Rehab Nursing Series : Intro to Rehabilitation i

Transcription

1 Rehab Nursing Series : Intro to Rehabilitation i

2 Rehab Nursing Series : Intro to Rehabilitation ii

3 T H E RE H A B NURS ING SERIES INTRODUCTION TO REHABILITATION & REHABILITATION NURSING Pamela Masters-Farrell, MSN, RN, CRRN This workbook is for use with the course Introduction to Rehabilitation & Rehabilitation Nursing, which is part of the Rehab Nursing Series published by Rehab ClassWorks, LLC. Notice: The clinical information and tools used in this course are based on current literature, research, and consultation with nursing, medical, and legal authorities. To the best of our knowledge, it reflects current practice. However, appropriate information sources should be consulted, especially for new or unfamiliar procedures. This course contains many references and resources using internet addresses. Although these sites were current at the time of the research, writing, and/or publication, many internet postings are dynamic and subject to expiration or deletion over time. Therefore, Rehab ClassWorks, LLC cannot guarantee currency of electronic references. Please check for the latest information on a cited topic using online search engines Rehab ClassWorks, LLC S W. Bluffdale, UT Phone: (888) Fax: (801) support@rehabclassworks.com Web Address: All rights reserved. This document, the associated computer course, or any part thereof, may not be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, storage in an information retrieval system or otherwise, without prior written permission of Rehab ClassWorks, LLC. Licensing of this course and workbook are nontransferable without prior written permission of Rehab ClassWorks, LLC. Purchasers of a registered multiuser license for the course are granted permission for copying of the workbook and computer course for use by staff covered by said license. Rehab Nursing Series : Intro to Rehabilitation iii

4 T H E RE H A B NURS ING SERIES The Rehab Nursing Series Second Edition NOVICE COURSES NEW TO REHABILITATION Introduction to Rehabilitation & Rehabilitation Nursing Take Care! Safe Patient Handling Works! 1, 2, Buckle My Shoe Functional Skill Development Not Documented? Not Done! Documenting Professional Rehabilitation Nursing Care Got a Plan, Man? Patient-Centered Care Planning in Rehabilitation See One, Do One Patient & Family Education in Rehabilitation Go HOM! Preventing Complications from Immobility Pediatric Rehabilitation INTERMEDIATE COURSES CORE REHABILITATION NURSING SKILLS Get Going! Mobilize Your Patients Gotta Go Right Now! Bladder Management in Rehabilitation Nursing Full of It! Bowel Management in Rehabilitation Nursing An Apple a Day Nutrition & Dysphagia Management He Said/She Said? Disorders of Communication, Speech, & Language Wandering, Confused, & Agitated? Cognition & Behavior Management A Little Romance? Providing Sexuality Education & Counseling in Rehabilitation Down, Not Out! Providing Psychosocial Support in Rehabilitation ADVANCED COURSES APPLICATION OF CORES SKILLS TO SPECIFIC POPULATIONS Rehabilitation of Stroke Rehabilitation of Brain Injury Rehabilitation of Spinal Cord Injury Cardiopulmonary Rehabilitation Certification Review for Rehabilitation Nurses I N T E R A C T I V E E D U C A T I O N N O V I C E T O E X P E R T W O R K I N G S M A R T E R Registration is required for continuing education credit. Register your course by going to Rehab Nursing Series : Intro to Rehabilitation iv

5 A C K N O W LEDGEMEN T S A C K N O W LEDGEMEN T S This course could not be completed without the help and expertise of our associates and reviewers, some of which are listed below. In the interest of privacy, we list only those who desire to be listed. Their contributions are gratefully acknowledged. Reviewers Irin Daniel, BSN, RN Robin Decker, MSN/Ed, RN, CRRN Melissa Grann, RN Tanja Hagen, MS, RN, CRRN Chris Hayball, RN Sharon P. Jacobson, RN Brook Jimenez, MBA, BSN, RN, CRRN Judy Kiefer, BSN, RN Janet Pratt, RN Ann Rogers, RN Patricia Safford, RN, CRRN Timothy Walsh, BSN, RN Elizabeth Woodrich, BSN, RN, CRRN Editor: Pamela Masters-Farrell, MSN, RN, CRRN Planning, Research, & Development: Pamela Masters-Farrell, MSN, RN, CRRN Michelle Edwards, MSN, RN Sherry Adkins, BSN, RN, CRRN Carolyn Schultz, RN, CRRN Art: Shantel Pilcher Programming & Quality: Suzanne Bawden Cheryl Micheel, BS Janet Plackemeier, BS Ed Yuliya Lange, BS-BA Individuals in a position to control content for this educational activity have nothing to disclose. This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest, and there is no commercial support being received for this activity. Visit us at to learn more about our course offerings, course expiration dates ( and quick tips. Visit our rehab nursing blog at We would love to hear from you regarding your rehabilitation nursing needs and questions. Contact us via to pam@rehabclassworks.com. Rehab Nursing Series : Intro to Rehabilitation v

6 TABLE OF CONTENTS Getting Started... ix Launching the Course... ix Logging In... ix Functions of the Main Menu... x Continuing Education Hours... x Using the Course... xi Workbook and Computer Course... xi Quizzes... xii Links... xii Functions of the Navigation Bar... xii Page Numbers... xii Reference... xii Main Menu... xii Index... xiii Help... xiii Read... xiii Progress Report... xiii Other Features... xiii Notes Books/Feedback... xiii Chapter 1 Introduction & Overview... 1 Chapter Objectives or What Is Your Job in This Chapter?... 1 Course Goal... 2 Rehabilitation Nursing and YOU!... 2 The History of Rehabilitation... 3 Before Rehab... 3 Rehab Is Born... 3 Rehab Comes Into Its Own... 4 You Make a Difference!... 6 Where Are We Now?... 7 What Does This Mean to Me?... 7 Chapter 2 What Is Rehab?... 8 What Is Your Job in This Chapter?... 8 Just What Is Rehabilitation?... 9 Trends in Rehabilitation... 9 The Continuum of Care...10 Philosophy of Care...11 Problem Lists...11 Goals...12 Chapter 3 The Rehabilitation Nurse What Is Your Job in This Chapter?...17 What Makes a Good Rehab Nurse?...18 The Rehab Nurse Is...18 Table of Contents Rehab Nursing Series : Intro to Rehabilitation vi

7 Professional Roles of Rehabilitation Nurses...20 Professional Standards...20 Myths of Rehab Nursing...22 Rehabilitation Work Is Teamwork!...24 Jargon...26 Professional Resources...26 Chapter 4 The Rehabilitation Team Chapter Objectives or What Is Your Job in This Chapter?...28 Why Should You Care?...28 Rehabilitation Team Synergy in Action...30 Other Team Members...32 Team Structure and Organization...32 Rehabilitation Team Functions...34 What Makes a Good Team Work Well Together?...34 Team Development...35 Characteristics of Effective Teams...36 Learn About Your Team...36 Chapter 5 Rehabilitation Populations What Is Your Job in This Chapter?...42 Rehabilitation Populations & Their Needs...43 Activity Limitations...43 Knock! Knock! Who s There?...44 Stroke...45 Spinal Cord Injury...46 Brain Injury...47 Other Patient Populations...47 Common Problems...48 Population-Specific Care...49 Impact of Disability...50 Aging...51 Access to Care...51 Chapter 6 Therapeutic Milieu What Is Your Job in This Chapter? Creating a Therapeutic Milieu...53 A Therapeutic Environment...53 More Than Physical Barriers...56 From Admit to Reintegration...58 Those Unwritten Rules and Expectations...58 Creating Expectations...59 Resource Allocation vs. Personal Productivity...60 Patient's Rights and Confidentiality...60 Teaching Patients and Families...61 Issues of Change in the Rehab Setting...63 What Next?...63 I Am My Own Best Advocate...63 Ethical Issues in Rehabilitation Settings...64 Chapter 7 Regulatory Issues What Is Your Job in This Chapter?...65 Regulatory Issues...66 Accreditation...66 Quality Improvement...66 Program Evaluation...67 Funding Sources...67 Meeting Medicare Regulations...68 Changing Medicare Regulations...68 The MDS Data Collection Tool...69 The OASIS-C2 Data Collection Tool...69 The IRF-PAI Data Collection Tool...70 Table of Contents Rehab Nursing Series : Intro to Rehabilitation vii

8 60% Rule for Acute Inpatient Rehabilitation Facilities...71 Answer Key Table of Contents Rehab Nursing Series : Intro to Rehabilitation viii

