining self-awareness and self-efficacy. As with chronic
illness teaching, self-care programs in rehabilitation often use
multifaceted approaches, including didactic teaching, group
sessions, individual learning plans, and web-based resources.
When planning the approach to self-care, it is important
that the nurse consider the individual patient’s knowledge,
experience, social and cultural background, level of formal
education, and psychological status. The preparation for self-
care must also be spread out over the course of the recovery
period, and it must be monitored and updated regularly as
aspects of self-care are mastered by the patient. Preparation
for self-care is also highly relevant for informal carers of
patients in rehabilitation. When a patient is discharged
from acute care or a rehabilitation facility, informal carers,
typically family members, often assume the care and support
of the patient.
Although the most obvious care tasks involve physical
care (e.g. personal hygiene, dressing, meal preparation),
other elements of the care giving role include psychosocial
support and a commitment to this supportive role. Thus, it
is necessary to assess the patient’s support system (family,
friends) well in advance of discharge. The attitudes of family
and friends towards the patient, his or her disability, and the
return home are important in making a successful transition
to home and to avoid unnecessary readmission (Reinhard
et al., 2008).
Not all families can carry out the arduous programs of
exercise, physical therapy and personal care that the patient
may need. They may not have the resources or stability to
care for family members with a severe disability. The physical,
emotional, economic and energy strains of a disabling con
dition may overwhelm even a stable family. Members of the
rehabilitation team must not judge the family but rather should
provide supportive interventions that help the family to attain
its highest level of function. The family members need to know
as much as possible about the patient’s condition and care so
that they do not fear the patient’s return home. The nurse
develops methods to help the patient and family cope with
problems that may arise (see Chart 10-8).
Continuing rehabilitation care
A community-based rehabilitation nurse may visit the patient
in the hospital, interview the patient and the family, and
review the ADL sheet to learn which activities the patient can
perform. This helps ensure that continuity of care is provided
and that the patient does not regress, but instead maintains
the independence gained while in the hospital or rehabili
tation setting. The family may need to purchase, borrow or
improvise needed equipment, such as safety rails, a raised toilet
seat or commode or a tub bench. Ramps may need to be built
or doorways widened to allow full access. Family members
CLINICAL REASONING CHALLENGE
A 48-year-old woman with severe rheumatoid arthritis
who resides in a nursing home is admitted to your medical-
surgical unit following surgical treatment for a fractured hip.
The overall goal of rehabilitation is to regain pre-fracture
function. What short-term goals of the rehabilitation pro
cess would support improvement in functional return? How
would you promote early mobilisation? What assessments
are important to consider when coordinating a rehabilita
tion plan with the interdisciplinary team?
