RH1550: REHABILITATION OF THE NEUROSCIENCE PATIENT

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RH1550: REHABILITATION OF THE NEUROSCIENCE PATIENT

Chapter 15: Rehabilitation of the Neuroscience Patient
Ellen Barker, Susan Dean-Baar

The goal of rehabilitation for the neuroscience patient is to improve the patient’s quality of life and help the individual to

“reach the fullest physical, psychologic, social, vocational, and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations, and desires and life plans.”⁸

Rehabilitation is a diverse team approach. It is a dynamic process with an active program to help the patient with a neurologic deficit reach his or her optimal level of functioning and adjust to the disability. This process begins at the onset of a neurologic insult that results in a disability and may continue indefinitely. Optimal rehabilitation occurs when it begins as soon as the actual or potential disability is identified, which is frequently while an individual is in an acute care setting; rehabilitation may continue with varying levels of intensity throughout one’s life. Rehabilitation involves a multidisciplinary team approach that includes the patient and family and a variety of health care professionals in all settings along the continuum of care from the acute hospital stay to return to the community.

This chapter presents a brief overview of general rehabilitation management principles for promoting functional self-care and health maintenance in patients with neurologic impairment. Specific rehabilitation interventions required by head– and spinal cord–injured patients and brain attack / stroke patients are discussed. Additional rehabilitation interventions for patients with other neurologic conditions, as well as suggestions for patient and family teaching, are included in other chapters. For example, rehabilitation interventions for coma patients, including coma stimulation programs, are discussed in RH1504. This chapter focuses on principles of rehabilitation, head injury rehabilitation, spinal cord injury rehabilitation, brain attack / stroke rehabilitation, psychosocial concerns, and the concept of life care planning.

PRINCIPLES OF REHABILITATION

The care of any patient with a neurologic deficit requires knowledge of rehabilitation concepts because rehabilitation begins in the acute phase of care, long before the patient ever reaches a specialized rehabilitation environment. The World Health Organization (WHO) has developed the International Classification of Impairment, Disability, and Handicap that provides a framework for all health care professionals ¹⁹:

Impairment: A loss or abnormality of a psychologic, physiologic, or anatomic structure or function

Disability: A restriction or lack of ability (resulting from an impairment) to perform an activity in the manner or within the range considered normal for a human being

Handicap: A disadvantage for a given individual resulting from impairment or disability that limits or prevents fulfillment of a role that would otherwise be normal for that individual

Rehabilitation is a patient-centered approach to achieving a maximal level of functioning. It is a goal-oriented process that always emphasizes abilities, including the ability of the patient and family to ultimately assume responsibility for their own self-care. Neuroscience clinicians must promptly recognize the presence of a neurologic impairment and potential disability, as well as assessing the patient’s response and potential for rehabilitation. For many patients with a neurologic impairment, rehabilitation is identified as an important component of the overall treatment plan. The patient and family are beginning a journey where they will learn to adjust to many changes in their lives. Education, adjustment, and change are three critical concepts in rehabilitation.

THE TEAM PROCESS

Rehabilitation is provided within the context of a team.¹³ The rehabilitation team provides care direction via goal setting (both short-term goals [STGs] and long-term goals [LTGs]). All members of the rehabilitation team collaborate to recommend functional goals for the patient that will facilitate reintegration into the home and / or community. O’Toole ¹³ has described the rehabilitation team as being dependent on the collaboration and cooperation of a variety of team members to achieve three major functions:

(1) establish realistic goals with the patient and family,

(2) ensure continuity of care and coordination of resources, and

(3) evaluate the progress of the patient and the quality of care.

Rehabilitation teams may function within a variety of models, depending on the setting and the needs of the patient. Three common models for teams are the multidisciplinary, interdisciplinary, and transdisciplinary teams. In a multi-disciplinary team the efforts of each team member are combined, but there are clear disciplinary boundaries and the goals for the patient are discipline specific. In an interdisciplinary team the team members collaborate to develop patient-centered goals as a team. Treatment is still provided by each team member and frequently includes cross-disciplinary problem solving.

Interdisciplinary teams are found in structured rehabilitation settings.

Transdisciplinary teams identify a primary therapist for a patient, depending on the needs of the patient. Input from all relevant disciplines is provided to the primary therapist to establish treatment goals. The majority of therapy is provided by the primary therapist or by a small number of therapists working with the patient. A transdisciplinary team requires cross-training and involves some blurring of disciplinary boundaries. Transdisciplinary teams are most frequently seen in brain injury and behavioral management settings, where minimizing the number of staff interacting with clients can be very beneficial to the treatment process.

Rehabilitation nursing is a specialty practice within the profession. Rehabilitation nurses are essential members of the rehabilitation team and diagnose and treat the human responses of individuals and groups to actual or potential health problems relative to altered functional ability and an altered lifestyle. The goal of rehabilitation nursing is to assist the individual who has a disability and/or chronic illness in restoring, maintaining, and promoting his or her maximal health.¹

A physiatrist is a physician who specializes in physical medicine and rehabilitation. As a member of the multidisciplinary team who treats neuroscience patients, physiatrists perform assessments to determine if patients with physical, behavioral, and social problems will benefit from appropriate rehabilitation. The central role of the physiatrist, as the rehabilitation medical manager, is to provide guidance and leadership in evaluating the patient’s potential for rehabilitation, make recommendations to the team, and prescribe appropriate medications, therapeutic modalities, exercise regimens, and assistive devices. After prescribing a comprehensive rehabilitation program, the physiatrist’s responsibility includes reassessment of overall functional progress and determination of the length of stay and need for follow-up therapy. The overall goal of a physiatrist is to provide appropriate rehabilitation interventions that will lead to optimal care and an optimal outcome for patients with neurologic dysfunction.

Rehabilitation subspecialties have evolved to care for pediatric, adult, and older adult populations. Among the many specialty programs in rehabilitation are those for patients with spinal cord injury (SCI), traumatic brain injury (TBI), a brain attack / stroke, or chronic pain. Case management is also frequently used for patients with catastrophic illness or injuries who require placement, treatment, coordination of home therapies, vocational evaluation, or academic programs. The case manager in rehabilitation is frequently involved in the decision making regarding the most appropriate setting for rehabilitation for a given patient. The rehabilitation nurse case manager is responsible for the coordination of care from admission through discharge. Case managers are frequently involved in the initial rehabilitation assessment and identification of patients who are candidates for rehabilitation; they are also involved in planning, in the identification of appropriate resources, and in the coordination of the overall rehabilitation plan.⁹ Members of the rehabilitation team vary depending on the needs of the patient. Box 15-1 identifies the various professionals who may be a member of a rehabilitation team.

CANDIDATES FOR REHABILITATION

The neuroscience nurse clinician is a key health care professional who is responsible for identifying patients who are candidates for rehabilitation and referring them as early as possible, regardless of whether the patients are in an acute or outpatient care setting. The notion that “rehabilitation begins at admission” can be applied, beginning in the intensive care unit. Many rehabilitation interventions can be implemented to prevent secondary complications associated with conditions such as brain attack / stroke, head injury, and spinal cord injury (SCI). All patients with neurologic impairments that may lead to disability should be assessed for rehabilitation. Any patient with a neurologic injury or disorder and who is in a prolonged immobilized state will benefit from referrals to a physiatrist, physical therapist, or occupational therapist for positioning recommendations, positioning aids (e.g., splints, wedges, cushions), range-of-motion (ROM) protocols, and activity tolerance assessment.

Therapists, in conjunction with the neuroscience team, can determine which patients are most likely to benefit from rehabilitation. Patients who have a lifelong disability and have recently experienced an exacerbation of their chronic condition, those who have had a recent onset of a condition that is known to result in a long-term progressive decline in function, and those with a sudden traumatic neurologic injury are prime candidates for rehabilitation.