9 GETTING STARTED This course is designed to assist nurses new to the specialty field of rehabilitation nursing to transition into this specialty. This workbook is intended to be used with the Rehab ClassWorks computer course: Introduction to Rehabilitation & Rehabilitation Nursing. Launching the Course Single User License: After installing the course, launch it on the computer by selecting it from your Windows menu or by using the desktop icon. Multiuser License: Follow your organization s instructions for accessing the course. Logging In Enter your login name as the name you want to see on the CE certificate. Select your own password and keep track of this information so you can use it in the future to enter the course. (Support cannot access this information.) Click the Start button on the login page to view the menu. Getting Started Rehab Nursing Series : Intro to Rehabilitation ix

10 Functions of the Main Menu The course is navigated from its Main Menu. 1. You can roll your mouse onto a chapter title to display information about a given chapter. 2. Click on the chapter title to enter the chapter. 3. Start with the Overview chapter for an introduction to the course and access to Course Help tools. Continuing Education Hours In order to receive continuing education contact hours, complete the course and workbook activities, pass the course posttest with a score of 80% or better, and complete the course evaluation per instructions provided at the conclusion of the posttest. This course is worth 8.7 contact hours. The posttest is in the computer course that accompanies this workbook. Your results are displayed on the computer when you complete the exam. Print or create a screen shot of your results page. Verify that the page has printed or the screen shot has been saved successfully before closing this screen because you will not be able to return to this page once you have left it without taking the test and passing it again. To receive contact hours you must submit both the Score Page and the Course Evaluation form. Instructions at the end of the posttest direct you to either print OR create a screen shot of your Score Page. (Save this image to attach to an or paste it into the .) This document must be manually sent to RCW. There is no way to electronically submit it from the course. You are then given the option to go to the Course Evaluation web page for electronic submission at OR, if you do not have web access, to complete and print (or create a screen shot of) your Course Evaluation form in the course. (Three pages will need to be processed.) Getting Started Rehab Nursing Series : Intro to Rehabilitation x

11 Send your documents to Rehab ClassWorks, LLC using one of the methods listed below. o Send by to cerequest@rehabclassworks.com (include screen shots and/or scan and attach print documents) o Send by fax to (801) o Send by mail to RCW, PO Box 1306, Riverton, UT Only persons with valid, registered serial numbers will receive continuing education credit. Go to to register the purchase of your course! (NOTE: Those with multiuser licenses are only required to register once for the group via the person managing the course.) The expiration date for this course can be found at Rehab ClassWorks, LLC is an approved provider of continuing nursing education by the Western Multi-State Division, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. Using the Course Listed below are features of the computer course and how to best use them. Workbook and Computer Course: To get the most out of this course, you should use this workbook concurrently with the computer course. There is a great deal of audio in the course, so be sure your speakers are on. There are exercises in the workbook and in the computer course to help you learn and remember the material. When you see the following, you should go to the designated section of the course on the computer. On the Computer Getting Started Rehab Nursing Series : Intro to Rehabilitation xi

12 Note that each chapter in the workbook matches the chapter of the same name in the computer course. Answers to questions in the workbook are in the back of the workbook for your reference. This course is a lengthy course and should therefore be approached in small chunks of time for best retention. Each chapter in the computer course has a bookmarking feature so that you can return to the page you last viewed when you return to the chapter. Be sure to exit the course using the EXIT button on the bottom right of the course navigation bar (not the X on the top right corner of the window) to initiate the bookmark. Quizzes: There are quizzes at the end of each chapter of the computer course to help you assess your understanding of the information in that part of the course. Links: There are links in the computer course that take you to more information when you click on them. They appear in blue underlined text. If your internet security system allows you to do so, you will be able to jump to external web pages as well as internal links while in this course. Otherwise, type the address in your web browser to view those resources. Functions of the Navigation Bar The Navigation Bar at the bottom of the screen allows access to information, return to the Main Menu, or the ability to go to a specific page in the course. Page Numbers: Page numbers in the computer course are located on the left side of the Navigation Bar. Reference: The Reference link displays definitions of terms and additional reference material. Main Menu: Return to the Main Menu by clicking that item on the Navigation Bar. Getting Started Rehab Nursing Series : Intro to Rehabilitation xii

13 Index: You can use the Index link to display the electronic pages of the chapter. Click on the page you want to go to when this tool is open. Help: This item provides information on using and navigating the course. If you do not find your answer there, contact technical support at or call (888) Read: This item opens a window that allows you to read the audio that occurs in a given frame. Progress Report: The Progress Report summarizes your scores on quizzes in the course. The posttest score also is recorded, but not the subset scores you will see at the end of the posttest. Only posttest scores are reported in a learning management system. Quizzes are for self-assessment of content learned in each chapter and are not reported in a learning management system. Other Features Notes Books/Feedback: Some screens contain a Notes Book icon in the top right corner. You can click on this icon for feedback or more information. The Notes Book icon is pictured here on the right. Getting Started Rehab Nursing Series : Intro to Rehabilitation xiii

14 CHAPTER 1 INTRODUCTION & OVERVIEW Rehabilitation is a rather new field in the big picture of life. Its development spans the last century or so and is closely associated with social and scientific advancement. This course introduces you to our specialty field, helps you understand where it has come from and where it is going, and introduces you to the patients and team members with whom you will be working. Chapter Objectives or What Is Your Job in This Chapter? In this chapter, your job is to learn about how the history of the specialty impacts our practice today. Each chapter will start with a description of the objectives or the job to be accomplished in the chapter. Chapter Highlights Course goal: Your goal in this course is to learn about the specialty of rehabilitation nursing. Rehabilitation nursing is a specialty practice with standards of care and professional behavior. Why should you care about specialty practice issues? Because, with impactful practice, we make a huge difference in the quality of life for our patients. An understanding of some of the history of the specialty will help you to better grasp issues impacting practice today. Overview Rehab Nursing Series : Intro to Rehabilitation 1

15 As a result of participating in this activity, you, the learner, should be able to pass the posttest with a score of 80% or better, demonstrating knowledge of: The key characteristics and behaviors of the specialty practice of rehabilitation and rehabilitation nursing The key characteristics and needs of typical patient populations receiving rehabilitation care, including types of patients and some of the safety precautions that will need to be applied to them The roles of fellow team members and strategies for learning about their therapeutic interventions and how to incorporate them into care of the patient A therapeutic milieu and how to support and facilitate it in the care environment The impact of regulatory agencies on the care of patients in rehabilitation settings Course Goal: The goal of this course is to introduce nurses new to the specialty of rehabilitation nursing to its goals, roles, and philosophies and to familiarize them with fellow team members, common regulatory standards, and patient populations. Rehabilitation Nursing and YOU! Rehabilitation nursing is an important specialty practice dedicated to helping those with disability maximize their skills and maintain quality of life. Rehabilitation relies heavily on teamwork, coordination, and continuity of care to facilitate goal achievement within the limitations of today's healthcare systems. In order to be successful within the regulatory and fiscal parameters in which we work, it is important that all staff quickly learn about the field and the forces driving it. Overview Rehab Nursing Series : Intro to Rehabilitation 2

16 On the Computer: Overview, pages 3-11 (Page numbers are on the bottom bar of the frame.) The History of Rehabilitation Rehabilitation is about adapting and creatively surviving, using all the resources available. 1. What factors influence the development and practice of rehabilitation? Before Rehab The technological advances which brought rehabilitation into a high-demand practice for those with disability did not occur until the 20th century. 2. What changes in healthcare had to occur before rehab could fully develop as a specialty practice? Rehab Is Born Rapid change in the delivery of healthcare has been the standard during the last few centuries. Community health, emergency medicine, intensive care, and the management of chronic conditions have influenced the development of rehabilitation as a specialty practice. 3. Why did the industrial age and increased recreation time increase the numbers of people in need of rehab services? Overview Rehab Nursing Series : Intro to Rehabilitation 3

17 Rehab Comes Into Its Own Research, stimulated by recent wartime needs and the rapid development of technology, is fueling new innovations in recovery from injury/illness and new ways of living with disability. 4. What do you think may potentially limit access to many of the innovations potentially available to persons with disability? For more information on finding reliable health information on the internet, consider one of these sites. Patient 101: How to Find Reliable Health Information at Finding and Evaluating Online Resources on Complementary Health Approaches at A User's Guide to Finding and Evaluating Health Information on the Web from Medical Library Association at Some of the sites below may be of assistance as you look for rehabilitationrelated information. Medlineplus.gov: Sponsored by the National Institutes of Health and managed by the U.S. National Library of Medicine, MedlinePlus provides information on more than 900 diseases and conditions in their Health Topics section and links to other trusted resources. It also provides a directory of hospitals, clinics, and healthcare providers; a medical encyclopedia and medical dictionary; tutorials on common conditions, tests, and treatments; extensive information on prescription drugs, supplements, and herbs; and links to thousands of clinical trials. It even offers a senior-specific health site (nihseniorhealth.gov) that makes age-related health information easier to get. Overview Rehab Nursing Series : Intro to Rehabilitation 4

