(5) Circulation. Provide SCI Education Manual to all SCI patients/caregivers (refer to Chapter 2: Circulation System)

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1 Scope of Services: To identify needs/problems and provide education and intervention to maximize functioning and quality of life along a continuum of care. 1. The documented scope of the Spinal Cord System of Care addresses the unique aspects of delivering care to the person served according to their level of impairment, activity, and participation in the following arrears: a. Medical/physiological sequelae: (1) Autoimmune disorders and immune suppression. Assess the patient for any medical, physical, or other needs related to immunosuppression and disease. Admit patient to a private room. Monitor labwork for any symptoms of infection or other medical complications. Obtain Nutritional Consult if indicated. Follow SCI treatment protocol. Provide education on disease problems. Follow universal precautions. (2) Autonomic dysreflexia. Provide SCI Education Notebook to all SCI patients/families within first week of admission. Refer to section in notebook for teaching and education (Chapter 4, Neuromusculoskeletal System) throughout the rehabilitation stay. Provide all patients with Autonomic Dysreflexia Management pamphlet from the Consortium for Spinal Cord Medicine, as well as a emergency wallet card that identifies how to treat AD if it occurs (to be used after discharge from hospital). Therapists have a specific protocol to follow in the Spinal Cord Injury Program Mission, Scope, and Goals. Establish intermittent catheterization schedule to prevent bladder distention. Educate patient/family about causes, symptoms, and treatments of AD. Identify and treat episodes of AD based on the step by step AD treatment protocol. (3) Bowel function. Evaluate bowel history. Perform physical exam to determine ASIA level. Assess knowledge, function, and performance in completing or directing safe and effective bowel care. Design an effective bowel management program based on patient/family abilities, lifestyle, dignity/privacy issues, etc. Refer to the Neurogenic Bowel Guidelines published by the Consortium for Spinal Cord Medicine.

2 Identify appropriate adaptive equipment and educate patient/family on use. Encourage diet, fluids, and activity to achieve desired stool consistency and evacuation frequency. Modify bowel program as needed. Protect skin from breakdown. Educate patient/family in bowel management techniques and complication management. Order any needed supplies/equipment prior to discharge. (4) Bladder function. Evaluate bladder history. Perform urinalysis, urine culture, and sensitivity as ordered by physician. Perform physical exam to determine ASIA level. Monitor intake and output. Discontinue use of Foley catheter when ordered by physician. Observe for control, sensation, and voiding pattern. Identify and treat any symptoms of UTI or AD. Protect skin from breakdown. Establish a voiding schedule based on patient s bladder function. Initiate bladder training or external catheters (for males) if having urinary incontinence. Initiate intermittent catherization schedule if unable to empty bladder. Educate patient/family about medications used for bladder management. Urodynamic studies as indicated. Urology consult as indicated. Determine most effective method of bladder management for patient based on level of injury, functional ability, lifestyle, dignity/privacy issues, etc. Educate patient/family in bladder program techniques. Identify appropriate adaptive equipment and educate patient/family on use. Educate patient/family on complication management. Order any supplies/equipment needed for bladder management. (5) Circulation. Provide SCI Education Manual to all SCI patients/caregivers (refer to Chapter 2: Circulation System)

3 Assess and monitor pulse, blood pressure, temperature, as well as extremity appearance of coloration and circumferential measurements If a problem is detected, staff will follow prescribed protocol in the Clinical Practice Guidelines of the Consortium for Spinal Cord Medicine and in the SCI program manual Utilize appropriate aids to assist the circulatory system of the SCI patient (i.e., abdominal binder, ace wraps for lower extremities, TED hose, recliner wheelchair, pharmacological interventions) Monitor and educate the patient/caregiver on complications of the circulatory system including postural hypotension, edema, DVT, PE, temperature regulation, etc. Provide SCI Education Manual to all SCI patients/caregivers (refer to Chapter 2: Circulation System) Assess and monitor pulse, blood pressure, temperature, as well as extremity appearance of coloration and circumferential measurements If a problem is detected, staff will follow prescribed protocol in the Clinical Practice Guidelines of the Consortium for Spinal Cord Medicine and in the SCI program manual Utilize appropriate aids to assist the circulatory system of the SCI patient (i.e., abdominal binder, ace wraps for lower extremities, TED hose, recliner wheelchair, pharmacological interventions) Monitor and educate the patient/caregiver on complications of the circulatory system including postural hypotension, edema, DVT, PE, temperature regulation, etc. (6) Demyelinating disorders. Patient education provided. Patient/family provided with appropriate community resources (7) Dysphagia. Physician referral to speech-language pathologist (SLP) as indicated SLP evaluate (observation, Modified Barium Swallow study, etc.) and treat (diet consistency changes, compensatory strategies, etc.) patients for swallowing disorders (8) Fertility. Patient provided with videotape Sexuality Reborn. Written information from Stanley Ducharme s book, Sexuality after Spinal Cord Injury provided. Patient provided with referral to urologist or reproductive specialist. (9) Infectious disorders. (10) Musculoskeletal Complications