ASSESSMENT

The health history should elicit information regarding the trajectory of a chronic condition or the mechanism, site, and time of injury; any history of loss of consciousness; and a systems review indicating the problems experienced since the injury or illness. The international “gold standard” for assessing functional status and for measuring motor, physical, and cognitive elements is the Functional Independence Measure (FIM) (Fig. 15-1). The 18 items include

• 13 motor and
• 5 cognitive measures, using a 7-point scale to estimate the severity of the disability and the need for assistance, which ranges from “1” for total assistance to “7” for complete independence.

Also included is an assessment of the individual’s family and their role in patient care on discharge. It is important to assess the patient for other health problems; the home situation, including the number of floors and potential barriers for the disabled patient; and the patient’s work status, driving status, educational level, and psychosocial status. Physical assessment findings include a neurologic assessment and a rehabilitation assessment to identify specific areas of concern that warrant consideration for rehabilitation, including the following:

• Cognitive dysfunction evidenced by impaired orientation, insight, awareness, judgment, arousal, executive function, reasoning, and concentration
  
• Communicative deficits evidenced by impaired comprehension, confused speech, aphasia, and confabulation
  
• Behavioral dysfunction evidenced by impulsivity and disinhibition, restlessness, irritability, increased emotional lability, aggression,
  withdrawal, depression, agitation, and other signs of inappropriate behavior
  
• Motor dysfunction evidenced by paresis, paralysis, spasticity, ataxia, and pathologic reflexes
  
• Impaired respiratory function with reduced airway clearance or an ineffective breathing pattern
  
• Sensory-perceptual deficits that may include cortical blindness; impaired position sense; impaired temperature, pain, and touch awareness; apraxia; agnosias; and deficits or loss in the visual field (from damage at the optic chiasm or other sites along the visual pathway)
  
• Cranial nerve dysfunction evidenced by dysphagia, diplopia, dysarthria, impaired taste and smell, and hearing loss

NEURODIAGNOSTIC / LABORATORY STUDIES

Neurodiagnostic studies (see RH1501) can augment the history and physical assessment findings both in the acute care setting and after discharge from the acute care facility:

CT: May be employed to rule out or detect hydrocephalus, brain swelling, and chronic or late-onset intracranial hematomas; can detect pressure on the spinal cord and differentiate between infarction and hemorrhage for patients with brain attack / stroke

MRI: Useful in identifying structural brain changes and / or abnormalities (e.g., central nervous system [CNS] infection)

Magnetic source imaging (MSI): Focal and / or diffuse brain dysfunction

SPECT: For assessment of cerebral perfusion changes

PET: Not often used, but where available can demonstrate cerebral metabolic changes, as well as chemical activity in the brain, and assess the extent of tissue damage

EEG: Provides extensive information regarding brain damage and possible seizure foci

Myelogram: Can detect tissue fragments that may have been propelled into the spinal canal

Multimodality evoked potentials (MEPs): Help detect and localize visual, auditory (brainstem auditory evoked responses—BAERs), and somatosensory deficits

Angiography: For assessment of cerebrovascular abnormalities (e.g., aneurysms or arteriovenous malformations [AVMs])

Chemosensory evaluation: For assessment of changes in smell and taste

Transcranial Doppler (TCD): For assessment of regional blood flow alterations

Polysomnography with median sleep latency test: For assessment of sleep disturbance (see RH1504)

Nocturnal penile tumescence monitoring: For assessment of erectile dysfunction (see RH1507)

Posturographic assessment: For assessment of problems with balance dysfunction

Electronystagmography: For assessment of vestibular dysfunction

WELLNESS PROMOTION

The primary goal of rehabilitation management is to help the patient achieve and maintain a high level of wellness while living with a disability. Wellness, as differentiated from “health” or the passive condition of being free of disease, is best understood as a holistic integration of all facets of the patient’s life. Far from being a passive state, wellness requires the patient’s full participation and motivation to seek growth- producing challenges, to relate to others in positive and flexible ways, to engage in health-enhancing activities, and to incorporate effective coping strategies to integrate all aspects of the patient’s life and achieve a sense of wellness. Similarly, health care professionals must develop attitudes whereby they no longer consider the patient as having an illness, but rather as an individual who must live with functional alterations and integrate them into new life patterns.

Achieving a sense of wellness may be an especially difficult challenge for patients with permanent neurologic deficits, since the social, physical, and psychologic dimensions of their lives are often severely disrupted. Their relationships, goals, careers, and physical abilities may all be altered for the rest of their lives, and these patients may need to acquire entirely new problem-solving, self-care, and psychosocial skills. The neuroscience or rehabilitation clinician plays an integral role in patients’ adjustment by assisting them in identifying the ways in which the neurologic impairments have affected various aspects of their lives and in integrating these changed dimensions into their lives to achieve a high level of wellness. The focus on developing a sense of wellness must also consider the patient’s cultural, religious, and ethnic background, as well as the patient’s ability to change and adapt to his or her new state of health.

DISCHARGE PLANNING AND PROGRAM EVALUATION

Rehabilitation following acute care may occur in various settings; the philosophy in each, however, remains the same. Rehabilitation strives to increase a patient’s functional capacity and develop a meaningful lifestyle that adjusts to the neurologic disability. Wellness promotion and patient/family teaching are important for lifelong rehabilitation management.

When one considers the choice of rehabilitation centers, evaluating the center’s program is essential to patient success. The patient and family must select the most appropriate rehabilitation setting. After the rehabilitation referrals, the family is encouraged to visit the site before making the final decision for transfer. Before a rehabilitation institution is selected, consideration should be given to many concerns (Box 15-2).

The patient’s disability and medical history ultimately determine the appropriate rehabilitation program. For example, a patient with traumatic brain injury (TBI) who is medically stable but requires cognitive retraining would best be served by a program capable of providing cognitive remediation, life skills training, community reintegration, psychologic counseling, and vocational / academic assessment. Another patient may require a rehabilitation program that specializes in coma management. The patient’s financial status and funding sources also must be considered in the selection and design of the rehabilitation program. Catastrophic care, such as that which may be required by TBI and spinal cord injury (SCI), usually involves lifelong management and may cost up to $1 million over a lifetime. Expenditures must be deemed appropriate and cost-effective within the parameters of the funding source policy. The patient’s financial limits may also affect the level and intensity of rehabilitation services available. Thus the patient’s financial ability to follow care guidelines after discharge, as well as third-party payment options, should be considered when the program is designed.

Patients who will return to the workplace may respond best to a work hardening rehabilitation program, a highly specialized rehabilitation program that bridges the gap between traditional therapeutic modalities and the return to work by simulating the workplace in the rehabilitation environment. These programs bolster the patient’s self-confidence and physical condition by using the work routine as the mechanism of rehabilitation. Nurse clinicians can be instrumental in identifying patients seeking a new alternative to the old problems of delayed recovery from neurologic injury.

The struggle to recover physical functions through a rehabilitation program is only the beginning. The patient with a neurologic impairment and resulting disability who is ready to leave the protective hospital environment must be prepared to face weeks or months of continued physical and cognitive rehabilitation and adjustment to returning to his or her home and community. Beginning with assessment, the rehabilitation interventions are key to the patient’s outcome as the clinician continues to monitor the patient’s progress and assist with beginning the process of lifelong adjustments.

Measures to minimize disability should be incorporated into every aspect of patient care from the moment of injury or illness through community, home, or long-term care (LTC) placement. Indeed, level I trauma centers require rehabilitation as an integrated part of trauma protocol. Such integrated trauma systems identify problems throughout recovery and seek to match appropriate professionals to the patient’s specific needs. This chapter focuses on rehabilitation interventions that can be used by clinicians in acute care settings both in minimizing or sometimes preventing disability and in preparing the patient for rehabilitation. A list of rehabilitation options for patients who require rehabilitation after discharge appears in Box 15-3.