18 MayoClinic.com: Owned by the Mayo Foundation for Medical Education and Research, this site is produced by more than 3,300 physicians, scientists, and researchers from Mayo Clinic, and provides in-depth, easyto-understand information on hundreds of diseases and conditions, drugs and supplements, tests and procedures. There are also dozens of sites dedicated to specific diseases and conditions. Here are a few that are directly related to rehabilitation populations. Brain Injury Brain Trauma Foundation: Traumatic Brain Injury Information Page from the National Institute of Neurological Disorders and Stroke at Brain Injury Association of America: Spinal Cord Injury Spinal Cord Injury Model System Information Network from the UAB School of Medicine: United Spinal Association: Paralyzed Veterans of America: terans_of_america_publications.htm Stroke National Stroke Association: American Stroke Association: A quick search will show that there are sites for almost any disease/injury that can result in disability. Overview Rehab Nursing Series : Intro to Rehabilitation 5

19 5. Identify at least three things to look for to determine if a website is a credible, reliable, and objective resource for rehabilitation and healthrelated information? For example, how would you know if a source offering stem cell therapy is trustworthy? You Make a Difference! The patient s success in rehabilitation is often dependent on the quality of the teamwork among the patient s caregivers. Continuity of care is as critical as developing a plan that considers the patient s abilities, resources, preferences, and responses to care strategies. You are an essential tool in the rehabilitation process. Your attitude, affect, approach, support, encouragement, discouragement, dress, distractibility, and attentiveness all influence your patient's responses. You are a therapeutic tool every time you interact with a patient. 6. How will you approach this role? Why do you want to be a rehabilitation nurse? Overview Rehab Nursing Series : Intro to Rehabilitation 6

20 Where Are We Now? Rehabilitation settings face the same challenges everyone else in healthcare is facing. What Does This Mean to Me? You need to be invested in delivering care that moves the patient toward goals every day that you are providing care. You need to document in a manner that reflects progress toward goals or strategies used to manage barriers to progress. You need to be very conscientious of your responsibilities to manage costs of care for both the patient and the organization for which you work. If this is not managed well by all of us, many of us will not have access to these very necessary rehabilitation services in the future. You need to provide high-quality care every single day. You need to incorporate regulatory and accreditation requirements for safe patient care into your daily care practices. You need to learn continuously about this specialty field and to incorporate new evidence-based care strategies into your practice as they are developed. This includes the use of technology for both treatment and functional adaptation. You need to take seriously your role as teacher and advocate of patients with disability and use yourself as a therapeutic tool to help your patients maximize their potential. On the Computer: Complete the Overview quiz, page 12. Then, return to the Main Menu and start the next chapter: What Is Rehab? Watch for the page that tells you to return to the workbook. One More Time! Coordination and continuity of care matter! YOU make a difference in each patient s quality of life. Overview Rehab Nursing Series : Intro to Rehabilitation 7

21 CHAPTER 2 WHAT IS REHAB? Rehabilitation is a simple concept. The hard part is the art of pushing, prodding, coaching, supporting, and releasing patients day after day. It is almost like rearing a child over and over again, giving them the tools to make them successful in the world we live in and then sending them off. What Is Your Job in This Chapter? Your job in this chapter is to learn about the philosophy and goals of rehabilitation. Think about how you will demonstrate this philosophy in your day-to-day practice in this specialty field. On the Computer: What Is Rehab?, pages 3-22 Chapter Highlights Rehabilitation is a process and philosophy. Rehabilitation care can be delivered in any setting. The field of rehabilitation is heavily impacted by laws and regulations and the number of people needing rehabilitation care. You need to develop strong skills in setting goals with your patients and measuring progress toward them. What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 8

22 Just What Is Rehabilitation? The World Health Organization has defined disability according to limitations in body structure, activity, and participation in community life. This paradigm promotes a focus on empowering persons with disability so that they can equally and fully participate in community-level activities. 1. What is the definition of rehabilitation? Trends in Rehabilitation Change continues to impact rehabilitation services as it does others in the healthcare industry. The Balanced Budget Act of 1997 and the Health Care and Education Reconciliation Act (amending the Patient Protection and Affordable Care Act) of 2010 have dramatically impacted rehabilitation services in all settings through its action on Medicare documentation and reimbursement. Other issues impacting the field include: Insurance companies continue to pick and choose the disciplines for which they will pay, leading to restructuring and the development of alternative treatment models that focus on smaller teams, alternative settings, and increased use of unlicensed assistive personnel. The number of disabled and elderly in our communities continues to grow. Our ability to meet their needs will depend on technological and sociological advances, and the outcome of healthcare reform efforts. Increased survivorship and improved health in those with disability will lead to the need to care for them as they age, a relatively new issue for the field. What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 9

23 2. What trends are impacting your work setting? Interview fellow team members who have worked in rehabilitation for more than several years to learn about the impact of local trends on your rehabilitation setting. The Continuum of Care With all of the changes impacting the rehab industry, the continuum of care has become very important to effective rehabilitation care. The process of care and adaptation is usually a lifelong event. 3. What two items are important when using the continuum of care if teams are to reduce duplication of effort and decrease the risk of relocation stress in patients? Caregivers should be aware of the stresses placed on the patient and family when they are moved from setting to setting. The effort required to learn and trust the new team is tremendous, especially when it occurs in an unfamiliar environment with many unwritten and unknown rules of conduct. The newly-arrived family group must learn to adapt to the new environment and the new team members, while trying to cope with losses and the reality of the situation. Team members must make every effort to be flexible and supportive. The best method of care for this problem is good planning and prevention. Symptoms of relocation stress include: Apprehension, depression, or increased confusion Changes in sleep patterns, eating patterns, or gastrointestinal disturbances What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 10

24 Expressions of distress or need for excessive reassurance Vigilance and withdrawal 4. What interventions can you think of that could prevent relocation stress from developing when a patient is transferred to your care? Philosophy of Care Philosophies are the principles that guide and shape healthcare delivery. They provide focus for the rehabilitation team. In rehabilitation, this means that patients, families, and caregivers have the right to become experts in their own care. 5. What must the team provide in order for patients and families to become experts in their own care? Problem Lists It is easier to write a good goal if the problem is clearly identified. Problems are often documented as a single word or simple phrase depending on the tools used for the care planning process. You learned in the course that many assumptions can occur that may or may not be accurate when shorthand is used to identify a problem. What would happen if the problem was descriptive of the data found in the assessment? What if the problem explained the issues of the problem to others using the plan of care, making the plan more meaningful? Let s review the example from the course again. What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 11

25 Instead of: Nutrition or Altered nutrition A descriptive problem might say: Altered nutrition related to: Increased nutrition needs due to excess energy expenditure because of agitation (Rancho IV brain injury) Decreased oral intake due to distractibility Mild oral motor control problems from jaw and facial injuries Difficulty sustaining nutritional support via tube feedings due to frequent pulling of tube Which of these do you think gives the oncoming caregiver the best picture of what is going on with this patient? Goals Most of us who spend any significant time in the practice of rehabilitation become experts in goal writing and goal development. Goal development should not be done simply to meet standards or requirements; it should be done to focus and guide care delivery and patient effort. The goals of rehabilitation focus on facilitating function and independence through adaptation and therapeutic intervention. 6. On what do most patient/family goals focus? Remember, goals should be specific, measurable, attainable, relevant, and time-related. Well-written goals will present a target for each caregiver. They should be written clearly enough to present the same picture to each person reading them including the patient and family. What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 12

26 Short-term goals build step-by-step to the final outcome you are working to help the patient achieve. What would be the likely outcome (or long-term goal) to be achieved for a patient with the above problem? How about the following? Patient meets nutritional needs (lab values within normal limits, weight at baseline) with oral intake without aspiration. This is the first week of the patient s care by the rehabilitation team. The team is working on short-term goals to move the patient toward the desired outcome. This week, they want to establish a safe way for the patient to eat so that the tube feedings are not needed and there is no aspiration. A short-term goal for this week may be: Patient able to eat finger foods without aspiration and tube feedings discontinued by Thursday. Perhaps next week s goal will be: Patient meets caloric target of 2200 kcals and a protein target of 60 g per day by Thursday. Remember not to confuse goals with interventions such as type of diet, safe swallowing strategies, removal of distractions, or need to complete an assessment or plan. In the following questions, write short-term goals for these examples of problems that are common to patients in rehabilitation settings. Feel free to make up any assessment information you may need to complete the picture for yourself as you work on this exercise. (Answers in the back of the workbook are suggested responses; evaluate your responses for completeness.) While this process may not match the process in your work environment, it will help you learn to develop goals. Use these steps, or remember: who will do what, to what degree, by when? Identify the goal Make it measurable Make it relevant Make it time-specific Make it specific What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 13

