Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

interactions, the nurse actively listens, encourages and shares patient and family successes. Using the nursing process, the nurse develops a plan of care designed to facilitate rehabilitation, restore and maintain optimal health and prevent complications. Coping with the disability, fostering self-care, identifying mobility limitations, and managing skin care and bowel and bladder training are areas that frequently require nursing care. The nurse acts as a caregiver, teacher, counsellor, patient advocate, case manager and consultant. The nurse is often responsible for coordinat­ ing the total rehabilitative plan and collaborating with and coordinating the services provided by all members of the healthcare team, including community nurses, who are respon­ sible for directing patient care after the patient returns home. Areas of specialty rehabilitation Although rehabilitation must be a component of every patient’s care, specialty rehabilitation programs have been established in general hospitals, free-standing rehabilitation hospitals and outpatient facilities. Examples of specialty reha­ bilitation are as follows: • Stroke recovery programs and traumatic brain injury rehabilitation emphasise cognitive remediation, helping patients compensate for memory, perceptual, judgement and safety deficits as well as teaching self-care and mobility skills. Other goals include helping patients swallow food safely and communicate effectively. Neurological disorders treated in addition to stroke and brain injury include multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, and nervous system tumours. • Spinal cord injury rehabilitation programs promote understanding of the effects and complications of spinal cord injury; neurogenic bowel and bladder management; sexuality and fertility enhancement; self-care, including prevention of skin breakdown; bed mobility and transfers; and driving with adaptive equipment. The programs also focus on vocational assessment, training and re-entry into employment and the community. • Orthopaedic rehabilitation programs provide comprehensive services to patients with traumatic or non-traumatic amputation, patients undergoing joint replacements, and patients with arthritis. Independence with a prosthesis or new joint is a major goal of these programs. Other goals include pain management, energy conservation, and joint protection. • Cardiac rehabilitation for patients who have had myocardial infarction begins during the acute hospitalisation and continues on an outpatient basis. Emphasis is placed on monitored, progressive exercise; nutritional counselling; stress management; sexuality; and risk reduction. • Pulmonary rehabilitation programs may be appropriate for patients with restrictive or chronic obstructive pulmonary illness or ventilator dependency. Physiotherapists and nurses help patients achieve more effective breathing patterns. The programs also teach energy conservation techniques, self-medication, and home ventilator management. • Comprehensive pain management programs are available for people with chronic pain, especially low back pain. These programs focus on alternative pain treatment modalities,

rehabilitation—sometimes called habilitation—patients adjust to disabilities by learning how to use resources and focus on existing abilities. In habilitation , making able; learning new skills and abilities to meet maximum potential abilities, not disabilities, are emphasised. An important goal of rehabilitation is to assist the patient to return to the home environment after learning to manage the disability. A referral system maintains continuity of care when the patient is transferred to the home or to a long-term care facility. The plan for discharge is formulated when the patient is first admitted to the hospital, and discharge plans are made with the patient’s functional potential in mind. Thus, rehabilitation begins in acute care. The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient. The goal of rehabilitation is to restore the patient’s ability to function independently or at a pre-illness or pre-injury level of functioning as quickly as possible. If this is not possible, the aims of rehabilitation are to maximise independence and prevent secondary disability as well as to promote a quality of life acceptable to the patient. Rehabilitation team Rehabilitation is a creative, dynamic process that requires a multidisciplinary team of professionals working together with patients and families. The team members represent a variety of disciplines, with each health professional making a unique contribution to the rehabilitation process. In addition to nurses, members of the rehabilitation team may include physicians, nurse practitioners, physiotherapists, occupational therapists, diversional therapists, speech-language therapists, psychologists, psychiatric liaison nurses, spiritual advisors, social workers, vocational counsellors and sex counsellors. Nurses assume an equal or, depending on the circumstances of the patient, a more critical role than other members of the healthcare team in the rehabilitation process. The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process. The rehabilitation process is cyclical and includes a comprehensive assessment; establish­ ment of short-term, medium-term and long-term goals; devel­ opment of a collaborative plan to work towards achieving the goals; and evaluation of progress towards the goals (Booth & Jester, 2007). In working towards maximising independence, nurses affirm the patient as an active participant and recognise the importance of informal carers in the rehabilitation process. The patient is a key member of the rehabilitation team, the focus of the team’s effort, and the one who determines the final outcomes of the process. The patient participates in goal setting, in learning to function using his or her remaining abil­ ities, and in adjusting to living with disabilities. The patient’s family is also incorporated into the team. Families are dynamic systems; therefore, the disability of one member affects other family members. Only by incorporating the family into the rehabilitation process can the family system adapt to the change in one of its members. The family provides ongoing support, participates in problem solving, and learns to participate in providing ongoing care. The nurse develops a therapeutic and supportive relationship with the patient and family. The nurse emphasises the patient’s assets and strengths, positively reinforcing the patient’s efforts to improve self- concept and self-care abilities. During nurse–patient