HEAD INJURY REHABILITATION

Head injury rehabilitation for patients with acute head injury requires attention to a wide range of possible physical, cognitive, social, emotional, and behavioral complications of the injury (Fig. 15-2). (See RH1507 for a complete overview of brain injury.) Deficits, strengths, and needs are evaluated for an outcome-based plan of care. Of the many patients who survive traumatic brain injury (TBI) each year, many experience moderate to severe neurobehavioral and physical se- quelae, although the long-term responses to injury are highly individualized and often difficult to anticipate exactly. It is estimated that 20% of persons who experience a brain injury incur long-term disability ¹¹ and that there are 5.3 million Americans living with TBI-related disability.¹⁶

The recovery of TBI patients is influenced by many disparate factors, including the site of injury, extent of neurologic damage, complications and associated or secondary injuries, patient age, premorbid level of function and physical ability, and medical risk factors. Musculoskeletal problems occur from immobility and disuse atrophy (Table 15-1).

High-Risk Nursing Diagnoses

• Impaired physical mobility related to motor deficits, paresis, paralysis, or spasticity
  
• Self-care deficit related to inability to perform activities of daily living (ADLs)
  
• Risk for injury related to cognitive deficit

Clinical Management

Complications associated with head injury
The following areas of functioning can be impaired after TBI:

• Motor and sensory
• Language and communication
• Visual-perceptual
• Attention
• Memory
• Executive functions
• Personality and emotions

Hydrocephalus is one of the most common treatable complications during rehabilitation of patients with TBI. Symptoms may include lethargy, incontinence, changes in behavior, or ataxia (see Chapter 10). External or communicating hydrocephalus may occur when the subarachnoid space contains excessive fluid with enlargement of the ventricles related to ventricular obstruction after the injury. It is usually surgically managed with shunt insertion. (See RH1505 for a discussion of cranial surgery for hydrocephalus.)

Normal-pressure hydrocephalus (NPH) may result over weeks or months from scarring of the basal cistern following TBI with ventricular enlargement and brain compression but normal cerebrospinal fluid (CSF) pressure. The clinical triad includes mental changes, gait disturbances, and urinary incontinence. Ventricular shunting is the accepted intervention in most cases.

Approximately 5% of patients with TBI eventually experience a late-onset seizure disorder up to 4 years after injury, and another 5% experience posttraumatic epilepsy during the acute phase after injury.¹⁸ After a thorough assessment and diagnostic evaluation, the treatment modality of choice for most TBI patients with seizure activity is pharmacologic management. (See RH1512 for information on seizures.) Status epilepticus is a rare but significant complication that may accompany seizure activity in individuals with TBI. Status epilepticus increases the morbidity and mortality associated with TBI.

Heterotopic ossification (HO) involves osteoblastic activity and bone formation in soft tissues at abnormal sites, such as large joints. HO is a rather common complication in head-injured patients that may result from the initial injury, prolonged immobilization, and comatose states. HO has been described as true osseous tissue rather than calcified soft tissue. Several months after TBI, patients may experience joint swelling, decreasing range of motion (ROM), pain associated with ROM, heat, swelling, spasticity, and increasing pain in joints (e.g., shoulders, elbows, hips, and knees). Patients older than 30 years of age and who have spasticity may be at higher risk. Confirmation is by elevated levels of serum alkaline phosphatase, radiographs, and bone scans. It may be necessary to rule out other problems (e.g., thrombophlebitis, septic arthritis, trauma, hematoma, or even a fracture) before initiating treatment. Preventive treatment to decrease new bone development has been recommended in some cases and consists of etidronate (Didronel) 20 mg/kg taken orally each day for 2 weeks, followed by 10 mg / kg per day for 10 weeks for a total of 12 weeks. In addition to etidronate, medical treatment may include nonsteroidal antiinflammatory medications (e.g., indomethacin [Indocin]), physical modalities (e.g., ROM), and in severe cases surgery and/or radiation to arrest further HO.

Nutritional deficits may create problems of malnutrition, muscle weakness, skin problems, fatigue, and other problems in patients with TBI. Patients may have special nutritional needs if the injury produced severe increases in basal metabolism, resulting in weight loss, low serum albumin levels, and a negative nitrogen balance. (See RH1503 for a discussion of the metabolic results of TBI.) Weight should be closely monitored, and skin thickness (anthropometry) measured. Routine laboratory studies to evaluate nutritional status may include decreased serum albumin, total protein, total lymphocyte count, transferrin, and thyroxin-binding prealbumin. Brain damage with impaired cognition and the impaired swallowing process may result in dysphagia (a swallowing disorder that interferes with oral feeding). A swallowing evaluation by a speech pathologist or dysphagia specialist helps to determine problems with swallowing, the potential for aspiration, and the need for a safe nutritional program to ensure weight gain, protein, and caloric intake.

Impaired physical mobility
Orthopedic and related injuries (e.g., long-bone fractures, joint dislocations, fractures to the pelvic girdle, soft tissue injuries, and vertebral fractures) are prevalent with acute head injury (HI). Interventions include traction (for limited periods), external fixation devices, open reduction internal fixation (ORIF), casting, splints, and various orthotics. It is critical to identify orthopedic impairments and provide appropriate intervention.

To prevent pressure ulcers, the clinician should assess the patient’s response to ROM and observe the skin for redness, edema, and physiologic responses (temperature elevation, diaphoresis as a response to pain, or autonomic dysfunction). Frequent repositioning and avoidance of positions that increase tone are important interventions.

Pain management is essential and is covered in RH1512.

Spasticity may include an upper motor neuron (UMN) lesion (Fig. 15-3). The evaluation may identify loss of limb control with specific muscles affected that result in motor dysfunction, muscle stiffness, or contractures (Box 15-4).

Inspection may reveal swelling and tenderness or pain with ROM. Review of x-ray findings will rule out missed fractures or HO. Electromyography (EMG) results may indicate the need for nerve blocks or other treatments. The physiatrist will prescribe a program of spasticity-preventing measures that includes antispasticity medications (e.g., baclofen [Lioresal]) (Table 15-2), cold therapy, exercise to stretch tight muscles, massage, splinting to maintain normal positioning, aquatic therapy, and other modalities (Fig. 15-4).

A 24-hour schedule should be implemented that balances rest therapy with active physical exercise. When the patient establishes and reaches rehabilitation goals, it is rewarding not only for the patient but also for the caregivers. Positive reinforcement with praise and encouragement for each goal achieved can be extremely motivating for the patient.

Conservative treatment for long-term spasticity includes appropriate positioning, inhibition of spastic patterns, and appropriate muscle conditioning. Serial casting (using progressive bivalved casts to gradually increase extension or flexion of an extremity by inhibiting spasticity) may also be effective. A patient could have serial casts on all four extremities. The nurse must monitor for weight changes or skin conditions that would influence the comfort and fitting of the cast (e.g., impaired sensation and circulation, and skin irritation). Temperature elevation, pulse changes, diaphoresis, pain, and agitation are frequent patient symptoms as a result of casting. On-off cast application schedules must be followed for therapeutic effectiveness (Fig. 15-5).

Self-care deficit
Patients with posttraumatic brain injury (PTBI) exhibit impairment in self-care activities because of cognitive, motor, and behavioral impairments interfering with their ability to perform ADLs. Very basic activities may require numerous rehabilitation team referrals to address appropriate skills and provide the necessary assistive devices. A structured environment, adapted to the patient both physically and cognitively, helps the patient successfully perform most self-care activities. The patient’s specific areas of cognitive impairment necessitate an individualized nursing care plan for ADLs.

The patient’s functional assessment provides the base from which specific rehabilitation management recommendations follow. Functional assessment is usually categorized according to the following rehabilitation terminology:

I: Independent

S: Supervision needed

CG: Contact guard required

Mod I: Modified independence

MinA: Minimal assistance (patient performs 75% or more of task / activity)

ModA: Moderate assistance (patient performs 50% to 75% of task / activity)

MaxA: Maximal assistance (patient performs 25% to 50% of task / activity)

D: Dependent (patient performs less than 25% of task / activity)

Different funding sources may require the use of different scales to determine the patient’s functional level. The Functional Independence Measure (FIM) is frequently used in rehabilitation settings (see Fig. 15-1).¹⁷

Basic interventions to promote self-care activities are as follows:

• Progress from maximal to minimal assistance with self-care.
  
