International
Journal of Caring Sciences 2012 May-August Vol 5 Issue 2 80
www.inernationaljournalofcaringsciences.org
S P
E C I A L P A P E R
Rehabilitation Nursing: Applications for Rehabilitation Nursing
Aysegül
Koç, PhD, RN
Assistant
Professor, School of Health, Bozok University, Yozgat, Turkey
Corespondence:
Aysegül Koç, PhD,
RN, Assistant Professor Bozok University School of Health
66100,
Yozgat, Turkey, Tel: +90 354 212 1190, Fax: +90 354 212 2653
Abstract
Rehabilitation nursing is a
specialist form of rehabilitation requiring specialist nursing. Furthermore, as
in many areas of nursing, nurses in this field recognize that there is a need
to increase the quality of and provide the most up-to-date care for their
patients and patients’ families. To achieve high levels of competence,
neurological rehabilitation nurses need to be aware of the existing body of
research in this field. Effective hospital and community rehabilitation
services are increasingly recognised as a means of meeting the changing pattern
of health and social care requirements. This review aims to validate the
existing knowledge base in this area by identifying and critically analysing
research conducted in the area of neurological
rehabilitation nursing.
Keywords: rehabilitation;
rehabilitation nurses; neurology; rehabilitation management; neurological
disorders; head injury; nurse
Introduction
The number of people requiring
rehabilitation is increasing (Teasell R. 2003 and Ed: 2006). NursesBtoday will
care for more patients with chronic neurological problems, more patients with
head injury, and more elderly people in need of care, and because these
patients often have a wide range of physical, cognitive and behavioural
problems, the rehabilitation needs of these patients are diverse and complex
(Green 1997, Green 2002). As rehabilitation nursing requires autonomous
professional knowledge, it is increasingly gaining momentum (Teasell R.2003).
However, like many areas of nursing, nurses in this field recognize that there
is a need to strengthen their knowledge in order to ensure that they provide
the best possible care for patients and their families. Rehabilitation nurses
can start by reviewing their application fields and competencies in order to upgrade
their professional skills.
Principles of
rehabilitation:
1. The prevention, diagnosis and
treatment of concomitant medical problems (co-morbid
illnesses, complications)
2. Training for maximum
functional independence,
3. To support psychosocial coping
and assist in the adaptation of patients and families,
4. To support the return to
community life
5. To improve the quality of life
of patient and family members who provide care
Rehabilitation
Nursing
Nurses are qualified health care
professionals that provide nursing services to help patients to develop problem-solving
and stress management skills and to improve patients’ quality of life by
following the physiological and psychological changes of the patients.
A
rehabilitation nurse is specialized in the care of dependent or semi-dependent
individuals, and provides direct patient care, educates patients and their
families, and provides care coordination. A rehabilitation nurse should first
start with what the patients and their families want to know and what they need,
and should be a good trainer and love their work.
A rehabilitation nurse creates a creative
and dynamic process which supports the individual's "functional
capacity", namely the dynamic interaction with the environment, and plays
a role in helping patients achieve their maximum functional capacity. Thus, a
rehabilitation nurse commences rehabilitation in the patient’s new life by
reorganizing the maintenance process of the individual or providing an
immediate protective care in the initial phases of an illness or an accident.
The disabled person's existing capacity should be considered holistically. A
rehabilitation nurse provides care, training and support for individuals and
their families. In addition, it is essential to regulate the adaptation process
to the new role and environment, and this is provided by the rehabilitation
nurse. According to the definition accepted by ‘International Council of
Nurses’, rehabilitation is a special application that can be regulated as a
part of care (Teasell R. 2003).
Rehabilitation nursing begins with immediate
preventive care in the beginning stages of accident or illness, is continued
through the restorative stage of care, and involves adaptation of the whole
being to a new life. The rehabilitation nurse provides care, education, and
support for the patient and the family. They play an active role in encouraging
the patients to develop abilities on their own as much as possible, such as
meeting basic needs, activities of daily living (eating, drinking, excretion,
dressing and undressing), and taking protective measures Three main points
constitute the goal of rehabilitation nursing and can be summarized as
"lifestyle changes in individuals", namely "adaptation",
"configuration of functions" and "upgrading autonomy"
(Hoeman2002).
Research on the role of rehabilitation
nursing has been determined to have a tendency to focus on elderly care centers
and general rehabilitation nursing. The majority of them are related to ongoing
interventions prescribed by doctors and physiotherapists, and they have
reported a tendency to underestimate the role of rehabilitation nurses (Sylvie 2000).
