Chapter 32 Rehabilitative and Restorative Care

Introduction Significance and prevalence of chronic conditions Frailty and disability Emphasis on saving lives Must be balanced with an emphasis on preserving quality of life (QOL)

The Need for Rehabilitation Defined broadly in geriatric care Improvement of functional capacity to promote coping Maximal independence Sense of well-being Enjoyment of a satisfying life

The Need for Rehabilitation (cont.) Symptoms of frailty Unplanned weight loss Slow walking speed Low grip strength Fatigue, poor endurance Low levels of activity Causes of frailty Sarcopenia

The Need for Rehabilitation (cont.) High risk for Falls Disability Hospitalization Nursing home admission Death

The Need for Rehabilitation (cont.) Prevention of frailty: Positive health practices Effective management of health conditions Early recognition and intervention Nursing assessment

Question Is the following statement true or false? Nursing assessment of older adults should include assessment of frailty or potential for frailty.

Answer True Rationale: Early recognition and intervention for symptoms of frailty can prevent or delay some of the frailty older adults experience. For this reason, it is especially useful to review symptoms of frailty during nursing assessments of older adults.

Living with Disability Sudden disability or disease progression Impact of disability: Losses and limitations Relationships, roles, and responsibilities disrupted Disfigurement and dysfunction alter body image and self-concept Vulnerability and frustration

Importance of Attitude and Coping Capacity Severity of a disability may be less important than the coping capacity of a disabled person Influence on reactions to disability Previous attitudes Personality Lifestyle Family response

Losses Accompanying Disability Multiple losses: Function Role Income Status Independence Anatomic structure May demonstrate stages of dying reactions Fluctuates

Principles of Rehabilitative Nursing Increase self-care capacity Eliminate or minimize self-care limitations Act for or do for when the person is unable to take action for himself or herself Improving functional capacity can promote well- being and QOL

Guidelines for Rehabilitative Nursing Know the unique capacities and limitations of the individual Emphasize function rather than dysfunction; capabilities rather than disabilities Provide time and flexibility Recognize and praise accomplishments

Guidelines for Rehabilitative Nursing (cont.) Do not equate physical disability with mental disability Prevent complications Demonstrate hope, optimism, and humor Rehabilitation is a highly individualized process Multidisciplinary team effort

Functional Assessment Functional status, rather than diagnosis, directs rehabilitative care Functional status varies widely among older adults Functional status can change within an individual depending on the control of symptoms, progression of the disease, and mood

Functional Assessment (cont.) Determine individuals ability to perform Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Tools Underlying causes needs to be identified and treated Can be totally independent, partially independent, or dependent

Question Which of the following assessment tools is frequently used to assess ADLs? PULSES Index for Daily Living Barthel Tool for Dependence Katz Index of Independence Geriatric Functional Tool

Answer C. Katz Index of Independence Rationale: The Katz Index of independence in ADLs assesses a person’s ability to meet basic requirements such as eating, bathing, dressing, toileting, and moving.

Interventions to Facilitate and Improve Functioning Facilitating proper positioning Correct body alignment facilitates Respiration Circulation Comfort Prevents complications

A. Supine position. B. Prone position. C. Lateral position. D A. Supine position. B. Prone position. C. Lateral position. D. Chair position.

Interventions to Facilitate and Improve Functioning (cont.) Assisting with range of motion (ROM) Exercises Exercise as essential component of health maintenance and promotion Benefits Types ROM exercises as a nursing intervention Cautions

Range-of-Motion Exercises

Range-of-Motion Exercises (cont.)

Range-of-Motion Exercises (cont.)

Question Which of the following statements is an incorrect statement related to assistance with ROM exercises? ROM should be performed at least once a day The joint should be moved slowly and smoothly Provide support above and below the joint being exercised Gently force the joint past the point of resistance

Answer D. Gently force the joint past the point of resistance Rationale: The joint being exercised should not be forced past the point of resistance or to the point where pain occurs.

Interventions to Facilitate and Improve Functioning Assisting with mobility aids and assistive technology Wheelchairs, canes, and walkers can increase independence and enhance functional capacity Education necessary to prevent injury Use mobility aids only when necessary Selection of an aid to mobility

Proper Use of Mobility Aids CANES Depending on the disability, various canes may be recommended. Canes should be individually fitted, usually based on the distance from the greater trochanter to a distance 6 inches from the side of the person’s foot. The cane is used on the unaffected side of the body and is advanced when the affected limb advances. For example, if the right leg is affected, the person holds the cane in his or her left hand and advances it with the advance of the right leg. WALKERS A variety of walkers can provide support and stability during ambulation.

Proper Use of Mobility Aids (cont.) WALKERS (cont.) Walkers are sized by the measurement from the patient’s trochanter to the floor. The person should place his or her hands on the sides of the walker, with the elbows slightly flexed. During ambulation, the person advances the walker and then steps forward. Appropriate use should be followed during transfer activities also. When lowering to a seat, the person should back the walker to the seat. When lifting from a seat, the person’s hands should be on the arm of the chair. The person pushes on the arms of the chair to a standing position; the person should not use the walker to pull himself or herself to a standing position.

Proper Use of Mobility Aids (cont.) WHEELCHAIRS A wheelchair should be individually fitted. The seat should be slightly larger than the person’s width to prevent pressure and friction. The person’s arm should be able to reach the wheels easily, and footrests should be adjusted to support the patient’s foot in a flat position. Removable or fold-down armrests facilitate transfer. Wheelchairs should be checked routinely for ease of wheeling; function of brakes; and freedom from jagged edges, tears in upholstery, and broken or missing hardware.

Interventions to Facilitate and Improve Functioning Teaching about bowel and bladder training Impact of incontinence on general health and well-being Education can improve continence Physical and mental nursing assessment Consistency is a crucial factor Adherence to the schedule

Interventions to Facilitate and Improve Functioning (cont.) Maintaining and promoting mental function Mental function can decline if not exercised Mental stimulation is a highly individualized process Specific therapies: Reminiscence or life review Reality orientation

Using Community Resources Disabled and their caregivers Education, support, and assistance Guidance in locating appropriate resources Variety of health care professionals Sources of information and services Local libraries Health departments