• Give simple, repeated one-step instructions.
  
• Control sensory input; provide minimal verbal cues, thereby encouraging the patient to initiate activities.
  
• Remain consistent in the sequencing of activities.
  
• Promote choice and decision making by the patient.
  
• Provide visual cues (e.g., checklist of dressing steps, pictures of staff, labels on toiletries).

The clinician should set up the environment to save the patient’s energy while providing assistive devices and adequate utensils to perform the tasks. One must allow ample time for the patient to complete each task and must encourage maximal independence.

Risk for injury
To prevent injury from behavioral impairments that commonly occur after head trauma, the nurse must be prepared for agitated behavior by the patient. The Rancho Los Amigos Scale of Cognitive Levels and Expected Behavior is used to evaluate the patient with TBI:

Level I: No response
Level II: Generalized response
Level III: Localized response
Level IV: Confused, agitated
Level V: Confused, inappropriate, nonagitated
Level VI: Confused, appropriate
Level VII: Automatic, appropriate
Level VIII: Purposeful, appropriate

Agitation is a behavioral change or state of heightened activity, restlessness, or increased psychomotor activity that can be sudden and unpredictable. Patients at a level IV on the Rancho Los Amigos Scale are typical of the patient who displays a heightened state of activity. The clinician, nonetheless, must ensure the safety of the patient, other patients, personnel, family members, and other visitors. (See RH1504 for a discussion of the stages of recovery from coma.) It is important to identify and remove noxious stimuli and rule out seizure activity, withdrawal from substance abuse, or other potential causes.

The interdisciplinary rehabilitation team chooses the appropriate interventions. The patient’s clinical status must first be assessed, and then management focuses on controlling the head-injured patient’s environment. Specific interventions for use with patients exhibiting agitation are found in Box 15-5.

A protective environment with padding on the floor and walls is created to allow the patient freedom of movement. Seat restraints are added to wheelchairs as appropriate. A unit or room, also padded, where the patient can stay during an episode of agitation, is secured. (This should be separate from the patient’s room so that the two rooms are not associated.) A Craig or netted bed allows the patient to move in bed and sit up and prevents falling or getting out of bed (see Fig. 7-3). Physical restraints are used with caution and with the least amount of restriction required for the patient’s safety (e.g., mitted gloves are preferable to securing the patient’s arms to the bed). Having a family member or sitter stay with the patient has a calming effect. Medication is used only as necessary, and those agents that have associated side effects that suppress cognitive function are avoided. The clinical staff should also formulate a plan of action that will minimize stimuli in anticipation of an episode of agitation, such as performing in-room or in-unit therapy to avoid moving the patient when possible. Therapeutic touch, massage, or music therapy will reduce agitation. Some patients respond better to a Geri chair, which allows them to be moved close to the nursing station. An individualized assessment is needed to determine the most effective and safest method to reduce agitation. Daily documentation is essential and required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

SPINAL CORD INJURY REHABILITATION

The majority of traumatic spinal cord injuries (SCIs) are the result of an automobile crash, fall, gunshot wound, or diving accident. The patient’s resulting condition may range from temporary neurologic deficits to permanent, total paralysis. (See RH1507 for a thorough review of SCI.) The entire rehabilitation team must work to maximize the functional abilities, minimize the complications, and encourage the psychosocial adjustment of patients who have sustained SCIs. See Table 15-3 for rehabilitation potential based on the functional level of spinal cord disruption.

SCI necessitates the patient’s participation in the management of his or her health care needs and the progress toward independence from the medical system. Even a patient with a C4 injury on mechanical ventilation can and should direct his or her own care, regardless of the 24-hour nursing care. The health care providers should consciously promote self-reliance and not foster dependence.

High-Risk Nursing Diagnoses

• Ineffective breathing pattern related to respiratory muscle paralysis and immobility
  
• Impaired skin integrity related to immobility, mechanical factors, and impaired sensation
  
• Impaired urinary elimination and sexual dysfunction related to neurologic dysfunction (e.g., diminished sphincter control) and lack of sensation
  
• Bowel incontinence related to neurologic impairment
  
• Impaired physical mobility related to paresis, plegia, or spasticity
  
• Disturbed thought processes related to changes in body image, increase in dependency, changes in lifestyle, and negative self-concept that affects sexuality
  
• Pain related to altered sensory response

Clinical Management

Ineffective breathing pattern
Respiratory impairment for spinal cord injury, especially high-level injury (C4 and above), may require quad coughing (assisted coughing), intermittent ventilation or long-term ventilator support, suctioning, and oxygen supplementation. Incentive spirometry and intermittent positive-pressure breathing (IPPB) or nebulizer treatments may be necessary. Although long-term tracheostomy care and mechanical ventilation do not prevent the patient from participating in vocational, academic, or community activities, patients with respiratory impairment do require ongoing, close assessment. Prevention of respiratory infection is a central goal of management. Moreover, a speech pathologist may be needed on the interdisciplinary care team if augmentative communication devices or recommendations regarding pacing and breath support are warranted. Also, the Passy-Muir valve should be used instead of a tracheostomy as recommended.

Impaired skin integrity
Prevention of pressure ulcers is the primary goal of clinical management. Devices such as gel cushions, water mattresses, positioning aids, and seating systems are often recommended to decrease skin breakdown, but weight shifts and routine skin inspections are the keystones of management. Patients should be taught techniques to relieve pressure over bony prominences every 20 minutes and how to inspect their own skin, including using a mirror to help check unexposed areas. (See Box 15-6 for skin care.)

Prevention techniques include avoidance of shearing during transfers or when moving the patient in bed, meticulous skin care, frequent repositioning, good nutrition and hydration, avoidance of incontinence, and prevention of dependent edema through elevation of limbs.

One hopes that death from infection caused by pressure ulcers and septicemia is a complication of the past. Pressure sore management protocols must be instituted immediately for any skin breakdown. Patients with a Halo vest need special teaching for home care and especially to prevent infection (Box 15-7).

Impaired urinary elimination and sexual dysfunction
The overall goal for bladder management is to reduce or eliminate factors leading to incontinence, maintain adequate hydration, prevent overdistention of the bladder, and teach the patient management of an effective bladder program. Teaching the patient meticulous self-bladder management has led to a significant decrease in renal failure in patients with SCI.

The bladder often has bacterial colonization that does not require aggressive pharmacologic interventions. One of the most common complications of SCI, however, is urinary tract infection (UTI), and the resistant strains of bacteria make UTI more difficult to treat. Other genitourinary (GU) complications include the following ³:

• Bladder cancer
  
• Calculi
  
• Urethral tears
  
• Hydronephrosis
  
• Bladder dilation
  
• Bladder trabeculations
  
• Chronic cystitis
  
• Prostatitis
  
• Epididymo-orchitis

Because the predisposition for UTI continues for life, the patient should be taught the signs and symptoms of UTI to enable early detection and treatment. Renal calculi formation is another complication seen with SCI. A fluid intake of 2000 to 4000 ml / day is encouraged, along with mobilization, to decrease the risks of both UTI and calculi formation; however, the plan must be individualized and must reflect the patient’s overall medical status. For example, a patient with a cardiac history might have fluid restrictions. (See Table 15-4 for types of neurogenic bladder.)

Various types of catheters (urethral and suprapubic), external collection devices (e.g., condom / Texas catheter), and drainage systems (e.g., leg bag, indwelling catheter, and bladder incontinence pads) are available for neurogenic bladder management. Frequently, the patient’s lifestyle or an infection may necessitate a combination of devices. The appropriate mode of urinary elimination management considers the patient’s history, lifestyle, environment, compliance, and financial resources. Research can be found that supports or criticizes any procedure, but in all cases the overall goals of bladder management are the prevention of long-term complications (i.e., reflux or chronic infection resulting in urinary diversion surgery) and the assimilation of bladder control into the patient’s lifestyle. Systems for urinary elimination include the following ⁴:

• Voluntary voiding at scheduled intervals, sensory- signaled voiding, reflex-triggered voiding, and Valsalva voiding. These are the least invasive methods.
  