There is a broad spectrum of neurological diseases in the field of rehabilitation.
There may be insufficient information on the frequency of neurological disorders
in the community (Newsom-Davis 1997). Today, there is an increasing number of
patients with disabilities, chronic diseases, degenerative diseases, and
elderly individuals in particular. However, up to 10 million people in England
are expected to be affected by a neurological condition. Approximately one-tenth
of these people have "head injuries" and a few million have neurodegenerative
– progressive disorders, such as "Multiple Sclerosis" and "Parkinson's
disease". Neurological emergencies constitute 20% of emergency room
admissions.Except for
long-term care, 850,000 people need to be employed for individuals in need of
neurological rehabilitation and 350,000 people for individuals who lack the
ability to perform the activities of daily living due to a neurological
condition(http://www.rcn.org.uk/__data/assets/pdf_file/0017/111752/003178.pdf).The
needs of these people, who constitute a large part of population, cannot be met
in the present status. Except for stroke, there is no definitive treatment or
preventive treatment for neurological conditions. Rehabilitation and support
should be focused on protection and improvement of the current situation of
affected individuals. Flexible, need-responsive, and individual-based studies
are Needed (http://www.rcn.org.uk/__data/assets/pdf_file/0017/11
1752/003178.pdf,
http://www.sdo.nihr.ac.uk/files/adhoc/132-132-
research-summary.pdf).
History of
Rehabilitation Nursing
In the United States, the field of
rehabilitation is linked most closely with, and has received its greatest
impetus from, the circumstances surrounding the consequences of wartime combat.
Rehabilitation principles were first applied by Florence Nightingale, who
planted the seeds of rehabilitation nursing in her seminal 1859 book.(http://currentnursing.com/nursing_theory/nursing_th
eorists.html,http://www.cot.org.uk/sites/default/files/publications/ public/Work_Matters_Vocational_Rehab_English.pdf).
Subsequently, the 1940s saw significant growth in the field of physical
medicine. In 1945, eight individuals with Spinal Cord Injury were reported to
have been administered psychosocial treatment and vocational therapy. The
specialty of rehabilitation medicine became firmly established, and by 1946,
physiatrists were being trained in rehabilitation medicine (Rundquist et
al.2011, Chen et al. 2005).
Rehabilitation
Nursing Interventions
A rehabilitation nurse initially plays an
active role in helping the patients to function at their best in meeting basic
needs, in the activities of daily living (eating, drinking, excretion, dressing
and undressing), and in taking protective measures for themselves.
- provides
coordination with the other members of the team after assessing the nutritional
status of the patient, e.g. in patients who have difficulty swallowing:
nutrition may be given via IV (intravenous) route or naso-gastric probe or
gastric tube.
- Toilet habits, which particularly affect the
social life of the patient, should be established again.
- Maintenance
and training practices for bladder emptying and urinary leakage should be
performed
- For skin care
and prevention of pressure ulcers, patient and family education should be
provided about periods of motion limitation, care for wheelchairbound patients,
and accurate positioning.
- The patient's
skin-care and self-care deficiencies should be identified and attempts should
be made to eliminate the source of the problem.
- In parallel
with the changing needs of the individuals, they should be given the
opportunity to acquire self-care skills.
- To prevent the
formation of contractures and atrophies, proper positioning and active-passive
ROM exercises should take place.
-The patient
should be encouraged to become independent.
- To evaluate
the patient's ways of coping with stress and to help improve problem-solving
skills, to support, and to direct the patient to a relevant unit if necessary.
- To provide a
safe environment against infections and accidents, to ensure compliance with
nursing care techniques (asepsis, sterilization, isolation, etc.), and to
provide necessary treatments for isolated patients.
- For patients and
their caregivers, to provide moral support and motivation, to provide
consulting and education and to inform about the disease and general health
issues, and to direct the relevant health professionals and institutions, if
necessary,
- To record each
phase of nursing applications completely and in a timely manner.
- To promote
patients’ social participation.
- Vital signs
should be monitored.
The rehabilitation process involves the
time spent in hospital and some phases after hospital discharge. The patient
ultimately should return home. Although it is very important to ensure the
continuity of the rehabilitation process at home, it is certain that other people
will have to deal with the patient's care. In view of this process, the time
spent in hospital is not too short when compared with the life remaining.
Maintaining self care as much as possible, or supportive care, is the
cornerstone of care. Here, the important point is the education of patients and
caregivers (Portillo et al. 2005).