4 Provide SCI Education Manual to all SCI patients/caregivers (refer to Chapter 4: Neuromusculoskeletal System) Provide physical assessment to establish baseline status Provide treatment to prevent complications and to address identified problems Provide interventions including range of motion, casting, splinting, functional electrical stimulation, etc. Encourage family/caregiver participation to assist/learn techniques to promote the overall health of the musculoskeletal system of the SCI patient Provide durable medical equipment, splinting, and orthotic appliances, etc. to address and/or prevent further complications. In consideration of complications that therapy treatment modalities cannot resolve, physician involvement will include pharmacological intervention, medical management, (11) Neurological changes. Neuropsychological testing initiated. Feedback provided to patient, family, and treatment team to facilitate inpatient treatment planning and outpatient discharge plan/follow-up. Speech therapy, cognitive assessment and cognitive remediation. Feedback about assessment and patient s progress provided to staff. Initiate communication with/involvement of oncology, neurology, neurosurgery and/or refer patient for MRI/CI scan. (12) Nutrition. (13) Pain. (14) Respiration. (15) Sexual function. Neruopsychology: Patient education and psychotherapy to introduce concept of changes in sexual function after spinal cord injury. Spouse/partner encouraged to attend session. Patient provided with videotape Sexuality Reborn. Patient provided with written information from Sexuality After Spinal Cord Injury (by Stanley Ducharme). Case Management: Provide written educational materials. Consult Urology by physician s order. Refer to additional medical support staff. Provide counseling. Educate patient on current adaptive trends. (16) Skin integrity. (17) Spasticity Provide SCI Education Manual to SCI patient/caregivers (refer to Chapter 4: Neuromusculoskeletal System)

5 Assess and monitor current spasticity levels using the Ashworth Scale Provide therapeutic interventions to optimize fuction while minimizing/controlling effects of spasticity (for example: ROM, splinting, pharmacological interventions, bed/wheelchair positioning, etc.) Promote interdisciplinary team communication regarding spasticity via weekly team conferences, Cardex, or as need arises Educate patient/caregiver regarding spastictiy and its effects on function Provide patient/caregiver with information on Intrathecal Balofen pump as indicated (18) Vision Vision assessment performed if patient presents with visual changes/complications after SCI Modified SCI information will be provided for patients with age-related visual difficulties/decreased acuity (i.e., large print text, audiotape of SCI education manual, optometry consults, magnifying lens, etc.) Optimize patient s functional potential through interdisciplinary communication of patient s visual deficits a. Functional: (1) Activities of Daily Living Provide ADL skills assessment to establish baseline function and set goals according to assessment results and outcomes expected at the injury level. Utilizing the FIM measures, areas assesses are: Bed mobility Toileting hygiene/clothing management Balance Transfers to various surfaces including toilet, be/chair/wheelchair, tub/shower Feeding Grooming Dressing skills Bathing Advanced ADL s include: Housekeeping, cooking, driving Provide therapeutic interventions including addressing ROM, flexibility, endurance and tenodesis preservation to maximize functional ADL independence and prevent complications Instruct in compensatory techniques such as paraplegic techniques, utilizing equipment/aids and muscle substitutions to optimize ADL skills Educate family on techniques to enhance the patient s independence. Encourage family/caregiver participation to learn equipment use, set-up techniques and SCI care during ADL tasks.