• Condom catheter drainage with a collecting device. This is an effective method, although the adhesive material may cause skin irritation and may be difficult for some individuals with SCI to use.
  
• Intermittent catheterization. This is an effective invasive method, and with good technique and timing, the patient can have scheduled emptying and remain catheter free in between.
  
• An indwelling urinary catheter with a drainage container via the urethral or suprapubic route. This is the method of choice for many patients but requires daily cleaning of the bag and changing monthly and creates a higher risk of UTI and calculi.

Periodic testing (e.g., routine urinalysis) and yearly urodynamic evaluation help reduce morbidity and mortality from GU complications. Ultrasound, 24-hour urine studies, renal radionucleotide scans, intravenous (IV) pyelograms, and cystoscopy are performed for specific complications. Management of neurogenic bladder, including drug therapy, is described in Box 15-8.

Changes in sexuality are based on the level of injury and whether the SCI was complete or incomplete. Potential sexual activity in men with SCI is described in Table 15-5.

Women with SCI may maintain their capacity for orgasm with the potential for a satisfactory sexual relationship with their partners. Selection of appropriate birth control must weigh the benefits and risks with each method in consultation with the SCI physician, the patient’s gynecologist, and other specialists. After the acute phase of SCI, women usually resume their normal menstrual cycles in approximately 6 to 12 months. Women who plan to have a family and become pregnant usually deliver a normal, healthy infant. Careful planning with a team of experts is needed to manage potential problems during pregnancy that are associated with SCI (e.g., autonomic dysreflexia and respiratory problems).

Bowel incontinence
A neurogenic bowel program may include medical management, dietary limits, hydration requirements, scheduled intervals between evacuations, and stimulation techniques for evacuation (Box 15-9).

Often the patient needs to schedule the bowel program around daily activities; it is critical that the patient’s normal routine not be structured around the bowel program or the caregiver’s requests. It is also important that the regimen remain constant and not change every few days. Although the patient may take several weeks to arrive at a consistent schedule, diligent bowel training usually prevents embarrassing accidents, promotes independence, and prevents bowel impaction and obstruction. The choice of regimen depends on the level of injury, amount of assistance required, and individual preference. Possible bowel programs include the following:

• Stool softeners
  
• Digital stimulation
  
• Regular addition of fiber to the diet
  
• Diet limitations
  
• Small-volume enema / suppository
  
• Special positioning
  
• Detailed bowel program

It may take months, and it requires careful management, to establish a successful bowel program. The goals of an effective bowel program are as follows ⁷:

• Minimize or prevent incontinence.
  
• Evacuate stool at a regular and predictable time.
  
• Minimize the secondary complications of colonic over-distention, fecal impaction, and diverticuli.

A large majority of patients with SCI report problems with constipation that may cause gastric pain. The embarrassment of bowel accidents may prevent patients from traveling or leaving home when they are unable to maintain a satisfactory bowel program. Hemorrhoids are also problematic. One study from the Model Spinal Cord Injury Systems revealed that 30.4% of patients with either complete or incomplete SCI required assistance with bowel management. The level of assistance varied according to the severity of injury, ranging from 78% for individuals with complete tetraplegia who required complete assistance to 11.8% for individuals with complete paraplegia who required complete assistance. Of the individuals with complete paraplegia, 53.3% managed their bowel care with modified assistance. In general, patients with SCI at or above the C5 level will be dependent and require total assistance for all aspects of bowel care.⁵ Medications must be evaluated for side effects of diarrhea or constipation, which make it difficult at times to treat spasticity, neurogenic bladder, infections, pain, and depression.

Factors that should be considered in designing a bowel program include the availability of caretakers for assistance (if needed), daily life schedules, and the availability of adaptive equipment.¹⁵ The following may be part of the bowel program management:

• Patient’s normal pattern of bowel elimination
  
• Dietary modulation of stool consistency with fiber and liquid intake
  
• Increased physical activity
  
• Regular scheduling of bowel care time and frequency
  
• Adaptive equipment (e.g., commode chair, digital stimulation devices) based on the individual’s functional status and home/community environmental needs
  
• Oral medications (that either promote or inhibit bowel function)
  
• Rectal medications (suppositories)

Impaired physical mobility
Acute assessment of mobility status is required after SCI to identify positioning and equipment needs. A wide array of assistive devices is available, including wheelchairs and accessible modified vans that allow even patients with quadriplegic levels of injury to continue driving.

Bed mobility must be assessed to determine the patient’s level of independence in performing ADLs. Splints and braces (e.g., molded ankle-foot orthoses [MAFOs] and ankle-foot orthoses [AFOs]) may be appropriate to assist the patient with mobility and self-care activities. These devices also support appropriate positioning for body alignment and at times inhibit spasticity.

Functional electrical stimulation (FES) is a growing area of research in SCI. FES stimulates specific muscle groups to create the contraction and relaxation necessary for assisted ambulation. Bioengineering has been instrumental in the development of FES, which has enabled some patients to stand and actually take steps with a walker. FES candidates are vigorously evaluated by the rehabilitation team and undergo prolonged cardiovascular conditioning. These patients must continue with a home exercise program designed to maintain functional ability.

Autonomic dysreflexia can result if bladder, bowel, and skin management are not appropriately implemented in SCI patients with injury at T6 or above (see RH1507). Precipitating factors include kinked or obstructed catheters, overdistention, UTI, calculi, constipation, and pressure ulcers. Ongoing assessment is necessary to prevent such complications and to reevaluate the effectiveness of interventions in these areas.

Osteoporosis is a long-term complication for many patients with SCI. Exercise, medications, and the use of weights placed on the lower extremities helps prevent osteoporosis and bone fractures.

Heterotopic ossification (HO) is present in approximately 16% to 53% of the SCI population.⁶ As described earlier under Head Injury Rehabilitation, HO is an accumulation of uncharacteristic bone that is usually deposited between layers of connective tissue. It is called myositis ossificans when the bone forms between muscles. The exact cause is unknown, but HO is found in patients who have experienced trauma. As rehabilitation progresses, the patient with SCI may experience severe limitations of mobility, including impairment of motion to joints or impairment of functional use of extremities.

Prevention of HO has not been clearly documented in the literature; however, it is an area of extensive investiga- tion, particularly in the area of medical management, including the use of prophylactic medication such as etidronate (Didronel). Aggressive range-of-motion (ROM) and other exercises recommended by the physical therapist to prevent contractures may also be effective in reducing the incidence of HO. As in patients with TBI, severe cases of HO may require surgery or radiation therapy.

As spinal shock wears off and the patient’s limbs are no longer flaccid, spasticity may develop. As described under head injury, this is a form of muscular hypertonicity with increased resistance to stretch. In some situations, limited spasticity may actually assist the patient. For example, a patient with spasticity in the lower extremities may have greater standing tolerance or transfer ability. In most instances, however, spasticity remains burdensome, interfering with ADLs and general functioning. Medical management often includes a combination of medications (e.g., tizanidine (Zanaflex) bac-lofen (Lioresal), dantrolene (Dantrium), or diazepam (Valium) administered in conjunction with conservative treatments. Single or serial botulinum toxin (Botox) injections in the muscle are a temporary measure that can be followed with aggressive therapy to strengthen the muscle and eventually overcome the spasticity. Surgical management may include rhizotomy (cutting of the roots of the spinal nerves), tenotomy (cutting of a tendon to release contracture), or a surgical procedure for placing a baclofen intrathecal pump.