The
common goals should be clarified to achieve success in harmony with the patient
and his/her family. In rehabilitation teamwork, nurses should have a broad
perspective and have the ability toforesee. The more the nurse realizes
the extent of the patient’s improvement, and how much more rehabilitation the
patient needs to achieve maximum improvement, the more the nurse will
contribute to the rehabilitation team (Lazar 1998). As a result, new roles and
functional areas of rehabilitation nursing are emerging. To provide effective
patient and family education, the rehabilitation nurse should be sensitive,
open-minded and sincere (Barthel & Mahoney 2002, Hachinski 2002).
Moreover, a few keywords to be added, may
be the potential, talent, quality of life, family-centered care, welfare,
cultural components of care, and integration. A few studies focusing on the
role of the rehabilitation nurse have reported that neurological
rehabilitationrequires more autonomy (Spasser & Weismantel 2006). Rehabilitation
nursing has been reported to have an independent professional role with a wide
range of activities, such as training, consulting, communication, management,
and collaboration and care giving. Similar findings were reported with regard
to how rehabilitation nurses perceive their roles. In some qualitative studies,
nurses reported to perceive themselves and their roles in health improvement as
independent. The nurses have considered that they have a central role in all
phases of rehabilitation (White et al. 2011 and Ross & Bower 1995).
It has been
reported that the role of the neurology
nurse is not
different from that of a rehabilitation
nurse in any
area (e.g. caregiving
activities, education, and upgrading independence that is not specific to
neurology). In the literature, work-related stress has been reported to be very
common among rehabilitation nurses working with patients with traumatic brain
injury (TBI) (Ishikawa 2011).
Specific
Problems Concerning Rehabilitation
Patients
Skin Care: Rehabilitation
patients may be faced with various skin problems. During periods of restricted
activity and in patients who remain in bed for long periods of time, there is a
risk of developing Pressure ulcers. Changing the position of the
patient in the bed, in other words, alternating between laying the patient on
their right side and laying them on their left side at intervals of two to
three hours would be highly beneficial for the patient. Some important points
are to keep the skin clean, taking care not to load excess weight on certain
areas of the body, and to use a pneumatic bed. The same risk also applies to
people sitting in a wheelchair. Therefore, the pressure applied to the
patient's thigh will be reduced by placing an appropriate wheelchair cushion.
In addition, fungal lesions or erythemas may occur underneath the breast in
women, in the inner side of the elbows in both genders, or between the body
layers in overweight individuals because of the inactivity. It is very
important to keep these areas clean and dry (Bakas et al. 2002).
Pressure ulcers: are ulcers
occurring as a result of skin and subcutaneous tissue injury due to poor circulation
in the pressure area that come into contact with the bed. Common locations of
pressure ulcers: hips, elbows, heels, shoulder blades, knees, protruding areas
of the ankle and head, ears and sacrum. The selection of appropriate clothes,
active-passive exercise, personal hygiene, and massage can be applied to
protect the patient (http://en.allexperts.com/q/Physical-Rehabilitation-
Medicine-981/2008/6/Bed-sore.htm).
Hygiene: Infection is
one of the most common complications, especially after stroke. One of the problems
of rehabilitation patients is difficulty in swallowing as well as poor oral
hygiene. Difficulty in emptying the bladder following a stroke leads to the
accumulation of urine and bacterial infection. Inadequate fluid intake is one
of the causes of the accumulation of urine. Therefore, it is important for post-stroke
patients to take plenty of fluids and to have their catheters changed within
twenty days (Stiefel & Truelove 1990).
If the patient is using a cloth wipe, it
is also very important to replace these cloth wipes at two to three hours
intervals. This will both relieve the patient and ventilate the back of the
patient. During the replacement of the cloth wipes, the urinary region and the
areas that are in contact with the cloth wipes should be cleaned with wet wipes
or a cotton cloth moistened with water. The perineum and the back of the
patients should be checked at certain intervals if the patients are able to
maintain their own hygiene (Bakas et al. 2002).
Bathing: After
returning home, it would be beneficial for the patient to take a bath at
frequent intervals (depending on the person's health status). This stimulates
blood circulation and allows the opening of skin pores. The patient can spend
one to two hours in the bath each day. Bath time should be a relaxing time. The
healthy hand can rub and massage the opposite side. Individuals are able to
regain somefunction of the hemiplegic hand with time. It is important to set
the temperature of the water to prevent burn injuries. It may be convenient to
use an automatic, touchless sensor sink. Showering should be preferred to a
bathtub. It is beneficial to apply body massage with baby oil or lanolin cream
after bathing (Bakas et al. 2002).