6 Provide assessment of durable medical equipment needs in preparation for home transition, as well as providing adaptive aids that are used in the ADL tasks Utilize Cardex/Plan of Care to enhance communications between disciplines to promote Referrals, as indicated, to South Carolina telecommunications Equipment Distribution Program (SC TEDP), Learning Resources Assistive technology, and American Cancer Society Neuropsychology: Interpreter provided for deaf and non-english speaking patients. Speech therapy assessment and intervention for patients with identified speech/language difficulties. (5) Community integration. Counseling. Discuss community resources. Refer to community resource directory. Provide community outings.\ Patient participation in recreational therapy. Address transportation issues/options. Transitional housing referral. Vehicle modification material. (6) Driving. Refer SCI patient Driver Rehabilitation Program per physician order to conduct the evaluation/intervention Driving evaluations are conducted by Certified Driving Instructor Driving evaluation is primarily performed on an outpatient basis but evaluations can be performed at any point along the continuum of care as appropriate Use of adaptive equipment is assessed to meet the SCI patient s needs. After equipment needs are identified, referrals are made to the appropriate providers of identified needs Certified Driving Instructor available to provide instruction/training on vehicle modifications All information/recommendations is provided in written format to all involved parties RCP has vehicles appropriately equipped for driving assessment of the SCI patient (7) Durable Medical Equipment Provide equipment assessment and provide appropriate equipment for the SCI patient in the inpatient phases Prior to discharge, a DME assessment will be completed for the SCI patient. Appropriate DMI will be provided or recommendations will be made

7 Equipment is available on site for demonstration and trial for the SCI patient. This includes manual/power wheelchairs, cushions, shower chairs, patient lifts, etc. Staff inservices are provided by manufacturer and DME company representatives to educate/update staff on DME (wheelchairs, cushions, beds, mattresses, etc.) Therapy staff attend annual Med Trade Conference and Exposition for DME update At time of discharge, if recommended DME has not arrived, appropriate loaner DME is provided to the SCI patient to use while awaiting ordered DME Outpatient Seating Clinic is offered weekly to current and newly injured SCI patients (8) Environmental Modifications Provide home assessment for the SCI patient. Assess current wheelchair accessibility as well as needed space for DME. Written report provided to family and the patient with suggestions for appropriate changes and modifications to maximize success in the transition to home Provide resource information about assistive technology appropriate to a patient s specific needs Make referrals to local/state agencies regarding assistive technology/environmental modifications Make referrals to assistive technology manufacturer representatives (i.e., TASH, local orthotic company, etc.) Case management refers SCI clients to agencies who may provide financial assistance for environmental modifications (i.e., HASCI program) Case management can provide a resource list of contractors who may be able to offer environmental modification services (9) Leisure and recreation. During the SCI patient s inpatient rehab phase, outings are provided through the Recreational Therapy Department Provide resource information concerning leisure opportunities available in the community for physically challenged individuals Annual adaptive Water Ski Clinic and Golf Clinic/Tournament, sponsored by Roger C. Peace, provide the SCI patient with instruction/adaptive equipment as needed to enjoy these pursuits of leisure (10) Medication. All medications must be ordered in writing on the patient s chart including dose, route, and frequency. Allergies to medication are identified on admission. Patients are asked on admission about the use of any herbal or over-the-counter medications. A list of all medications currently being taken by the patient is made by the nurse and sent to the pharmacy. All medications are given according to GHS Nursing Policies. Medication administration is documented on the Medication Administration Record per GHS Nursing Policies.

8 Pharmacists review each medication order to verify accuracy of dosing (age appropriate), route, food/drug interactions, etc. The pharmacy places colored drug education sheets in the discharge section of charts for common drug/food interactions. The nurse is to review and give these sheets to the patient at discharge. Lab work to monitor drug levels and effects of medication is ordered by the physician. The physician follows the lab work and makes changes based on these levels. All adverse reactions to medications are treated immediately. The physician is notified by the nurse; an Adverse Drug Reaction Reporting Form is completed and sent to pharmacy. The pharmacist will review and track the reaction, then return the form to the nurse manager. This reaction is documented in the patient s medical record by the nurse. The drug name is also added to the patient s list of allergies. At discharge, the patient is to give prescriptions for medications that are to be taken at home. Patients receive education regarding medication during their hospital stay (food/drug interactions, side effects, safety precautions, etc.). If patient is taking an injectable medication for the first time (low molecular weight heparin, insulin, etc.), the nursing staff will have the patient practice and demonstrate ability to inject own medicine prior to discharge. If patient has difficulty remembering medication schedule or has poor vision or reading skills, the staff will develop a plan to help the patient administer the medication safely at home (medication chart/schedule, color coding, pill box, alarm, etc.). This is an interdisciplinary process, usually coordinated by the psychologist, nurse or clinical nurse specialist. (11) Mobility. Provide physical assessment and identify needs to optimize function. Areas of assessment include bed mobility, transfers, gait, wheelchair mobility, etc. Provide therapeutic interventions to maximize functional independence and prevent complications. Instruct patient in compensatory techniques (muscle substitutions, paraplegic dressing techniques, use of equipment) to maximize functional level. Allow/encourage staff to attend continuing education to enhance skills. Encourage family/caregiver participation/education to learn techniques to assist with mobility of patient and to learn precautions as they apply. Provide patient with adaptive equipment (as indicated to enhance level of mobility independence (i.e., transfer board, thigh straps, gait assistive devices, brace, wheelchair, etc.)