27 Problem: Impaired physical mobility Right hemisphere stroke with left hemiparesis Limits in bed mobility, coming to sit, and transfers Dependent for wheelchair mobility Very poor endurance, but does try to follow cues and participate 7. Goal: Problem: Bowel incontinence Frequent oozing of stool Lack of voluntary or reflexive emptying because of spinal shock following spinal cord injury 8. Goal: Problem: Impaired verbal communication Stroke with expressive aphasia Inability to accurately indicate yes/no or to use call light 9. Goal: What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 14

28 Problem: Fluid volume deficit Cranial nerve damage from traumatic brain injury Dysphagia Negative intake and output balance Concentrated urine, weight loss, poor skin turgor 10. Goal: Problem: Risk for injury Brain injury Poor balance, though tries to ambulate Poor judgment Tries to leave unit when up in wheelchair 11. Goal: It is important that those new to rehabilitation care spend some time with the appropriate person(s) on your team to learn your care planning and discharge planning processes. (The Rehab Nursing Series provides additional training on this topic in the course Got a Plan, Man? Patient-Centered Care Planning in Rehabilitation. You can find information at What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 15

29 Documentation of individualized plans of care and progress toward goals is simply good rehab nursing practice. Remember that documentation of the team is audited by payers to evaluate if a patient is receiving the appropriate level of care. On the Computer: What Is Rehab?, pages 23-24, Case Study and Quiz Then, return to the Main Menu and start the next chapter: The Rehabilitation Nurse. Watch for the page that tells you to return to the workbook. One More Time! Rehabilitation is a process of providing coordinated care aimed at improving health, reducing future risks, and improving function. Transitions between settings can be difficult for patients. Be proactive in reducing stresses associated with them. Develop skills in writing and tracking the patient s progress toward goal achievement. What Is Rehab? Rehab Nursing Series : Intro to Rehabilitation 16

30 CHAPTER 3 THE REHABILITATION NURSE The nurse is the pivotal point of all inpatient rehabilitation care. In addition to facilitating self-management of healthcare needs, the nurse is active in blending all that the patient learns in therapy into daily care, driving the success (or failure) and efficiency of the program. With limited lengths of stays and shrinking resources, it is imperative that the nurse understands the pivotal role he or she plays and aggressively acts on it each and every day. What Is Your Job in This Chapter? In this chapter you will identify the roles of the rehabilitation nurse. You will learn to differentiate fact from fiction when it comes to rehabilitation nursing practice. You also will be introduced to the Association of Rehabilitation Nurses and the process for becoming certified as a rehabilitation nurse. Chapter Highlights You are a therapeutic tool central to the process of rehabilitating the patients in your care. The rehabilitation nurse wears many hats and changes them frequently. The art of rehabilitation nursing revolves around wearing the right hat at the right time. Rehabilitation nursing is about teamwork and the delivery of patient-centered care. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 17

31 On the Computer: The Rehabilitation Nurse, pages 3-18 What Makes a Good Rehab Nurse? Rehabilitation nursing can be very rewarding. It can be the most important job you have ever done in your life. You will touch the very hearts and souls of those in your care. Never forget that you are a tool which will influence the way they will live the rest of their lives. Rehabilitation nursing combines medical/surgical nursing with additional skills in functional skill development. 1. Identify at least three traits evident in great rehab nurses. The Rehab Nurse Is A rehab nurse has many roles and uses them all on almost any given day. The challenge is in learning to be good at all of them. Most nurses new to the field of rehabilitation are comfortable with the caregiving role. However, they may be challenged by the educator role that often requires that they coach or sit on their hands and allow the patient the opportunity to struggle through a skill, solve a problem, or learn a process on their own. The art is in determining when the patient has been pushed enough and needs assistance and when to push the patient for more. This skill is developed through experience and role-modeling by other team members. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 18

32 Match the following roles to their descriptions. a. Educator b. Caregiver c. Advocate d. Collaborator e. Coordinator f. Counselor 2. Nurses provide care that is consistent, thorough, and supportive of the patients' and caregivers' efforts to learn their own care. Caregiving is integrated with education and identification of the tools and resources needed to reduce the burden of care and transfer skills and responsibilities to the patient or caregiver. 3. Together, the team facilitates positive coping and assists patients and families to plan, practice, and problem-solve community reintegration issues. 4. In order to do this well, the nurse must know the patient's wishes and desires well enough to be an effective and true representative. The nurse often spends more time with the patient than other team members and may have more insight into the patient's desires. 5. This is one of the most important roles of the nurse in a rehab setting. One of our basic principles is that every nursing encounter is a potential teaching opportunity, an opportunity to teach them how to live, not just survive, in the community. Your job is to teach, to coach, and to give them the skills they need to solve their problems and use the resources in their community. 6. Effective and efficient care results from the efforts of all team members working together to be creative, problem-solve, and promote functional gains in each patient. This work across and between disciplines increases the potential of each interaction through shared knowledge and resources. 7. The rehab nurse has responsibility for the patient around the clock. Practicing skills repeatedly throughout the day, in a coordinated and consistent manner, will help patients acquire effective problem-solving skills and become experts in their own care. This also requires support, listening, and advising for optimum health and well-being in the community. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 19

33 Professional Roles of Rehabilitation Nurses Role descriptions of many subspecialists in rehabilitation nursing are available from the Association of Rehabilitation Nurses (ARN). These roles were developed by consensus of the ARN Special Interest Groups and include: Gerontological Rehabilitation Nurse Home Care Rehabilitation Nurse Pain Management Rehabilitation Nurse Pediatric Rehabilitation Nurse Rehabilitation Nurse Manager The Rehabilitation Admissions Liaison Nurse The Advance Practice Rehabilitation Nurse The Rehabilitation Nurse Case Manager The Rehabilitation Nurse Educator The Rehabilitation Staff Nurse The Rehabilitation Nurse Researcher LPN/LVN on the Rehabilitation Team Access these role descriptions at Professional Standards The Association of Rehabilitation Nurses (ARN) publishes the following as the definitions and scope of practice for rehabilitation nursing. Definitions and Scope of Practice Rehabilitation nursing is a specialty practice area within the scope of professional nursing. It involves the diagnosis and treatment of human responses of individuals and groups to actual or potential health problems resulting from altered functional ability and altered lifestyle. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 20

34 The goal of rehabilitation nursing is to assist individuals with disabilities and chronic illness in the restoration, maintenance, and promotion of optimal health. The rehabilitation nurse is skilled at treating alterations in functional ability and lifestyle resulting from injury, disability, and chronic illness. Association of Rehabilitation Nurses (ARN), n.d. As noted in the computer component of the course, the Association publishes Standards of Care and Standards of Professional Performance in a booklet called Standards & Scope of Rehabilitation Nursing Practice, 6th Edition (2014). See ARN bookstore at 8. Define the standard of practice for planning noted in the synopsis of Standards & Scope of Rehabilitation Nursing Practice. It is not uncommon to hear that rehabilitation nurses address primarily bowel, bladder, and skin issues. The Association of Rehabilitation Nurses defines the practice of rehabilitation nursing in a much broader manner, as noted in their position statement sent to the Centers for Medicare & Medicaid Services (Rehabilitation Nursing Criteria for Determination and Documentation of Medical Necessity in an Inpatient Rehabilitation Facility, The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 21

35 Rehabilitation nurses address all of these areas and more in daily practice. Rehabilitation diagnoses, course of treatment, plan of care, and expected outcomes Bladder and bowel management Skin care management Medication and pain management Reinforcement of self-care and mobility skills Cardiovascular, autonomic, and pulmonary management Energy conservation and sleep Intimacy and sexuality Nutrition and lifestyle adaptations Role changes and psychosocial manifestations Primary prevention and adoption of health and wellness Aftercare, including community resources, physician and ancillary services, durable medical equipment procurement, and emergency procedures What are the standards and scope of practice for rehabilitation nursing in your setting? If you cannot define them, review them with your mentor. Myths of Rehab Nursing Myths abound regarding how hard it is, physically, to work in rehab and that it is an unrewarding, even depressing, area in which to work. Reality is that most rehab nurses are seldom injured if they use the techniques taught to them. And rehab The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 22

