Rehabilitation and Restorative services
INTRODUCTION TO REHABILITATION AND RESTORATIVE
CARERehabilitation and restorative care are provided to improve and
maintain the patients physical abilities. This may include mobility
skills (Figure 1) and the ability to carry out activities of daily
living (ADLs). Activities of daily living are the tasks that we
learn as children and do throughout life. These tasks include
bathing, oral care, hair and nail care, dressing and undressing,
eating, toileting, and mobility. Being independent with daily care
promotespositive self-esteem.Figure 1Rehabilitation is a process in
which the person is assisted to reach an optimal level of physical,
mental, and emotional health. Rehabilitation and restorative care
are similar,but there are some differences.
http://www.youtube.com/watch?v=deB3Zx_NEG8
How Rehabilitation and Restorative Nursing are Alike
Assists patient to attain optimum level of physical, mental, and
psychosocial function in light of condition Considers how one weak
area of function can affect the whole person Helps patient adapt to
limitations imposed by illnessor injury Helps patient regain lost
skills or learn a new way of doing skills lost because of illness
or injury Requires physician orderTABLE 1 COMPARISON OF
REHABILITATION AND RESTORATIVE NURSING
Rehabilitation Restorative NursingAggressive and Slower
paceIntensive
Scheduled 14 hours Not scheduled, given 24 hoursa day, 7 days a
week a day, whenever needed
A separate and Approaches integrated intodistinct service
regular nursing care
Goal is to improve Goal is to maintain; improvement is
desirable, but not required
Patient makes rapid, Patient may or may notsignificant progress
progress, but does not decline
Planned and Planned and implemented byimplemented by
nursingtherapists
Must have potential May participate even if nofor improvement
potential for improvement
Provided in any Required in long-term care;setting, but not
usually provided in homerequired health care, long-term care
facilities, subacute care, and long-term acute care hospitals
Licensed personnel Licensed and unlicensedprovide most personnel
provide services;services unlicensed personnel are primary
caregivers
Paid by Medicare, Inconsistently paid byMedicaid, private
Medicare and Medicaid inInsurance some situations; usually not paid
by private insurance Requires initial evaluation and periodic
re-evaluation Must be verified by documentation Documentation must
be measurable Safety an important factor Patient teaching is part
of program; staff and family teaching may also be done May use
services of others outside the department Assists with activities
of daily living Works toward goals Patient benefits from service
Provides a necessary service; not given as an activity or to keep
the patient occupied Prevents complications Maintains current
abilities Improves quality of lifeThe information in this unit
applies to both rehabilitation and restorative care. These services
complement each other. They do not compete. A restorative program
established by the therapist to complement the rehabilitation
program reinforces what the therapists are teaching, and the
patient masters the skill more quickly. When you follow the program
developed by the licensed nurse, you are helping the atient master
skills for which nursing is responsible, suchas bowel and bladder
management. Regardless of whether the service is planned and
provided by therapy or nursing, it is a functional service for the
patient. For example: The speech therapist works with a patient who
is recovering from a stroke to communicate the need for basic
services that are essential to daily life, such as hunger, thirst,
pain, and elimination. The therapist would not work with the
patient to teach words that the patient is not likely to use, such
as aardvark or kumquat. The physical therapist works with a patient
who recently had a hip replacement to relearn safe ambulation. On
the nursing unit, personnel follow a safe ambulation program to
complement rehabilitation rather than applying restraints to
prevent falls. A restorative nursing program may establish a goal
for a patient to walk 150 feet with a walker, gait belt, and one
assistant. The purpose of the program is to walk to the dining
room, which is 150 feet from the patients room. The patient would
not walk back and forth in the hallway until the 150-foot goal is
reached. As you can see, both rehabilitation and restorative
nursing work with functional skills that the patient needs each
day. This process is called restoration.REASONS FOR
-REHABILITATION/RESTORATIVE CAREA person may need rehabilitation
because of a disability. A disability exists when the person has an
impairment that affects the ability to perform an activity that a
person of that age would normally be able to do. Adults, for
example, are able to dress and undress independently. If a person
is unable to do this because of a disease or injury, a disability
exists. A disability may be temporary or permanent. Impairments or
disabilities result from trauma or disease. Disorders of the
musculoskeletal system, such as amputation (Figure 2) of an
extremity or arthritis, may require rehabilitation.
figure 2A handicap exists if the disability limits or prevents
the person from fulfilling a role that is normal for that person.