Bed Bath:
Water-repellent products should be placed under the patient to protect the bed.
Gloves must be used during the post-toilet cleaning of the patient. The
cleaning procedure must be performed from top to bottom and from interior to
exterior. After controlling the room temperature, up to two thirds of the hand
bath should be filled with water up to 43 to 46 degrees. The patient's body
should be rinsed with soapy water from top to bottom, and from distal to
proximal, and dried. The genital area should be cleaned from front to back. It
is important to use a moisturizing lotion for moistening the skin (Knapp 1959).
Toilet: Toilet grip
handles can be used to facilitate the ability to sit and stand. Sometimes,
raising the toilet seat height can be of critical value (Knapp 1959).
Eating: Eating with
other family members at the same table at home can improve the morale of the patient.
In this regard, caregivers should encourage the patient. Nonfunctional body,
sensory problems, difficulty swallowing and relaxed facial muscles can make it
hard to eat. To divide the food into the small pieces, to use mixers when
necessary, to wipe the patient's mouth with a wet wipe, and to use a smock
would be useful. Oral care is an important component of eating and appetite
(Knapp 1959).
Exercise: The aim of
exercise is to regulate the distribution of oxygen and metabolic processes, enhance
strength and endurance, reduce body fat, and improve muscle-joint movements.
All of these benefits are necessary for good health and everyone should undertake
a routine exercise program in daily life. There is no distinction between young
and old people; however, strenuous exercise might have some risks. Exercising
for 20 minutes or more, three times a week is sufficient. Fifteen - 25 minutes
of daily exercise five or more days a week provides high level of benefits. The
exercise period can be started with light warm-ups and completed with
stretching exercises (Nas et al 2001).
PEG
(percutaneous gastrostomy) or nasogastric tube: If a PEG or NG
has been inserted due to poor feeding, the patient's head should be
elevated at least 45 degrees during and one to two hours after feeding.
Before and after each feeding, catheters should be washed with 20cc
water. The catheter site must be inspected daily, and checked for
swelling and erythema, and be kept clean and dry. The catheter should be rotated
around itself once a day and adhesion of the catheter to the skin should be
avoided (Williams 2006, http://www.sign.ac.uk/pdf/sign78.pdf).
Traveling: If car travel
is planned, it would be useful for the patient to sit in the front seat pulled back,
and to place a cushion under the buttocks, a U-shaped pillow on the neck, and a
pillow supporting the back of the patient. To give short breaks and to wear
comfortable and loose clothing during the journey would make the journey more
comfortable. It should be kept in mind that a change in air pressure in
aircraft travel can have different effects on metabolism, and a medical
examination should be done and necessary recommendations should be followed,
e.g. wearing varicose stockings that can support venous circulation (
Lapostolle et al. 2003).
Stroke
Rehabilitation:
Recovery after a stroke is associated with many factors. Stroke affects the
whole body, as well as causes problems such as perception deficiencies, sensory
problems, speech disorders, pain, and difficulty in performing the activities
of daily living independently. The goal of rehabilitation is to ensure the
return of the patient to daily life and to protect quality of life. Rehabilitation
should be performed by a health care staff member experienced in hemiplegia,
such as medical physical therapist, occupational therapist, speech therapist,
nurse and neuropsychologist. Once the patient's condition has stabilized, it is
recommended to initiate post-stroke rehabilitation. In our country, usually
patients are included in a rehabilitation program in physical therapy and
rehabilitation services of hospitals and in private rehabilitation centers.
Rehabilitation is a costly and exhausting process. Nursing care is complex and
versatile in equipped hospitals that can provide acute or chronic care,
rehabilitation centers, or at home. As the stroke can affect the individual in
many ways, more than one nursing diagnosis may be appropriate for the care of
an individual with stroke (Wright 1999).
Motor
rehabilitation should be initiated in ischemic stroke patients in the early
period. Patients who receive bed rest within the first 24 hours should be
mobilized in the following two to three days. Mobilization is the most
important way to prevent pressure ulcers, deep vein thrombosis, atelectasis, bronchopulmonary
infectious complications, and constipation. The patients that will be mobilized
should be monitored for worsening of neurological signs due to orthostatism,
and mobilization should be continued if the neurological status does not
change. Mobilization alone should not be allowed because of the high risk of
falling. It is important for bed-bound patients to alternate sides at short
intervals and to use pneumatic beds for pressure ulcer prophylaxis. In order to
prevent contractures and orthopedic complications, active or passive ROM
exercises should be used for paretic arms and legs. Most stroke patients have
difficulty swallowing in the acute phase, and feeding should not be delayed in
these patients. In the early period, nasogastric tube or enteral nutrition via
gastrostomy can be considered. Oral feeding should not be initiated in any of
the stroke patients without the evaluation of the swallowing function. The
prognosis of aspiration pneumonia can be worse in patients with impaired
swallowing (Teel et al. 1999).