36 nursing is as rewarding as any other area of nursing, if you are vested in assisting your patients in achieving the best possible quality of life. (The Rehab Nursing Series provides additional training on moving and handling patients in the course Take Care! Safe Patient Handling Works! You can find information at 9. Identify the best way to avoid back injuries while caring for patients. Rehab nursing is impacted by the same issues impacting the rest of healthcare. Changing demands in the industry with a constant stream of new regulations intended to improve the quality and reduce the cost of care Recruitment and retention issues impacting the supply of rehabilitation professionals, including the loss of seasoned staff and mentors in the field Changes in the role of the nurse on the team variable from setting to setting and heavily impacted by regulatory requirements Reflecting on what you learned when you reviewed the Standards & Scope of Rehabilitation Nursing Practice, answer the following questions True or False. 10. In order to provide quality and cost-effective care, each nurse is accountable to stay current regarding trends in the healthcare industry. 11. The nurse's role may vary from setting to setting and even from year to year depending on the impact of industry trends and regulatory directives. 12. The nurse can participate proactively in meeting industry demands by being creative, collecting data, and supporting improvement efforts. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 23

37 13. The nurse should not lose sight of the patient and quality of care when faced with changing demands of the industry. 14. The experienced nurse should actively mentor and teach those new to the team to enhance skill development. Rehabilitation Work Is Teamwork! If you are new to the field of rehabilitation, you will quickly learn that you need to meet others on your team and establish your role with them. The rehab nurse and assistant at the bedside in inpatient settings are the ones who, 24 hours a day and 7 days a week, reinforce teaching and training done by other disciplines. Continuity becomes critical. One hour of therapy can be undone repeatedly each day or reinforced throughout each day. Successful rehabilitation inpatient programs are heavily dependent on the commitment and efforts of a solid rehab nursing team. Here are some tips to help you assimilate your experiences as a nursing team member: Arrange opportunities for observation of your fellow team members as part of your continuing education in your role. Avoid storytelling and focus on problem solving to meet goals when discussing the care of patients in team meetings. Communicate results back to the nurses who will care for the patient after you. Focus on integration and continuity of care! Remember that it is easier to undo previous training by failing to follow through than it is to reinforce it. It is difficult enough for a patient with cognitive and perceptual deficits to learn The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 24

38 without the nurses and therapists being inconsistent, changing expectations, or offering new solutions each time a task is approached. It is a little like taking advanced math classes with a different teacher each day and no communication between them. What would your learning curve be? Remember, you have a very limited amount of time to teach survival skills to each patient. Listed below are the tips for building rapport with team members. Fill in the blanks to complete the statements with words from this list. clarify educate prepare listen reliable needs support respect humor impression 15. Be visible and create a good. Be aware of when you are on stage. 16. Anticipate. Volunteer, pick up the phone and answer it, help cover call lights, etc. 17. Be. 18., really listen. 19. Act with confidence, and in advance for the worstcase scenario or the unexpected crash of a patient. Rehearsal always pays off. 20. yourself and ask appropriate questions. Keep a small notebook handy to write down questions when you think of them. 21. Use appropriately. 22. and share perspectives. Find a mentor. 23. Treat others with. Learn their names and their roles. 24. Say thank you and show. Develop a team spirit that supports the unit s morale. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 25

39 Jargon Jargon can be very confusing, but using common language facilitates communication among team members. To get you started on familiarizing yourself with jargon common to rehab settings, you completed jargon exercises in the computer component of the course. This was just a sampling. Keep learning! When you see an unfamiliar term, ask what it means or look it up. Be consistent with the team in use of terms that describe the amount of assistance required when a patient is completing a task. The terms reflect the amount of assistance provided (e.g., set up, minimum, moderate, maximum, or total assistance). Learn the names of the equipment used in rehabilitation settings and how to use it. Define the terms below. 25. ADLs: 26. Hemiplegia: 27. Paraplegia: 28. Tetraplegia: Professional Resources The Association of Rehabilitation Nurses (ARN) is your nursing organization. There are journals, newsletters, user groups, and conferences to help you network and develop your professional role. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 26

40 These ARN web pages can provide you with more information on these topics. ARN home page: List of local chapters: Join the list serve or electronic discussion group: Information about why to become certified: You can also continue to develop your skills in rehabilitation nursing by working your way through the Rehab Nursing Series. This course is the first course in this series. All titles in the series are listed in the front of the workbook. You can access more information on these courses at On the Computer: The Rehabilitation Nurse, pages 19-21, Review, Case Study, and Quiz Then, return to the Main Menu and start the next chapter: The Rehabilitation Team. Watch for the page that tells you to return to the workbook. One More Time! Incorporate the many roles of rehabilitation nursing into your practice. You will need them all almost every day. Learn the jargon of your team so that you are communicating accurately with each other. Learn strategies from therapists that you can incorporate into daily care to improve patient function. The Rehabilitation Nurse Rehab Nursing Series : Intro to Rehabilitation 27

41 CHAPTER 4 THE REHABILITATION TEAM The most critical tool each team member should have is a great skill in communicating including good listening skills! Why Should You Care? Chapter Objectives or What Is Your Job in This Chapter? Your task in this section is to learn about your fellow team members and how to interface with them to improve the care provided to your patients. You have already been introduced to the concept that rehab work is team work. This concept should be embraced by all members of the rehabilitation team. Chapter Highlights An inpatient rehabilitation nursing team has 24/7 accountability for patients and must, therefore, incorporate the skills that patients learn with the therapists into the patients daily routine. Outcomes are improved with tight coordination and continuity of care between nursing and therapy team members. Quality and safety are enhanced when appropriate delegation to assistive personnel occurs. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 28

42 When the team does not collaborate, coordinate, and communicate effectively, the patient, the organization, and the community suffer. Perhaps you think that is a bit far-fetched. It is not. For every patient who does not receive coordinated, collaborative care there is a domino effect impacting all of us. The patient does not maximize his potential in the time allotted to him in rehabilitation care because of variable support, training, expectations, and education. The patient/family begin to pick and choose what is important to them and what they will implement on their return to the community, increasing the risk of needing more healthcare services in the future. Increased use of the continuum results when a patient does not reach full potential at any one point in the continuum. While this is what the continuum is for, we should work hard to maximize benefits at each level of care. Increased use of services due to inefficiencies in the work of the team increases the cost of care. Increased costs require payers to restrict access to services and to raise amounts paid by all of us in insurance premiums or by federal deductions from paychecks. Restricted access eventually means that you or one of your loved ones may have difficulty getting the care needed when faced with a healthcare need. Rehabilitation teams MUST collaborate, coordinate, and communicate so that there is continuity of care between all team members and the patient is supported in achieving the best possible outcomes in the most efficient manner. On the Computer: The Rehabilitation Team, pages 3-10 The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 29

43 Rehabilitation Team Synergy in Action There is some variability in team membership across the continuum of care. As a new member of the team, you will need to meet others on your team and establish your role with them. This is easier if you have some basic understanding of their roles and backgrounds. Remember that integration of care is a key responsibility of nursing team members. Integration and continuity are dependent on communication and the understanding of each other's roles and expertise. Make an effort to get involved with your patients and fellow team members and all will benefit. Complete the statements with names of rehabilitation team members from the list below. Terms may be used more than once. patient physiatrist physical therapist occupational therapist social worker neuropsychologist speech-language pathologist rehabilitation nurse 1. The is generally considered to be the most important member of the team. 2. The professional (2 words) is a pivotal member of the team, responsible to coordinate care from many disciplines while maintaining health and preventing complications in assigned patient groups. 3. The (2 words) recommends and adapts equipment and the environment to facilitate independence. 4. The (2 words) creates a therapeutic milieu and provides education and reinforcement of prior learning. 5. A is a physician who has special training in physical medicine and rehabilitation. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 30

44 6. The (3 words) addresses cognition, information processing, and memory deficits along with other team members such as a neuropsychologist and occupational therapist. 7. The identifies medical diagnosis and prognosis, manages medical needs, and prescribes therapies, testing, medications, therapeutic aids, and adaptive equipment. 8. The (2 words) facilitates the development of functional skills related to activities of daily living at home, work, or school. 9. The (2 words) addresses mobility issues through the use of exercise, strengthening, inhibition of abnormal reflexes and tone, positioning strategies, gait training, use of orthotics and prosthetics, and facilitation of sensorimotor function. 10. The (2 words) also works closely with the prosthetist and orthotist to ensure the correct fit and use of prosthetic and orthotic devices. 11. The (3 words) evaluates receptive and expressive communication skills. 12. The (3 words) also evaluates the patient at risk for swallowing disorders, making recommendations for diet, food, and fluid consistency, and adaptive eating techniques to decrease the risk of aspiration. 13. A specializes in the treatment of cognitive disorders associated with brain injury or disease. He or she can be very helpful in identifying cognitive process impairments and in advising the team and significant others regarding interventions and coping strategies. 14. The (2 words) focuses on coping, adapting, and facilitating a return to the community. This role is also active in assisting patients and significant others in addressing the impact of the disease or disability on the living arrangements, roles, and finances of the family. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 31