Disturbed thought processes
The overall incidence of a major depressive episode associated with acute SCI has been estimated at 10% to 50%. The etiology of the depression (i.e., whether it is a natural part of recovery after SCI or caused by the psychosocial ramifications and reactions of catastrophic injury) is controversial. Certainly, clinicians may be confronted by various behaviors after SCI that can be misinterpreted as anger directed toward caretakers, rather than as behaviors resulting from catastrophic trauma. Clinicians who care for the patient with SCI, regardless of the care setting, must be familiar with all possible behaviors, which may range from withdrawal, extreme anger, and verbal abuse to demonstrations of frustration. These behaviors are a result of the injury and the attempts of the injured patient to cope with a devastating and life-altering condition.

It is critical to assess the level of the patient’s support, including friends, significant others, and vocational/academic peer groups, as well as the patient’s own capacity to participate in counseling. Often support groups, patient advocacy groups, and peer groups with a specific focus (e.g., sports or a political issue) benefit both the patient and the family. A support network may enable the patient to direct his or her reactions and responses to catastrophic injury in a productive, positive manner. Health care providers, particularly clinicians who interact with the patient in postacute and/or home settings, are responsible for making appropriate referrals for psychologic counseling for both the patient with SCI and the immediate family as indicated. The entire family should understand the patient’s behavior and the appropriate interventions as much as possible.

Pain
Spinal pain has been described by many patients as a burning, hot poker, throbbing type of sensation that never completely leaves. When present, spinal pain is within the zone of injury or below the level of injury, and it may be exacerbated by spasticity. Biofeedback and diversion therapy have been partially effective, but chronic pain programs are recommended for patients with long-term chronic pain symptoms (i.e., pain persisting longer than 6 months). (See RH1512 for pain management.)

Pain rehabilitation programs may consist of medication, behavior modification, creative imagery, aquatic therapy (hydrotherapy), leisure counseling, and psychologic counseling. Total pain alleviation may not be a realistic goal; pain management, which encourages a lifestyle that is not pain oriented, is the overall goal.

BRAIN ATTACK / STROKE REHABILITATION

This section provides management strategies focused on the rehabilitation needs of individuals who have experienced a brain attack/stroke. (See the general discussion of brain attack / stroke in RH1510.) It is estimated that more than 2 million people in the United States have a disability from a stroke. Approximately half of individuals who survive a stroke have some type of residual physical or social disability.¹⁰ Rehabilitation for individuals who have experienced a stroke begins immediately in the acute care setting as soon as the patient is stable, usually after 24 hours. Depending on the severity of neurologic impairment following a stroke, individuals may continue their rehabilitation in rehabilitation settings, long-term care, home, or outpatient settings. Most brain attack / stroke patients returning to the home setting require ongoing rehabilitation and recovery. The rehabilitation goals are the maintenance of functioning and the promotion of additional recovery. Outpatient therapy often includes physical therapy, occupational therapy, speech therapy, and psychology. Case management is also necessary to coordinate the physician’s recommendations for care, equipment rental, transportation services, and day care center enrollment.

High-Risk Nursing Diagnoses

• Impaired physical mobility related to paresis or paralysis
  
• Impaired swallowing related to a disorder of swallowing (dysphagia)
  
• Disturbed thought processes related to impaired cognition
  
• Impaired verbal communication related to effects of aphasia
  
• Risk for injury related to impaired mobility and cognitive deficits (i.e., impulsivity or neglect)

Clinical Management

Impaired physical mobility
The overall goals for a patient with impaired physical mobility resulting from a brain attack / stroke include maintenance of normal alignment; prevention of edema, which can further decrease movement; reduction of spasticity; and prevention of the complications associated with immobility. Depending on the level of disability, a patient with a brain attack / stroke may require a home evaluation to determine whether home modifications are necessary. Recommendations may include nonskid floor surfaces, handrails in living areas, short-pile carpeting, safety bars in bathrooms, and double stair rails. If the patient is wheelchair dependent, modifications might include entrance / exit ramps, a safety intercom system, a roll-in shower stall, a shower chair, and a transfer bench or sliding transfer board. Above all, concern for the patient’s safety determines which home modifications are necessary. The patient with severe impairments must rely on caregivers for positioning, turning, joint mobility, and safety.

Since 1986 a new therapeutic approach to rehabilitation of movement after stroke, termed constraint-induced (CI) movement therapy, has been derived from basic research with monkeys given somatosensory deafferentation. CI therapy consists of a family of therapies; their common element is that they involve constraining the functioning arm to induce stroke patients to greatly increase the use of the affected upper extremity for many hours a day over a consecutive period of 1 to 14 days. These therapies have significantly improved quality of movement and substantially increased the amount of use of the affected extremity in the activities of daily living (ADLs). CI therapy has potential benefits for patients with chronic stroke who meet specific inclusion criteria for upper extremity motor function¹² (see RH1510).

Impaired swallowing
Described previously under head injury, a dysphagia program is usually initiated in the acute care setting and continued with the help of a rehabilitation dysphagia specialist, speech/language pathologist, or occupational therapist. Swallowing should be continually evaluated to minimize the risk of aspiration. Ongoing assessment of the patient’s ability to chew, drink, and swallow is needed to ensure that a correct diet with an appropriate consistency has been ordered. Attention must be paid to the caloric and fluid intake that a patient is consuming to avoid dehydration and ensure adequate caloric intake.

After a bedside swallowing assessment, further studies may be required (e.g., the modified barium swallow [MBS]). The radiologist and dysphagia specialist or speech therapist or both) perform the evaluation with videofluoroscopy. The MBS allows the team to observe the different aspects of swallowing, signs of aspiration, and compensatory strategies used by the patient. Ultrasound may be performed for patients who need only an assessment of oral function. Fiberoptic endoscopic evaluation of swallowing (FEES) is used to evaluate laryngeal/pharyngeal function and risks of aspiration. An endoscope is passed transnasally during the evaluation. With results of the bedside assessment and diagnostic test results, the team makes the decision regarding the type of nutritional support needed by the patient.

Enteral feedings include short-term tube feedings (i.e., passing a nasogastric [NG] tube with selected commercial supplements using the gastrointestinal route). If this method is not appropriate and a longer period of alternative nutrition is needed, invasive methods may be needed (e.g., a percutaneous endoscopic gastrostomy [PEG] tube may be placed surgically with the feeding passing directly into the stomach and reducing the risk of aspiration).

If enteral feedings are being tapered, with oral feedings increasing, a dietitian should be consulted to ensure adequate caloric intake and hydration. When oral feedings are begun, the patient must be positioned to facilitate the swallowing process and minimize the risk for aspiration. The patient should be sitting upright with the head and neck positioned slightly forward and flexed. Soft or semisoft foods and fluids are preferred. Thickening powders are available to add to foods and fluids to increase the consistency to the appropriate thickness. Some individuals may have a tendency to pocket food on the side of the mouth where there is decreased sensation, which can pose a risk for choking. These patients should be taught to use their tongue to sweep the inside of their cheek for food. These patients should be attended throughout the meal. They may become compulsive and “shovel” food, thereby overfilling the oral cavity, which may result in choking and/or aspiration.

Some patients who have experienced a stroke have no difficulty with swallowing but may be easily distracted and impulsive, which can also lead to an increased risk for aspiration. Individuals exhibiting these behaviors should eat their meals in a quiet environment with minimal distractions.

Disturbed thought processes
The brain attack / stroke patient may demonstrate significant cognitive impairments that require cognitive retraining with professional assistance. The family must be taught that the patient may show some of the signs of cognitive impairment listed in Box 15-10.

The clinician can assist the patient in developing coping skills to compensate for these cognitive deficits. The patient must understand that these cognitive deficits are the result of brain damage after a stroke. Effective teaching strategies include the following:

• Reduce distractions and nonessential information.
  
• Associate new skills with old skills.
  
• Encourage the patient to structure relationships between particular facts, wider principles, and generalizations.
  
• Use memory aids as needed.
  
• Maintain consistency in the structure, scheduling, and duration of teaching sessions.