This might include such functions as holding a job, managinga
household, and raising a family. If a disability is permanent, such
as tetraplegia (paralysisfrom the neck down) from a spinal cord
injury, it is unrealistic to expect that rehabilitation will enable
the patient to walk again. In these situations, the goals will be
to teach the patient to: Adapt to the present circumstances. Use
adaptive devices to increase independence. Learn new ways of doing
routine tasks, such as dressing or bathing. Become as independent
as possible in light of the disability. Patients with severely
limiting conditions, such as tetraplegia, are taught to assume
responsibility for personal well-being, including verbally
directing caregivers to accomplish the results the patient
wants.THE INTERDISCIPLINARY -HEALTH CARE TEAMPhysicians who
specialize in rehabilitation are called physiatrists. Nurses and
nursing assistants who work in rehabilitation receive specialized
education. Many other disciplines may be involved in the
rehabilitation process. For instance, a person who has had a stroke
may receive: Physical therapy to learn how to walk again
Occupational therapy to relearn the activities of daily living
Speech therapy to learn new communication or swallowing methods
Nursing services for bowel and bladder management, prevention of
pressure ulcers, and other complications Dietitian services to help
the patient learn to manage new dietary restrictions for a
low-sodium diet (to reduce blood pressure), and to plan and prepare
meals Psychological support to adapt to the sudden changes brought
about by the stroke Social services to plan for the impending
discharge http://www.youtube.com/watch?v=sKygX-BbiLs
All disciplines work together with the patient and family to
solve problems and plan care. There are many subspecialties in
rehabilitation. Health care professionals may choose to work in
geriatric (care of the elderly) or pediatric rehabilitation. Others
may specialize in the care of patients with strokes, spinal cord
injuries, brain injuries, amputations, burns, or
arthritis.http://www.youtube.com/watch?v=vU0jJoo05vI
THE ROLE OF THE NURSING ASSISTANTThe nursing assistant who works
in the rehabilitation and restorative nursing unit will assist the
nurses with: Procedures to prevent complications Mobility skills
(transfers and ambulation) Bathing and personal care procedures
Bowel and bladder management programs Maintaining the patients
nutritional status Programs to increase the patients
independence
PRINCIPLES OF REHABILITATION
Four principles form the foundation of successful rehabilitation
or restorative care.1. Treatment begins as soon as possible.This
means that services begin as soon as the patients condition is
stable. For example, if a patient has had a stroke, passive
exercises and positioning techniques are initiated in the critical
care unit to prevent contractures, pressure ulcers, and other
complications that would prohibit or delay rehabilitation.2. Stress
the persons ability, not the disability. Workers must think in
terms of what the patient can do, not what he or she cannot do. The
patients strengths are used to help in adapting to limitations. A
strength refers to anything the patient can do. Perhaps a patient
whose dominant hand is paralyzed cannot use that hand to feed
himselfbut instead of having nursing staff feed him, he can be
taught to use the other, stronger hand. Use the restorative
philosophy when communicating with patients. Avoid statements such
as, You cant use your right hand. Instead, say, You can use your
left hand. Allow the patient to struggle a little, but avoid
letting him progress to the point of frustration before you step in
to assist.3. Activity strengthens and inactivity weakens.
Complications result from physical and mentalinactivity. These can
cause further disability or even be life-threatening. A
rehabilitation or restorative plan of care always includes
approaches and goals for physical and mental activity.4. Treat the
whole person.When we give care to patients, we are concerned with
the whole person (Figure 41-4). We must also work with the patients
families. They directly influence the emotional and mental health
of the patients. Keys to success in rehabilitation and restorative
nursing programs are: Teamwork. All staff cooperate with each other
and other departments involved in care of the patient. Use of the
care plan. All staff are familiar with the patients problems,
goals, and approaches. Consistency of care. All staff use the same
approaches (as listed on the care plan) when caring for the
patient. Continuity of care. There is a smooth progression and flow
between caregivers and between shifts. Good communication among all
caregivers, the patient, and interested family
members.COMPLICATIONS FROM INACTIVITYPeople with disabilities may
be unable to move about at will. The inactivity or immobility can
result in numerous complications affecting body systems, as shown
in Table 2.
TABLE 2 COMPLICATIONS OF IMMOBILITY
System Complication
IntegumentaryPressure ulcers may develop in a short time from
lack of oxygen to the tissues. Pressure ulcers may worsen quickly
and be dif ficult or impossible to reverse.
MuscularWeakness and atrophy from lack of use. Contractures
develop because of the patients position, freezing the muscle in a
permanent state of flexion. Contractures arepainful and difficult
or impossible to reverse.
SkeletalCalcium drains from the bones when they are inactive.
This contributes to fractures, lack ofhealing, osteoporosis, and
other complications.
RespiratoryFluid and secretions collect in the lungs. The
patient has more difficulty expanding the lungs,increasing the risk
of pneumonia and other lung infections.
CirculatoryBlood clots caused by pooling of blood and pressure
on the legs . Edema may be caused by lack of movement. The heart
must work har der to pump blood through thebody. Changes in the
blood vessels may cause dizziness and fainting when the patient
isplaced in the upright position.