Nursing
Interventions
It is noteworthy that publications on
rehabilitation nursing practices are usually international and related to
stroke. Studies generally examine issues of nursing care and patient education
(Burton CR. 2003). In different studies, different assessments have been made
on the impact of stroke support groups, self-care skills and perceptions of the
patients. In the studies, specific therapeutic applications, such as bowel management,
feeding and laughing are mostly included in individual nursing practices.
Moreover, the studies have evaluated the differences between conventional
nursing approaches and semiexperimental models (http://www.freeed. net/sweethaven/MedTech/NurseCare/NeuroNurse0
1.asp, Williams et al. 2009).The needs of rehabilitation nurses are not
precisely defined. For example, the standardization of a guide including
behavioral and cognitive factors will be helpful for rehabilitation nurses in
terms of the care needs of patients with neurological disability. Thus, the
outcome of care can be measured. Large-scale prospective studies on different
cultures will be more informative. In many rehabilitation units, nurses prepare
the patient before the application. In addition, in some units, a taxonomic
guide can be used. Especially in studies focused on stroke, when "the
perception of patients" for the nurses working with patients with depression
after stroke is evaluated, nurses have been found to listen to and support the patients
by encouraging them to speak (Bennett 1996).
The Family of
the Rehabilitation Patient
The patient's family plays an important
role in rehabilitation. To have a relevant and resourceful family that can
provide care is an important factor affecting the rehabilitation process
positively. What kind of problems the patient may experience and how these
problems affect the patient should be explained to family members. In this way,
it will be easier for the family to find solutions after the discharge.
If you are a relative of someone in need
of rehabilitation, you should support and encourage him. You should not leave
the patient alone in hospital or the rehabilitation center, and should make
him/her feel that you are with them. Watching television, listening to the
radio, playing chess or card games with family members may make the patient
more comfortable. This is a good way to learn how rehabilitation works and how
you can help the patient to do better.
It is of utmost importance in
rehabilitation to help and encourage the patient to apply relearned skills. A
patient diary can be used to clarify what the patient can do alone and what
they can do with support. In this way, the patient's family can refrain from
executing actions that the patient can do alone. The patient's self-confidence
will increase as he/she performs tasks without help. Long-term care and
rehabilitation needs can create pressure and despair in patients and their
families. Stroke, spinal cord injury and traumatic brain injuries happen so
quickly and everybody may be shocked. At the end of the acute period, the most
important partner of the health care team is the family. Early inclusion of family
members in care interventions will facilitate the long-term struggle with the
disease and create an efficient climate of trust. To take a patient approach to
problem solving, to offer alternative solutions, and to provide psychological
support for the patient and family in long term disability is an important task
of health personnel dealing with stroke. In short, it is obvious that the
patient's family need to be informed to adapt to the new condition in the early
period. In recent literature, the amount of research concerning the patient and
family is increasing. In these studies, the education needs of the family of
the rehabilitation patients have been mentioned, and the participation of the
family in the rehabilitation process has been reported to be important (Wright
et al. 1999, Crotty et al. 2003, Zinzi et al. 2009, http://www.mageerehab.org/caregivers.php, http://www.ohioafp.org/pdfs/symposium_pres/Kelly_ Koenig.pdf).
Informal care-givers have been reported
to be willing to participate in patient care. Family support has been emphasized
to be important in the publications, despite its limitations. More
comprehensive research that can clarify this issue may be proposed.
Conclusion
An efficient information network
can be created in the field of rehabilitation nursing. For stroke, cost-effective
models can be compared with community-based rehabilitation practices. For neurological
conditions other than stroke, welldesigned randomized controlled trials and
economic evaluation of the service can be carried out. Patient records related
to the long-term care needs involved in the rehabilitation of patients can be
created. The importance of these records should be taken into account for the
continuity between phases of rehabilitation and service provision. Volunteer
services and web and telephone services can be used more efficiently. Home care
can be an alternative to hospital care for patients and their families.
Community-based rehabilitation and therapeutic interventions can be tried for
Parkinson's disease, spinal cord injuries and multiple sclerosis. Follow-up at
home can be recommended for epilepsy. Qualitative studies can be offered to
assess the rehabilitation needs of all groups.
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