Impaired verbal communication
Strategies used for rehabilitation in the area of impaired verbal communication depend on the type of aphasia present:

• receptive,
• expressive, or
• mixed (see RH1501).

In all cases the goal is to establish an effect mechanism for communication. A speech / language pathologist should be involved in the assessment of the actual type and degree of aphasia and in the development of effective, alternative communication strategies, such as picture boards. Individuals with receptive aphasia will require that directions be provided in a simple step-by-step and repetitive manner. Communication with the patient should be slow, and simple sentences and phrases should be used with sufficient time allowed for the patient to understand and process the information. Staff and family members should take opportunities to repeat the names of common objects throughout the day. Individuals with expressive aphasia are frequently aware of their difficulties with communication and become very frustrated with their inability to express themselves.

COMPREHENSIVE PATIENT MANAGEMENT: REHABILITATION

Health Teaching

Patient and family health teaching is the key to helping the patient reach and maintain a high level of wellness. A multidimensional education program should begin as early as possible in the patient’s care and should include the patient’s family and / or significant others. Teaching addresses the psychosocial and physiologic aspects of the patient’s life and offers opportunities for the patient to develop new skills, coping mechanisms, and behaviors to adjust to aspects of a temporary or permanent neurologic impairment.

Several factors may influence the patient’s ability to learn, including his or her neurologic status (i.e., cognitive and sensory deficits, impaired memory, and pain) and developmental level. With time, however, the patient can be taught the skills necessary to begin a lifelong course toward the highest possible level of wellness within the context of his or her disability.

Patient and family education is essential to a successful rehabilitation experience. This education most appropriately begins in the acute care setting. The current health care delivery system results in patients and families being moved quickly along the continuum of care. The rehabilitation process is enhanced when patients and families have been provided with accurate information conveyed in a manner that is simple and straightforward about the care that is being provided in the acute care phase. Patient education requires a high level of skill on the part of the nurse to determine the amount of information to provide and how to deliver the information to patients and families. An individual, for example, with spinal cord injury (SCI) is likely to have an alteration in bowel function that will require extensive learning before discharge home. In-depth detailed teaching and establishment of a new bowel elimination program will most likely occur in the rehabilitation phase of care. Early simple and factual information about what is being done to avoid constipation and bowel obstructions, beginning in the acute care phase, will serve to familiarize the patient and family with the terms and importance of this area of care for when detailed teaching is done in the rehabilitation phase.

Patient education is closely related to the concepts of adjustment and change. For many patients and families with neurologic impairments leading to disability, the magnitude of changes that occur is enormous. Rehabilitation may require months of relearning the most basic activities of daily living (ADLs), including mobility, bathing, dressing, toileting, grooming, and feeding. In addition, brain injury requires cognitive intervention for the patient and family to adapt to the onset of a major neurologic event—patients and families require considerable support to develop successful strategies to adjust to the changes. Clinicians along the continuum of care need to recognize the importance of repetition and reinforcement of information in ways that are meaningful and accessible to patients and families. Paterson, Kieloch, and Gmiterek ¹⁴ report that families of survivors of TBI did not remember being taught what to expect after discharge or what resources were available to them, despite health care professionals reporting that extensive discharge planning and teaching occurred. These findings point out how critical it is that clinicians and caregivers along the continuum understand the stress that patients and families encounter. There is also a need to develop strategies that regularly assess the patient’s and family’s understanding of the individual’s condition and the care that will be needed.

Psychosocial Considerations

Sexuality
Preliminary teaching for altered sexual functioning may begin in acute care when the patient voices a readiness to deal with the topic (see RH1507). Cognitively impaired patients may express sexual inappropriateness (e.g., male patients making advances toward female health care providers or using sexually explicit language). Firm responses that let the patient know that the behavior is unacceptable will extinguish the inappropriate behavior over time. Initially, health care professionals are responsible for preparing the patient to discuss sexual relations, focusing on bowel and bladder management, spasticity, and problems with performing ADLs that may affect sexual activity. Sexual concerns should be integrated into the rehabilitation treatment program, which includes counseling, educational tapes, books, and discussion groups. Sexual therapists often counsel both the patient and his or her partner to discuss expectations and changes in their sexual relationship. The clinician can help patients maintain their sexual identity by minimizing embarrassing situations, supporting patients’ attempts to maintain their physical appearance, providing uninterrupted, private time for patients and their partners, and encouraging the patient to explore sexual feelings and alternative modes of sexual expression.

Fertility and sexual performance are frequent concerns, particularly for patients with SCI. Sildenafil (Viagra) is an effective, well-tolerated treatment for erectile dysfunction (ED) that is taken orally before sexual activity. Viagra is currently under investigation for neurologically impaired women. For the male patient, erection assistive devices are available, such as vacuum suction pumps, prostaglandin penile injections, and penile prosthetics or implants. Electroejaculation, vibratory stimulation, and pharmacologic intervention may be useful for ejaculation and producing sperm (see Table 15-5). For female patients, issues of bowel and bladder management and childbirth are continuous. These patients have special needs for accessible gynecologic and obstetric care during childbirth.

The patient’s self-perception
The neurologic patient experiences periods of frustration and depression intermittently throughout the recovery process or as a new phase in the trajectory of a chronic illness is experienced. Confronting the aging process and its effect on residual neurologic deficits may prove especially difficult. People in America have expressed that they are more fearful of being disabled by stroke than of death itself. When individuals are diagnosed with a stroke, they may develop a negative body image reinforced by memories of a friend or relative who was disabled by a stroke and left helpless, physically impaired, and unable to speak, move, or control his or her bowels or bladder. Referrals for psychologic counseling, support groups, patient advocacy groups, and community organizations are often helpful, especially if the patient will be discharged to the community from the acute care setting and will be receiving rehabilitation services on an outpatient basis or at home.

Adjustment and coping with SCI may result in emotions that range from sadness to varying stages of depression during the initial recovery phase. Long-term psychologic adjustment for individuals with SCI may be enhanced with rehabilitation counseling, support groups, and a supportive family. Individuals unable to successfully cope may benefit from professional psychologic evaluation and antidepressant medications.

Depending on the extent of neurologic deficit, the patient may be able to live a completely independent life. Unfortunately, this is often not possible, and appropriate caregiver services must be secured. If the patient hires caregivers independently, the patient may become the employer of several attendants, nurses, or therapists. This, along with the duties of health maintenance, may be overwhelming. In such instances the patient may need medical services and/or therapy to be reinitiated. Nonetheless, independence in directing his or her own care and maintaining his or her functional status is critical to the patient’s self-concept. Health care professionals should encourage independence rather than foster dependence on health care systems.

The clinician can help improve the patient’s self-esteem by assisting with the identification of realistic goals that capitalize on the patient’s strengths and resources. The rehabilitation patient needs to verbalize a clear understanding of the rehabilitation process and the nature of the injury or illness to the extent possible. This helps the patient feel in control. A supportive environment should also be provided so that the patient can be encouraged to explore new feelings and activities without fear of failure or criticism.

Family support
By the time the patient with TBI, SCI, or a brain attack/ stroke is in rehabilitation, the family or significant others often have become very knowledgeable in many aspects of the care. Nevertheless, the rehabilitation phase may prove to be the most challenging for the family. Teaching the patient and family to function without health care providers or hospital resources may invoke stress and anxiety. Teaching the patient to take control of his or her care may meet with some resistance, and teaching the family to allow the patient to take control may also be difficult. Finding an appropriate support group for the patient and / or family is usually very therapeutic.

Stress
Stress has been described as a prevalent health problem in America. Stress can increase during recovery and rehabilitation and actually become a barrier to improvement by tightening muscles and causing discomfort. Stress reduction is helpful in boosting the immune system, relaxing muscles, and promoting a sense of well-being. Stress reduction classes or individual sessions with a therapist can be recommended to determine the most appropriate therapeutic relaxation procedures. Choices may include biofeedback, Herbert Benson’s “Relaxation Response,” deep breathing, guided imagery, therapeutic touch, music therapy, or meditation. Aquatic therapy, or hydrotherapy, is another therapeutic modality whereby patients can use flotation devices in the deep end of the pool and relax to music or close their eyes for fantasy exercises (e.g., a trip in the sun to Hawaii) (Fig. 15-6). Once patients learn to recognize when tension is developing, they can learn how to avoid tension buildup and use their progressive relaxation techniques.