GenitourinaryThe extra calcium in the system from the bones
promotes the development of kidney stones.Retention of urine is
common, and is often caused by the patients position in bed.
Overflowof a full bladder leads to incontinence. The patient is at
high risk of urinary tract infection.
GastrointestinalIndigestion and heartburn may result if the
patient is not positioned properly for meals. Lossof appetite may
occur from lack of activity, illness, and boredom. Constipation and
fecalimpaction result from immobility.
NervousWeakness and limited mobility. Insomnia may result from
sleeping too much during the day,then being unable to sleep at
night.
Mental changesIrritability, boredom, lethargy, and depression
result from the patients frustration andfeelings of helplessness.
Lack of social contact and sensory stimulation result in
disorientation .
ACTIVITIES OF DAILY LIVINGOne purpose of restorative care is to
increase the persons physical abilities. Healthy adults do ADLs
automatically. If a person cannot complete any or all of the ADLs,
a self-care deficit exists. Deficits are caused by problems that
limit the ability to do self-care, such as decreased strength, lack
of endurance, or disorientation. Patients with self-care deficits
are evaluated by therapists and nurses. The results of the
evaluations will determine whether the patients functional
(physical) abilities can be increased. In other words, can the
interdisciplinary team help this patient to relearn an activity of
daily living? This is discussed with the patient and the
family.
FIGURE 3
Restorative ProgramsIf the patient has the potential to relearn
an ADL and is motivated to try, a restorative program is planned.
These programs are sometimes called retraining programs or ADL
programs.
Approaches Used in Restorative ProgramsThe approaches to use
will be listed on the care plan. It is important that the same
approach be used consistently. Setup. Patients with self-care
deficits are not able to set up or prepare for activities of daily
living. You may need to provide the setup (Figure 4). Verbal cues.
The care provider uses short, simple phrases to prompt the patient.
Example: Give the patient a prepared washcloth and then say, Please
wash your face (Figure 5). Hand-over-hand techniques. Example for
eating program: Place a glass in the patients hand. Place your hand
over the patients hand. Guide the glass to the patients
mouth(Figure 6). Demonstration. Act out what you want the patient
to do. Example: Before giving the patient a toothbrush, make the
motions of brushing your teeth with the toothbrush
Adaptive DevicesAdaptive devices are sometimes used to simplify
an ADL. Adaptive devices are ordinary items that have been modified
for use by patients with various types of problems. A person with a
disability may be unable to perform certainADLs. Adding a device
that changes the way the task is done may enable the person to
perform it independently.The person is taught to use the device for
everyday tasks
FIGURE 4 This patient is able to feed herself if thenursing
assistant sets up the tray
FIGURE 5 The nursing assistant uses verbal cues toassist the
patient with ADLs.
(Figure 6). Your role as a nursing assistant is to makesure the
device is clean, available, and used by the patient.You may need to
work on the skill with the patient whileshe is learning to use the
device. The care plan will provideinstructions on the types of
devices the patient uses.
Adaptive devices for eating The most common adaptive devices are
used to enable patients to feed themselves. Many individual devices
are available to meet patients needs. The most common devices are
adaptive silverware (Figures 7A and 7B), plates and plateguards
(Figure 7C), and cups (Figure 7D). Other items, such as a straw
holder (Figure 7E), may also be necessary.
Adaptive devices for dressing Dressing aids are also commonly
used. These devices make it easier for patients to dress
themselves. Using these adaptive devices may appear awkward to you,
but being able to dress independently is important to a patients
self-esteem.Adaptive devices for grooming and hygieneBeing able to
bathe and groom oneself are important skills. Everyone has a
personal hygienic routine. Grooming and hygiene are very private
activities. Using adaptive devices permits the patient to perform
these skills and increases self-esteem and comfort.ABCDEFIGURE 7 A.
Many types of adaptive utensils ar e available to meet individual
needs and enable patients to feedthemselves. B. The wrist cuf f
enables the patient to hold silverwar e and eat independently. C.
Adaptive plates and bowlshave raised edges so patients can scoop
food easily. D. An adaptive cup. E. The straw holder centers the
straw and holdsit in place.
http://www.youtube.com/watch?v=69xC7j0HmiMTHE RESTORATIVE
ENVIRONMENTAll patients benefit from living in an environment that
promotes quality of life. The interdisciplinary team helps promote
this environment. Give the patient a sense of control and
opportunities to make decisions. Remember that mental and physical
activity are essential to well-being. Provide cues for orientation.
Create an environment that is safe, serene, and colorful.