9 Use Cardex/Plan of Care to enhance communication between disciplines regarding precautions relating to mobility, techniques to enhance mobility/carryover, and outcome status. (12) Orthoses. Provide follow-up/assessment to monitor for adjustment needs of vertebral orthoses contact orthotist regarding necessary changes. Evaluate the SCI patient for upper/lower extremity orthotic needs with regards to positioning, prevention, and to enhance functional mobility. Training has been provided by the Miami J cervical collar representative to the staff dedicated to the treatment of the SCI patient population. Miami J collars are used through the Greenville Hospital System New nursing staff are trained in the use of orthoses by the Clinical Nurse Specialist and/or a Certified Rehabilitation Registered Nurse by video, lecture, and demonstration. Provide trial lower extremity orthoses to enhance functional mobility (i.e., transfers, ambulation). Provide instruction/training to the SCI patient and family/caregiver regarding proper application, wearing schedule, care, skin assessment and other precautions appropriate to the appliance. Cardex is used to enhance communication between disciplines about orthotics. (13) Personal care assistants. Provide sitter list. Refer to sitter agencies. Refer to alternate level of care facilities. Offer training to assistants/attendants (when assistants identified before discharge). (14) Prostheses. Perform assessment regarding upper/lower extremity needs. Contact local prosthetic company with recommendations and work with prosthetist on appropriate adjustments/fit of the prosthesis. Monitor fit/function of newly acquired or previously owned prosthetic appliance. Educate/train patient and family/caregiver on proper application, wearing schedule, care, skin assessment and other precautions appropriate to the appliance. (15) Seating. Provide appropriate wheelchair and cushion during the SCI patient s inpatient phase of care. Perform assessment of seating and positioning needs, as indicated, along the continuum of care. Roger C. Peace offers a weekly wheelchair clinic to clients with seating and positioning needs.

10 Roger C. Peace sponsored a seating and positioning course (September 2002) attended by staff and community professionals. A second wheelchair seating and positioning course is scheduled for February Inservices are provided by wheelchair/cushion manufacturer s representatives throughout each year. Staff attend inservices/continuing education courses to increase their knowledge of seating and positioning in order to provide the SCI patient with quality care. Wheelchairs and cushions are available onsite for trial and assessment. Pressure mapping system is available to assess appropriate seating needs. (16) Vocational. Refer to Vocational Rehabilitation. Contact place of employment for evaluation of job as indicated. c. Psychosocial: (1) Chemical use/abuse/dependency. Assessment of tobacco, alcohol, prescription, and street drugs during initial psychological evaluation. Collateral information garnered from family members and/or medical chart as appropriate. Use/abuse/dependency addressed in psychotherapy/patient education sessions as well as in SCI Manual. Substance abuse history taken into consideration when making pharmacologic decisions. Patient encouraged to seek inpatient/outpatient substance abuse treatment after Roger C. Peace discharge. Family encouraged to assist patient in following through with services and seeking counseling for themselves. Options/referrals for substance abuse treatment provided to patient/family. (2) Family/support system counseling. Patient/family informed during initial psychological evaluation that counseling available to patient, family and any caregiver during course of inpatient rehabilitation. Referrals for outpatient psychotherapy provided for families, as necessary. Psychology initiates therapy with family when treatment team identifies family issues (3) Mental health. Patient s psychological history garnered and current psychological status assessed during initial psychological evaluation. Patient s psychological status monitored via follow-up with patient, communication with interdisciplinary team, and family.