Suicide
Patients who are unable to cope with their disability, who suffer from severe depression, who become reclusive following their neurologic injury, and who feel helpless and hopeless in their rehabilitation efforts should be assessed for the potential for suicide. Early counseling and psychologic support, in addition to rehabilitation, is often needed for individuals with chronic or catastrophic neurologic outcomes. Older adults may not exhibit the typical signs of suicide and are often successful using lethal means. Risk assessment with early referral to a mental health professional is important for patients who have severe depression and are at risk for suicide.

Rehabilitation is physically taxing and requires a highly motivated patient and a strong support system to be successful. The rehabilitation process may be particularly stressful for the families of patients with TBI, and to intervene effectively, neuroscience clinicians should act on three main premises:

1. Crisis theory is applicable to the family situation.
   
2. Clinical interventions must be based on the behavioral response of the family.
   
3. Family dynamics directly correlate with the recovery status of the patient.

Living in a constant crisis state reduces the family’s ability to mobilize and use all available resources. The key clinical goal is to assist the family in identifying and using all coping resources.

Older Adult Considerations

With about 15% of the population now over 65 years of age and older adults making up the majority of the rehabilitation population, the Association of Rehabilitation Nurses in 1994 described the subspecialty of rehabilitation for older adults as follows:

Gerontologic rehabilitation nursing practice provides care and expertise to promote health, maintain and restore function, and provides education and counseling to older clients and their families. Gerontologic rehabilitation nurses combine rehabilitation knowledge and skills with gerontologic principles to focus on individuals who are 65 years or age and older.

With the aging of the 78 million baby boomers, by 2010, 50% of the population will be 50 years of age or older. Gerontologic rehabilitation is a specialty that will require a large body of health care providers to focus on the unique needs of the older population with neurologic deficits. The older patient, as a result of the normal aging process, may have physical and cognitive limitations, visual and hearing deficits, increased fatigability from poor nutrition and weight loss, delayed healing, decreased muscle mass, and frail, thinner skin that rapidly breaks down (Table 15-6).

These normal aging processes, in combination with a major neurologic injury, make rehabilitation a challenge that requires additional time and resources to help the patient adapt and recover from a neurologic disability.

Gerontologic specialists are available in most acute care hospitals and rehabilitation facilities to deal with the special needs of older adults. After discharge, however, the older patient who returns home may require a home assessment with potential home alterations, someone to adapt the home environment for the older patient with a disability, a hospital bed, and other special equipment to continue the rehabilitation. The spouse, who may also be older, may be anxious and frustrated if he or she is the only caregiver 24 hours per day. Attendant care is therefore essential in these cases to supervise and provide relief for the spouse, who often claims to have become a prisoner in his or her own home.

A personal attendant can provide range-of-motion (ROM), ambulation, and good nutrition, as well as teach safety and how to prevent falls and injury. Patients who display poor judgment, impulsiveness, and unwillingness to accept help can benefit from an attendant using behavior modification and positive reinforcement until the older patient adapts and learns to cope with the disability.

In addition to physical therapy and occupational therapy, rehabilitation centers and community fitness clubs now offer therapeutic recreation. Included are exercise and fitness programs for rehabilitation of the older adult that includes land (tai chi) and water therapy. Aquatic classes for aquatic motion and strength training, gait therapy, muscle lengthening, and stress release improve gait with less energy expended, improve balance, provide relief of back pain, and increase muscle flexibility (see Fig. 15-6). Many programs offer wheelchair accessibility and maintain the ideal temperature for older patients. Socializing with other older adults with disabilities is an added benefit. Pet therapy and a canine companion have proven therapeutic benefits, especially for older patients who have fond memories of pets they have owned (see RH1507).

The potential for elder abuse should be considered when the stress and strain appear to overtax the spouse or family members. Abuse is suspected when there is evidence of neglect, unexplained wounds, dehydration, malnutrition, an unkempt home appearance, the patient’s being left alone for long periods of time, poor personal hygiene of the older patient (including soiled bed linen), and no evidence of shopping for food or cooking. Older patients may be reluctant to report family violence or abuse for fear of abandonment or being moved from the home to long-term care. Frequent checks or unannounced follow-up visits can dispel the suspicion or give evidence for contacting protective services to get involved. Patients in imminent danger should be removed immediately.

Adequate support and rehabilitation are rewarding when older adults regain their independence and function. With community services and family support, older patients can recover from neurologic disorders to live long and productive lives.

CONTINUUM OF CARE

Case Management Considerations

Effective care coordination is the responsibility of the case manager, who will continue the patient’s prescribed rehabilitation plan in the home setting.⁹ After the patient evaluation, the case manager will meet with the health care team of rehabilitation professionals and family to carefully develop a plan designed to restore the individual to his or her highest level of functioning and increase his or her mobility and capacity for independence. Once the cost-effective plan has been approved by the third-party payers to cover the needed funding for services and equipment, the goal is to help the patient complete the rehabilitation process, prevent complications, and avoid rehospitalization.

Familiarity with not only the patient’s neurologic condition and concepts of rehabilitation, but also safety and equipment, is essential. Patients and families also require health teaching regarding medications, including their side effects or adverse reactions; the use of special equipment for transfers and ambulation; and transportation using automobiles and vans, properly fitted wheelchairs, and devices to assist caregivers (e.g., lifts).

Steps and bathrooms, for example, can pose serious problems as patients return to their homes with walkers, braces, power wheelchairs, and physical disabilities that are new and frightening. Case managers can assess how the patient functions in the home setting and can offer appropriate recommendations. For those patients with a lifelong catastrophic neurologic injury (e.g., SCI, TBI, or brain attack/stroke), the challenge of case management includes advocating for funds and resources to cover the rehabilitation services long enough to help achieve the individual’s goals of independence and a satisfactory quality of life.

Life Care Planning

Life care planning (LCP) is the process of identifying a patient’s current health status, future health care needs, and appropriate resources and associated costs to address lifelong disability/illness management.² Many neurologic disorders may require LCP, especially TBI, SCI, brain attack / stroke, and brain tumors. When the nurse designs a life care plan, the nursing process functions as the conceptual framework and nursing diagnoses serve as the rationale for the recommendation of future care and related expense. LCP is reviewed in RH1551.

CONCLUSION

Rehabilitation of the patient with a neurologic illness is a specialty that has made significant contributions to patients’ quality of life. This chapter has provided the reader with an overview of rehabilitation interventions. Rehabilitation encompasses a vast range of treatment methods of various disciplines to accomplish the patient’s goals. It does not stop with the rehabilitation team’s final session. Exercises and individual therapy can be continued for a lifetime.

American Academy of Orthopaedic Surgeons
http://www.aaos.org

American Academy of Physical Medicine and Rehabilitation
http://www.aapmr.org

American Association of SCI Nurses
http://www.aascin.org

American Paraplegia Society
http://www.apssci.org

Association of Rehabilitation Nurses
(800) 229-7530
http://www.rehabnurse.org

CARF—The Rehabilitation Accreditation Commission
http://www.carf.org

disAbility Resources
http://www.disabilityresources.org

Model Spinal Cord Injury Systems
http://www.ncddr.org/rpp/hf/hfdw/mscis

National Center for the Dissemination of Disability Research
http://www.ncddr.org

National Rehabilitation Information Center
http://www.naric.com

New Mobility
http://www.newmobility.com

Spinal Cord Resources
http://www.makoa.org/sci.htm

U.S. Department of Education, National Institute on Disability and Rehabilitation Research
http://www.ed.gov/offices/OSERS/NIDRR

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