45 Other Team Members Membership and responsibilities of the team may vary greatly from setting to setting according to the needs of the patient. Any number of other specialists may be involved in the patient's care. These experts generally are pulled into the team according to need. They are excellent resources; get to know them and incorporate them into your network. Chaplain: provides emotional and spiritual support Driving Instructor: assesses driving abilities and retrains in driving with adaptive equipment Vocational Specialist: assesses vocational aptitude and abilities and facilitates return to productive employment Prosthetist: designs, fits, and prescribes prosthetic devices Orthotist: designs, fits, and prescribes supportive devices used for joint stabilization Additionally, you will be working with a variety of assistive personnel. Answer the following as True or False. 15. Unlicensed assistive personnel are unskilled labor. 16. Unlicensed assistive personnel have bad jobs and are stuck doing all the grunt work. 17. Stress and burnout are no worse for unlicensed assistive personnel than for other professionals. 18. Patients are concerned about the healthcare, food, and environment, not about the unlicensed assistive personnel caring for them. Team Structure and Organization Teams may be organized in a hierarchical or matrix reporting system and the variations are numerous. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 32

46 Interdisciplinary teams are at risk for ineffectiveness and turmoil if there is not an organizational framework that addresses issues of territoriality, overlapping roles, and communication processes. This may be further compounded when groups change due to staff turnover or reassignments. Ultimately, this may leave team members in different stages of development. Teams can remain in a given stage of development for extended periods of time or may fluctuate wildly through stages due to external forces. Scholtes, Joiner, & Streibel, List at least 5 things that drive team structure and composition. Match the type of team organizational pattern to its description. Multidisciplinary Interdisciplinary Transdisciplinary 20. A limited number of team members interact with the patient and significant others. The rest of the team functions as consultants to the identified caregivers. 21. Team members are accountable for their own area of expertise, but also are accountable to work toward common goals with the rest of the team. Problem solving crosses discipline boundaries and goals are common to the patient rather than to individual disciplines. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 33

47 22. Each team member is accountable for their own specialty area and works in a coordinated manner with fellow team members (though focused primarily on their own discipline) to facilitate the patient s return to the community. Rehabilitation Team Functions The Commission on Accreditation of Rehabilitation Facilities (CARF) has established the core functions of the rehabilitation team. These functions should sound familiar because they are very similar to the nursing process. 23. List the core functions of the rehabilitation team. What Makes a Good Team Work Well Together? What makes a good team? And what makes them work so well together? If you could bottle this and sell it, you would make a million dollars. Good teams develop from the dynamics of leadership, respect, and collaboration. They work well together when their processes and goals are clear and the members are motivated. Answer the following questions as True or False. 24. Good leadership means that energy will be put into building the team's skills and relationships, improving their ability to meet their goals, and avoiding stagnation. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 34

48 25. Competition can occur between disciplines and lead to turf issues. This is particularly difficult when one discipline feels that it is less important or when it is being affected by reimbursement and cost issues that it feels are unfair. 26. All team members should be adept at conflict resolution, addressing issues in a timely manner before they interfere with the team's function. 27. Collaboration is the foundation on which teamwork is built. 28. Advocacy keeps the team focused on the patient's goals rather than the goals of individual team members. Team Development Teams grow and develop like any other group. Match the following to the description of team development that best matches the stages listed below. Forming Storming Norming Performing 29. Members demonstrate dependency on the designated leader, anxiety about roles, and may participate in pseudo-work (telling stories about patients that are not relevant to the treatment decisions at hand). 30. The team is highly productive and effective during this stage, and members understand each other's strengths and weaknesses. 31. The team works harmoniously together. Trust and structure increase, facilitating cohesion and dynamics. 32. Conflict is obvious. Members are less dependent on the leader and more vested in own views, often questioning the process or procedures they are required to follow. Teams do not stay in any one stage but rather move back and forth through various stages as members and the industry change. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 35

49 Characteristics of Effective Teams Effective teams share a common set of traits. A relaxed environment that supports balanced participation and respectful disagreement helps to avoid uncomfortable conflict that can interfere with the effectiveness of the team. 33. List at least 5 traits that are characteristic of effective teams. On the Computer: The Rehabilitation Team, pages 11-13, Review, Case Study, and Quiz Complete the exercises on the next several pages in the workbook with your mentor. Then, return to the Main Menu and start the next chapter: Rehabilitation Populations. Watch for the page that tells you to return to the workbook. One More Time! You will quickly become involved in team processes, so learn about them early on and prepare yourself for professional interactions. Continuity matters! One hour of therapy can be undone repeatedly each day or reinforced throughout each day. If you delegate care, make sure you spend adequate time with patients so that you actually know what is going on with them. The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 36

50 Learn About Your Team Much can be learned about your team and how it functions through observation and reflective thinking/discussion. Use this worksheet to learn about your team and its functions. You can further your understanding by discussing your observations with your manager, educator, or preceptor. Identify your fellow team members: Patient/Significant Others Nursing Staff Physiatrist/Physician Physical Therapists Occupational Therapists Speech-Language Pathologists Clinical Dietitians Respiratory Therapists Recreational Therapists Other (list): Identify your team's structure: Multidisciplinary Interdisciplinary Transdisciplinary Other: The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 37

51 Identify your role in the patient's assessment: Identify your role in patient/family education: Identify your role in identifying the patient's goals: Identify your role in planning the patient's care: Identify your role in communicating and coordinating the plan of care: The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 38

52 Identify your role in evaluating the effectiveness of the plan of care: Who is the formal leader of your team? If there is an informal leader, who is it? What kind of competition is there among team members? How is conflict resolved? Describe at least one situation in which you have observed team members advocating for the patient: The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 39

53 What stage of development is your team at? Forming Storming Norming Performing Which of the following characteristics are evident in your team? Clear rules Defined goals and roles Comfortable and relaxed environment Nurture and develop each other Effective communication Well-defined decision making procedures Beneficial team behaviors and balanced participation Awareness of group processes Are you evaluated for your participation in the team process? How is this measured? What is your plan for achieving a high score in this area? The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 40

54 Are you able to do the following on your team? Identify overall team goals and determine if you understand them, can support them, and feel ownership of them. Place the patient s goals ahead of your individual goals within the team. Get to know and understand fellow team members; build trusting, respectful relationships. Communicate openly and honestly. Respect differences and value diversity in people, thoughts, and ideas. Willingly listen to all team members and try to understand the others point of view. Facilitate team development through participation, constructive use of conflict, reaching consensus, maintaining good relationships with fellow team members, and compromising when necessary. Avoid group think and encourage divergent views by voicing honest opinions and presenting pertinent facts and by respecting others for doing the same. Network with your fellow team members. What are you most concerned about regarding team relationships and the team s care planning process? The Rehabilitation Team Rehab Nursing Series : Intro to Rehabilitation 41

55 CHAPTER 5 REHABILITATION POPULATIONS Funding continues to have a significant impact on access to and utilization of services. Legislation continues to urge creative and economical approaches to care. What Is Your Job in This Chapter? Your job in this chapter is to identify the types of patients commonly found in rehabilitation care. Using this as a basis, you will consider how approaches to disability, population-specific care, and cultural sensitivity need to be incorporated into your care strategies. On the Computer: Rehabilitation Populations, pages 3-15 Chapter Highlights Stroke, brain injury, and spinal cord injury are the most common neurological diagnoses found in typical rehabilitation care, though a variety of less common diagnoses may be addressed. Debility from a variety of health problems and orthopedic problems are a second common subset of patients receiving rehabilitation care. Care must be delivered with consideration of age, culture, resources, and functional ability. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 42

56 Rehabilitation Populations & Their Needs The practice of physical medicine and rehabilitation provides care to those with disabilities in an effort to minimize handicaps. During assessment, the rehabilitation team determines the patient s strengths and assets as well as his limitations and devises a plan to improve activity and participation levels. CARF, 2015 Match the following WHO definitions to the correct term. Impairment Activity Participation 1. The nature and extent of functioning at the level of the person; may be limited in nature, duration, and quality (e.g., taking care of oneself) 2. The nature and extent of a person's involvement in life situations in relation to impairment, activities, health conditions, and contextual factors; may be restricted in nature, duration, and quality 3. A loss or abnormality of a psychological, physiological, or anatomical structure or function Activity Limitations The rehabilitation team reduces impairment and improves environmental factors in an effort to increase activity and participation. The rehab nurse incorporates techniques for improving function into care. There were some tips to this end provided in the computer component of the course. Indicate True or False for the following to see what you remember. 4. In most circumstances, it generally is easier for a patient to don both pants and shirt while lying in bed. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 43