11 (4) Peer support. Case Management: Offer contact/communication with SCI persons in community as indicated. Patient/patient interaction. Refer to local SCI sport teams. Mauler Spinners Refer to local SCI support group. Refer to community agencies. PT/OT: Access list of spinal cord injured individuals in the community who can provide appropriate peer support to the SCI patient along the continuum of care. Roger C. Peace sponsored events, including the annual Water Ski Clinic, Annual Golf Clinic/Tournament, and Triumph of the Human Spirit Banquet, provide opportunities for peer interaction for the spinal cord injury individual. Discharge Leisure Planning Book is provided by the recreational therapist. (5) Sexuality. Neuropsychology: Patient education and psychotherapy to discuss changes in sexual function after spinal cord injury. Spouse/partner encouraged to attend session(s). Patient provided with videotape Sexuality Reborn as part of patient education. Patient provided with written information from Sexuality after Spinal Cord Injury (by Stanley Ducharme). Perceptions/definitions of sexuality addressed via psychotherapy and educational materials. Case Management: Provide individual/family counseling. Provide written educational material. Provide educational video material. Refer to additional medical support staff. Consult Urology by physician s order. d. Education and training for: (1) The persons served. Family conferences for patient/family as needed. Provide SCI notebook. Educational materials (written, video, online). Individual counseling. One-on-one therapies (verbal and demonstration) Provide adequate space for patient care/privacy. Interdisciplinary team approach. Specialized spinal cord team (PT, OT, RN)

12 Participation in plan of care Case management assigned to patient (2) Their families/support systems. Neurosychology: Involvement of family members contigent upon permission of patient and role family member to play in care giving for the patient. Educaton and training may be initiated at the request of the patient, family member or treatment team. May include, but not limited to, demonstration, hands-on participation, verbal/written video information, referral to community resources. Case Management: Provide SCI notebook. Provide educational materials (written, video, online). Family training. Family counseling/individual counseling. Family conference with physician, nursing, physical therapy, occupational therapy, speech therapy, recreational therapy. Home evaluation. e. Aging. Neuropsychological assessments interpreted by age-appropriate measures and norms. Psychological impressions, recommendations and interventions made within context of developmental perspective. f. Case management. Implementation of rehabilitation plan. Complete psychosocial assessment of patient. Liaison between team members and patient family and 3 rd party payors. Educate patient regarding rehabilitation program. Utilization review. One-to-one support with patient/families. Discharge planning. Coordinates/distributes appropriate referral. Initiate plan of care upon admission. Offer/assist with additional follow-up. g. Resource management. Provide with appropriate list of community resources to meet patients individual needs, i.e.: Financial Transportation Housing Pyschotherapy Medication Disability Equipment Continuation of care Skilled nursing facility Long Term Community Care h. Transition planning.

13 Review patients current level of care and progression towards patient/family goal. Educate patient/family on alternate levels of care. Case Management to coordinate actual transition. Case Management to offer supports and additional follow-up post transition. Review financial coverage for transition. i. Primary prevention related to preventing recurrence of impairments, activity limitations, and participation restrictions. Nursing: Patient education (verbal, demonstration, written, video) provided along continuum of acute care to rehabilitation to outpatient follow-up for SCI-related complications, e.g. skin, nutrition, pain, automatic dysreflexia, bladder/bowel management, DVT s, etc. Ongoing assessment and prophylactic treatment, dysreflexia, bladder/bowel management, DVT s, etc. See specific sections (above) for details. PT/OT: Think First Program staff involved in community area high schools to promote educational prevention of SCI and head injury. Pressure Relief Program outlined in SCI notebook. Provide measures to assist in preventing skin breakdown such as pressure relief schedule, turning schedules, appropriate mattress, cushions, early education to patient and family regarding skin health. Bowel/bladder programs are provided along the continuum of care to prevent complications and promote overall function. Provide education/training to the SCI patient and family in areas that could complicate future health including autonomic dysreflexia, circulation, respiratory, nutrition, musculoskeletal complications, mental health, etc. Provide education/information regarding available community resources to enchance the individual s involvement and participation in functional activities of daily living. Neuropsychology: Patient/family education/psychotherapy addressing signs/symptoms of clinical and anxiey, adaptive coping skills, setting realistic expectations, and identifying community resources. j. Secondary prevention related to potential risks and complications due to impairments, activity limitations, and participation restrictions. Nursing: Patient education (verbal, demonstration, written, video) provided along continuum of acute care to rehabilitation to outpatient follow-up for SCI-related complications, e.g. skin, nutrition, pain, autonomic dysreflexia, bladder/bowel management, DVT s, etc. If/when problem identified, physician referral as indicated.

14 Early intervention to minimize impact of complication and maximize patient s functioning. Repeat assessments, as necessary. See specific sections (above) for details. Neuropsychology: Pharmacologic intervention for mood disorder.