When our disabled or elderly patients are admitted to a either an acute or sub-acute rehab, the focus is typically on therapy. This is appropriate because these patients have most likely just spent at least three nights in a qualified Medicare Part A hospital stay for something like stroke, pneumonia, a fracture, surgery, urinary tract infection, or injury from a fall. Since they likely spent most of their hospitalization in bed and are now weaker than before they were admitted, they need therapy to get them back to at least their pre-hospital level of activity.
The problem is that these patients are only in acute or sub-acute therapy a few hours per day so that leaves over twenty hours each day that they are the responsibility of nursing. A few hours of therapy each day without continued support from nursing is very likely not enough for the patient to reach their rehab potential. Unless they are encouraged and assisted by nursing to walk and exercise, they tend to remain immobile – and immobility results in weakness and adversely effects every system of the body. They also need adequate and quality sleep at night, and rest time after therapy.
The reasons for immobility are numerous: loss of the use of a body part; pain; fear of falling; weakness; confusion (especially if they have a urinary tract infection (UTI)); depression; feelings of hopelessness; and lack of balance to name a few. After a stroke the patient is dealing with multiple issues. They may have difficulty swallowing, loss of center of gravity that can make them more prone to falls, vertigo, loss of self-image, loss of use or weakness of at least one body part, loss of bowel or bladder control, and potential for increased muscle tone or lack of muscle tone (flaccid body part). Pain is a significant reason a patient may desire to limit their movement so nursing must monitor their pain and use continual pain-relieving measures. This might be a cold or hot pack, pressure relief and other positioning strategies, pharmaceutic pain relievers (given before therapy is good so they do not have pain during their therapy session but not enough medication to adversely affect their ability to do quality therapy). Adequate nutrition is important for energy. Someone who fears falling must have assistance and encouragement with transfers, standing, toileting and walking – and feel confident that the staff person will support them and not allow them to fall. Nursing must encourage an increase of fluid intake and strictly give antibiotics as directed for UTI. They must attempt to keep a depressed person active and out of their room and around others. And, they must stay close to anyone with balance issues when they are standing or walking to prevent falls and other injuries. These nursing measures need to be on the patients’ overall plan of care and scheduled on their daily task list or they will not be accomplished.
In order to assist these sometimes frail and fragile patients to their highest potential, we have to train staff to automatically think of all of the holistic needs of their patients and the importance of carry through with patience and kindness. Care plans and schedules must reflect all needs and potential needs of the patient. Assignment changes must be carried over from shift to shift. Therapy is vital to “get people back on their feet” and as independent as possible, but it is nursing that is the glue that makes true rehabilitation a success.
Karen L. Bonn, RN, COF
Clinical Specialist for Restorative Medical