57 5. Allow adequate time for a patient to remember, process, and problem-solve before offering another cue to help with selfcare. 6. Address healthcare regimens separately from other functional activities. Knock! Knock! Who s There? Each rehabilitation setting has its own pattern of admissions. The patterns of admission and the regulatory requirements shape patterns of practice. Answer these questions for your setting. 7. What types of patients are commonly admitted to your program? 8. What are their lengths of stay? 9. What is the average workload or acuity? This is often reported as hours of care per day per patient (hours per patient day) in inpatient settings. 10. How are decisions made regarding who gets admitted to your unit and who does not? Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 44

58 Stroke Stroke is one of the most common diagnoses found in rehabilitation settings. (The Rehab Nursing Series provides additional training on this population in the course Rehabilitation of Stroke. You can find information at Patient safety, management of comorbidities, maximizing functional skills, and providing training and support to the caregiver are important to successful stroke rehabilitation. 11. Why is stroke incidence increasing? Patterns of deficits following stroke are directly related to the type of stroke and vessel (part of brain) involved. 12. List 5 deficits common to left hemisphere stroke. 13. List 5 deficits common to right hemisphere stroke. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 45

59 Spinal Cord Injury Spinal cord injury results in various levels of disability. Deficits are directly related to the site and amount of damage sustained by the spinal cord and often include motor and sensory impairment; alterations in bowel, bladder, and sexual function; and, in those with higher injuries, alterations in autonomic nervous system functions. (The Rehab Nursing Series provides additional training on this population in the course Rehabilitation of Spinal Cord Injury. You can find information at What population group sustains the most spinal cord injuries? 15. What is the most common cause of spinal cord injuries in older adults? 16. When does rehabilitation begin for the patient with a spinal cord injury? 17. What is the purpose of early rehabilitative interventions for patients following spinal cord injury? 18. List at least 5 deficits common to spinal cord injury. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 46

60 Brain Injury Brain injury remains an all-too-common result of motor vehicle accidents, violence, and recreational activities. Regular and consistent use of helmets, seat belts, and other safety devices can dramatically decrease the incidence of traumatic brain injury. Cognitive deficits are some of the most devastating problems following brain injury. (The Rehab Nursing Series provides additional training on this population in the course Rehabilitation of Brain Injury. You can find information at How severe are the majority of brain injuries? 20. List at least 5 deficits common to brain injury. Other Patient Populations Depending on the environment in which you work, you may see a number of other diagnoses. 21. What other types of patients do you see in your environment? Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 47

61 Common Problems There are some problems that occur regularly in the rehabilitation care of patients. The computer component of the course addressed medication safety, elimination, dysphagia, cognitive problems, communication disorders, and skin care. This is only a basic introduction to these care needs. Answer the following questions to see what you remember. 22. What type of medications should not be crushed? 23. Should you use applesauce to help a patient with dysphagia to swallow medications? Why or why not? 24. Why should the bladder be emptied within 6-8 hours? 25. What is wrong with simply using incontinence products to manage elimination accidents? 26. Is there such a thing as a silent aspirator in patients with dysphagia? 27. Should patients with dysphagia lie down and rest after meals? Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 48

62 28. What strategy can be used to increase a confused patient s ability to focus on the task at hand? 29. What must be remembered if a patient requires 1:1 care due to confusion and risk for injury? 30. Is it likely that a patient with receptive aphasia will be able to read? 31. How do you evaluate yes-no reliability? 32. Should turning schedules for patients on rehabilitation units routinely be every 2 hours? Why or why not? 33. What is the first thing that should be done if the patient develops a red area? Population-Specific Care Patients of different age groups and maturity levels have different physical, psychological, and social needs. There are four populations that often need population-specific care related to their developmental level: infants, children, adolescents, and elders. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 49

63 Remember the following regarding population-specific care. Adapt the way you perform a task to the physical and social needs of the patient. Interactions are more effective when they are developmentally appropriate. Explain procedures to patients at a developmentally-appropriate level and allow a suitable amount of time, if possible, for understanding and assimilation. Accommodate for changes in physical skills and cognitive function. 34. List at least 5 situations that require a developmentally-appropriate response. Impact of Disability Disability impacts developmental tasks. Answer these questions regarding care of children. 35. What should be incorporated into care for children? 36. Should teens be encouraged to participate in problem solving and decision making? Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 50

64 Aging Complete these phrases reminding you of issues to remember when caring for the elderly. 37. Cardiac output. 38. About times the light is needed to see. 39. Tolerance for debt is low. 40. GI motility. 41. Diminished renal function increases the risk of. Access to Care Rehabilitation services are more prominently available in urban regions than rural. Rural access to long-term care and home health services is also more limited. Technology will provide options and opportunities in the future. 42. List one reason why access to care may be limited. On the Computer: Rehabilitation Populations, pages 16-18, Population-Specific Review, Case Study, and Quiz Then, return to the Main Menu and start the next chapter: Therapeutic Milieu. Watch for the page that tells you to return to the workbook. One More Time! Learn about the needs of the patient populations typically cared for by your team. This will help you develop expertise for most patients. Provide care in a developmentally-appropriate and functionally-appropriate manner. Involve family members too! Learn about issues related to patient access to care both in the organization and in the community. Rehabilitation Populations Rehab Nursing Series : Intro to Rehabilitation 51

65 CHAPTER 6 THERAPEUTIC MILIEU Milieu: the physical or social setting in which something occurs or develops What Is Your Job in This Chapter? In this chapter you will learn what a therapeutic milieu is, identify ways you can facilitate it, and evaluate the importance of education in maintaining it in your unit. Your first job is to define the term milieu. A milieu is a powerful therapeutic tool, just as you are a powerful tool as you use different personas with different patients to gain their trust and cooperation. The use of self and milieu is as important as the use of any other tool to promote positive coping and functional gain in the rehabilitation process. Chapter Highlights The milieu creates support and opportunity for the patient. It also provides rules and expectations for behavior for patients and team members alike. The team creates, supports, and maintains the milieu through patient/family education. Consistency in team members reduces stress in patients/families. The team must earn the trust of the patient and help them to manage limited resources. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 52

66 On the Computer: The Therapeutic Milieu, pages 3-18 Creating a Therapeutic Milieu Many rehabilitation professionals are unaware of the difficulties and stresses of life in the community in a wheelchair or of life caring for a family member 24/7 without relief or a change of shift. In our current healthcare world, those working in acute settings have a lack of exposure to the long-term effects of disability; there are shorter lengths of stay in each stage of the continuum, and there often is a lack of training regarding the realities of life in the community with a disability. At times, rehab personnel do not ask critical questions about the environment and lifestyle to which the patient will be returning. This lack of exposure limits their ability to help patients and caregivers rehearse and prepare for worst-case scenarios following discharge. The creation of an effective milieu in inpatient settings can help to bridge this gap. 1. What is the definition of a milieu? 2. List at least 3 attributes that contribute to the milieu of a rehabilitation setting. A Therapeutic Environment Creating an environment that facilitates community skill development requires planning, thought, and understanding of the transitions most patients in your care will face. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 53

67 Failure to provide opportunities to learn and practice skills required in the community is a significant injustice for rehab patients, leaving them to struggle on their own without support. All too often, the team assumes that skills practiced in the gym are readily transferred into other settings. Patients will tell you that this is not as easy as it seems. There is a huge difference between being successful in the rehabilitation environment and being successful in the community. The rehab program should be incorporated into the real world in a manner that facilitates application of learned skills to the community environment. Staff can improve their ability to facilitate transitions and provide appropriate coaching and training with the ideas below. Evaluate the environment, in relation to the type of patients cared for, to determine how close it is to the conditions of the real world. Make appropriate changes or identify a way to provide opportunities to practice. Ask questions of patients regarding the environment to which they will be returning and problems they anticipate having. Encourage and praise practical problem solving. Use passes into the community to provide opportunities to practice skills and identify problems. This allows patients to be introduced into reality in a gradual and supportive manner. (While this is a valued practice in rehabilitation care, insurance companies may not support the activity. Thus, it must be used selectively, and the therapeutic value must be documented.)* Hold forums or discussions with patients who have been in the community for some time for ideas and suggestions for support and training of newer patients. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 54

68 Critically assess discharge plans for opportunities to facilitate rehearsal of worst-case scenarios and transference of skills to life in the community. Make sure there is a follow-up plan to support the patient and caregiver on return to the community. *(The Rehab Nursing Series provides additional training on the use of therapeutic community passes to improve discharge planning in the course Got a Plan, Man? Patient-Centered Care Planning in Rehabilitation. You can find information at Consider your organization and determine their effectiveness in meeting the challenge of creating an environment that is a) supportive to those newly admitted, but b) representative of reality for those close to discharge. Identify actions your team needs to take (if any) to more aggressively meet the patient's needs in each of the following areas. 3. The patient s immediate room (including the patient's bed, bathroom, doorways, dining and eating facilities, flooring, closets, cabinets, etc.): 4. The community areas of the unit and facility: 5. The environments used for transition or community-level training: The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 55

