Textbook of Medical-Surgical Nursing 3e

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Chapter 10

Chronic illness, disability and rehabilitation

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?

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