Safety ConcernsSafety is a primary concern when there is a loss
of function. If a patients condition changes, evaluate his or her
awareness. If the level of consciousness or mental status has
changed, report to your supervisor. Changes in consciousness and
mental status may indicate serious problems. Other important
observations that should be reported are: Whether the patient is
aware of the change Whether the patient denies that there has been
a change Whether the patient asks for assistance when needed The
patients desire to remain independent despite the increased safety
risk Any falls that you know of Changes in vision Changes in bowel
and bladder control The patients ability to ambulate Problems with
standing, balance, or coordinationIf you observe any of these
changes, notify your supervisor immediately. A licensed health care
professional will assess the patient. He or she makes other team
members aware of the changes. They will reevaluate the care plan
and write new approaches, if necessary. The restorative program
will be designed with the changes in mind. The overall goal is
keeping the patient safe. If the patient has been on bedrest for a
long time, he or she must gradually increase activity. Inactivity
and bedrest cause changes in blood pressure and balance. Your
supervisorwill develop a schedule to gradually increase the length
of time that the patient will be up.
Restorative CareG U I D E L I N E S for Become familiar with the
patients condition. Provide restorative care at the usual time of
day for the activity. Make sure that the treatment area is ready,
equipment is gathered, and the patients physical needs are met
before beginning. Follow the instructions on the care plan. Check
frequently for changes to the plan. Provide privacy. The patient
will make mistakes and become frustrated. Avoid embarrassing the
patient in front of others. Eliminate as many distractions as
possible. Apply orthotic and prosthetic devices as ordered. These
will be listed on the care plan. Orthoticdevices improve function
and prevent deformities. Prosthetic devices are replacements for
body parts, such as the eye, breast, hand, leg, or foot. Modify the
environment to promote independence, if necessary. Practice good
body mechanics for yourself and the patient. Practice safety, and
teach the patient safety measures. Remember that all ADLs have many
steps. If the patient cannot complete one step, he or she will not
be able to complete the activity. Treat the patient with dignity.
Be positive and encouraging. Stress what the patient can do. Give
the patient as much control as possible by allowing him or her to
make choices and decisions. Allow enough time for the activity. Be
patient and avoid rushing the patient. Work on one step at a time.
When the patient masters one step, move to the next. Remember that
the patients progress may be inconsistent from one day to the next.
Provide frequent, positive feedback during the procedure. Be
patient. Provide simple, clear directions. Keep directions as clear
and simple as possible. If the patient does not understand,
demonstrate. Give verbal cues, whenever necessary , to describe
what you want the patient to do. If the patient does not respond to
verbal cues, use hand-over-hand technique. Place your hand on top
of the patients hand and guide him or her to begin the activity. If
the patient does not respond, replace your hand and guide the
patient through the activity. Allow the patient to do as much
self-care as possible. Show the patient that you are confident in
his or her ability. Use adaptive devices, if necessary. If the
patient cannot complete an ADL, praise his or her accomplishment.
Complete the task without comment or complaint. Report your
observations to your supervisor. Notify the proper person if you
feel that the patients condition requires evaluation. Document care
immediately after providing it. Never document in advance.
MONITORING THE PATIENTS RESPONSE TO CAREYou must observe how the
restorative program affects the patient. This is particularly true
in the early stages of an illness. The patient may become easily
frustrated. Allow the patient to struggle a little. Intervene
before the patient reaches the point of frustration. Remind him
orher that learning takes time. Practice empathy. Tell the patient
you understand how frustrated he or she feels. Be aware of the
patients fears. A fear of falling or spilling may prevent the
patient from participating in an activity or attempting to do a
task. Early in the restorative program, the patient may have an
unexpected physical response. You have learned that even a short
period of bedrest has a negative effect on the body. Any physical
activity may cause a change in the physical condition. Monitor for
signs of fatigue. Be alert for changes, and report them to your
supervisor. A good practice is to take the patients pulse before
beginning, then perform theactivity. Monitor the pulse every five
minutes during the activity. Normally, the pulse increases slightly
with activity.Assuming the pulse is under 100 during the activity,
continue. If the rate is more than 100, or if the patient develops
other problems, such as pain, shortness of breath, nausea,or
perspiration, stop the activity. If the patient is standing, assist
him or her to sit down. Notify your supervisor or a nurse
immediately. Pull the call signal, or send someone else to get
help. Do not leave the patient alone. After you complete the
activity, check the pulse again. It should return to within 10
beats of the resting pulse rate within 5 minutes.
Precautions and Special SituationsPatients with certain
conditions require special care and handling. Avoid exercising
extremities that have fractures or dislocations. The bones of
patients with osteoporosis or bone cancer break easily.
Osteoporosis is a condition in which bone mass decreases, leading
to fractures with little or no trauma. Check with your supervisor
and the care plan before continuing. Notify a nurse if the patient
has a wound, red, or open area on the joint you are exercising.
Inquire if exercise will be harmful before continuing. If a patient
is combative or resists care, explain why it is important. Try to
coax him or her into participating. Try singinga song with the
patient for distraction. Avoid forcing a patient to accept care.
Notify your supervisor if the patient continues to refuse.