69 More Than Physical Barriers Society's views of disability and chronic illness are not always kind. As a result, many laws have been implemented to protect the rights of and provide opportunities to those with disabilities. Quality of life is improving for many through the use of education, technology, and media support. What are your feelings about quantity versus quality of life? Perceptions of the quality of life are personal and very individual. Rehab team members are expected to provide support, education, counseling, and respect to the patient and significant others as they traverse this path. It is difficult to acknowledge that, for some, improving their quality of life may not include extending the length of it. What are your beliefs about the healthcare process and issues of care versus cure? In spite of the fact that the media portrays healthcare as curing almost everything, rehabilitation seldom cures anyone. Instead, the focus is to address the residual deficits of a disease or injury in the effort to minimize its effects. How comfortable are you in allowing your patients to have more control selfcare versus caregiving? Nurses and many family caregivers are conditioned to take care of others in need. However, we do a significant injustice to our patients if we consistently do for them and fail to prepare them for the realities of the community in which they are going to be living (limitations of funding, time, and resources). Staff with negative attitudes toward disability may feel helpless when facing persons with significant limitations. What do you feel empathy or sympathy? Empathy will help you develop solutions; sympathy will limit your ability to prepare your patients for the real world. Consider your team s interactions with patients, and answer the following questions for your setting. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 56

70 6. What messages are sent to your patient population regarding attitudes toward disability? 7. Are there good and bad disabilities, or some that are preferred by the team over others? Which types of patient does everyone want to be assigned to, and which types do they avoid? 8. What kind of reactions do you see when you watch visitors interacting with your patients? 9. What are your feelings about quantity versus quality of life? 10. What are your beliefs about the healthcare process and issues of care versus cure? The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 57

71 11. How comfortable are you in allowing your patients to have more control self-care versus caregiving? 12. What do you feel when caring for your patients empathy or sympathy? From Admit to Reintegration A therapeutic milieu facilitates the processes of rehabilitation. 13. List at least 3 premises that support the development of a therapeutic milieu. Those Unwritten Rules and Expectations All inpatient units have some sort of milieu. Some of this is formalized in orientation materials for patients and families, informing them of the processes and resources of the unit. Even those in community settings are informed of the rules of the game. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 58

72 14. What informal rules exist in your environment regarding how patients are expected to act? Creating Expectations From the moment a patient and his or her family enters our world, we are consciously and unconsciously sending messages that provide them with information and feedback. By being consciously aware of this, the team can define and create expectations for participation and success. 15. List at least 5 expectations your team has of patients and family members which are directly or indirectly communicated to them and describe how you know that the message is received. 16. How does your team care for the caregiver? The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 59

73 Resource Allocation vs. Personal Productivity Resources are limited and most rehabilitation professionals have very high productivity requirements. Access to care is limited, and the team is expected to use the patient s limited resources wisely. 17. Each day that you are delivering care, you are using up some of the patient's resources. How is the patient getting his money s worth? Patient's Rights and Confidentiality Protection of the patient's rights and confidentiality is not only common sense, but it is also mandated by regulations and laws. One of the most common confidentiality problems on the rehab unit is the question of how much information should be given to fellow patients and friends of the patient. Confidentiality rules do apply in these situations, and failure to follow the guidelines of your organization can result in legal action. When fellow patients ask what is going on with another patient, you may suggest that they ask the patient or even go so far as to remind them of confidentiality requirements. If you must tell other patients and family members of a patient at risk on a unit (such as an agitation or elopement risk), you can simply say, "One of our patients is having a very hard time and is at risk for leaving the unit. Would you please be very cautious going in and out of the doors?" There are many polite ways both to maintain confidentiality and to meet the needs of the patients on the unit as a group. They will talk amongst themselves and share information. You do not need to be the bearer of it. 18. Where are your weak links in protecting patient confidentiality? The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 60

74 19. How will you reply to a patient who is asking pointed questions about another patient's situation? Teaching Patients and Families In rehabilitation settings, every interaction with the patient and family is a potential learning situation. The rehab team is consistently role modeling and reinforcing (or failing to reinforce) the messages they are sending to patients and their caregivers. Use the nursing process to assess, plan, implement, and document. (The Rehab Nursing Series provides additional training on this topic in the course See One, Do One Patient & Family Education in Rehabilitation. You can find information at Assess: Identify needs, concerns, current perceptions, beliefs, attitudes, skills, and readiness to learn. Are there barriers to learning? Don't work from assumptions. Establish rapport and find out about the patient's support systems, limitations, and cultural history. Understand the patient's beliefs and knowledge level regarding his diagnosis. Be attentive to age, cognition, and perceptual skills. Verify literacy level. Be attentive to emotional or health factors that may interfere with the ability to learn. Plan: Plan with the patient/family. Use appropriate tools and stay organized. Prioritize education, starting with the information that is critical to the patient's survival. Implement: Stay organized; make sure the patient stays on track. Allow enough time for the patient to practice and experiment. Document: Check off objectives as completed. Keep current records to avoid duplication of work. Document return demonstrations, ability to feed back information that has been shared, or other responses. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 61

75 If your patient does not speak English, be certain to use a certified healthcare translator according to your organization s processes. Providing a good learning environment includes your body language, the environment, and privacy. Make sure patients know what they should do and why, when they should expect results, danger signs to watch out for, what to do if there are problems, and whom to contact for referrals. The Joint Commission (TJC) requires that an assessment be completed prior to implementing a teaching plan. This should be plain old common sense but requires regulation because care providers short-cut this step and assume they know the patient s needs. Plans are expected to be based on identified needs and should include the following. Education on appropriate medication administration Use of medical equipment Information on potential food/drug interactions Counseling on nutrition and modified diets Information on healthcare management, further treatments, and rehabilitation needs Appropriate information should be provided to the discharge setting and caregivers, and documentation should include responses to teaching. The TJC surveyor may ask you how you assess and identify what your patient needs to learn, may ask to see the materials you use, and may ask to see documentation of your work. 20. List at least 5 strategies to enhance patient and family education. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 62

76 Issues of Change in the Rehab Setting Much of the learning required of persons with acquired disabilities under our care will result in extreme demands to change family roles and lifestyles. 21. When does change occur? What Next? Discharge planning is a key component of maintaining continuity of care and alleviating anxiety over transitions. There are a myriad of resources available to patients and their families. These resources range from community support services to volunteers and support organizations. 22. What is the discharge planning process in your setting, and how is it communicated to your patients? I Am My Own Best Advocate One of the hardest things to teach a patient or caregiver is how to be one's own best advocate. We do our patients no favors by doing everything for them. They will not always have the team at their side. Be cautious and avoid creating a codependency that further handicaps them in the community. 23. How does your team teach patients and families self-advocacy? The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 63

77 Ethical Issues in Rehabilitation Settings Ethical issues come in many shapes and sizes in rehabilitation settings. Many rehabilitation organizations have access to resources to help them solve ethical dilemmas. 24. What would happen if a patient under your care chose to refuse care in an effort to die rather than live with a disability? On the Computer: The Therapeutic Milieu, pages 19-21, Review, Case Study, and Quiz Then, return to the Main Menu and start the next chapter: Regulatory Issues. Watch for the page that tells you to return to the workbook. One More Time! A therapeutic milieu requires consistent nurturing by all team members. Remember that you are a therapeutic tool when interacting with patients. Creative approaches are used to improve quality of life within the limits of resources. Learn effective patient/family education strategies and use them to prepare patients for self-management in the community. The Therapeutic Milieu Rehab Nursing Series : Intro to Rehabilitation 64

78 CHAPTER 7 REGULATORY ISSUES Minimal standards are defined by regulations and accreditation standards. The trick is to understand the intent of them so that you can incorporate them into your daily care. What Is Your Job in This Chapter? In this chapter you will learn who the regulatory bodies are that drive rehabilitation practice. You will be introduced to a few of the regulations that apply to the continuum of care and will take a quick look at your possible involvement in quality and outcomes management. Regulations are different at different levels of care. Pay particular attention to the information related to the setting in which you work. On the Computer: Regulatory Issues, pages 3-16 Chapter Highlights Your practice in rehabilitation (just like any other healthcare setting) is impacted by regulatory and legal requirements. They change frequently and influence care delivery. Practice according to regulatory/legal guidelines every day to protect yourself and reduce the risk of compromising the patient s care or the organization s status. Invest in understanding and improving outcomes and quality of care. Regulatory Issues Rehab Nursing Series : Intro to Rehabilitation 65