Rehabilitation Nursing

Ann S. Bines

DEFINITION

Rehabilitation nursing is a specialty that centers on the diagnosis and treatment of human responses of individuals and/or groups to actual or potential health problems relative to altered functional ability and lifestyle [1].

• Major areas of focus with the inpatient traumatic brain injury (TBI) population:

Pain assessment and treatment

Maintenance/assessment and treatment of skin integrity

Promotion of a physiologic sleep/wake pattern

Continence of bowel and bladder

Prevention of aspiration/promotion of oral health

Assessment/participation in behavior management

Providing for safety/promoting independence restraint reduction

Promoting advocacy through education

Emotional/psychosocial support

PAIN ASSESSMENT AND TREATMENT

• Incidence of pain in this patient population is significant.

• Etiology is variable. In the acute stage, pain may be caused by fractures, intra-abdominal injuries, soft tissue injuries, and pain associated with invasive procedures. In the chronic stage, pain may be due to spasticity, contractures, pressure sores, soft tissue injuries, peripheral nerve injuries, headache, and/or postsurgical incisional pain.

• Assessment is inherently difficult in this patient population due to cognitive issues. Few conventional tools have been validated in the cognitively impaired TBI population. Pain assessment in patients who cannot verbalize their pain should include subjective assessment of pain behaviors [2,3].

• Validated tools (primarily validated in elderly patients with dementia) include:

Checklist of Nonverbal Pain Indicators: Scoring of six behaviors—vocalization, grimaces, bracing, rubbing, restlessness, and verbal complaints [4].

Critical Care Pain Observation Tool: Facial expression, body movements, muscle tension, vocalization, or compliance with ventilator [5].

Face, Legs, Activity, Cry, Consolability Scale: Facial expression, leg movement, body activity, cry/vocalization, and consolability [6].

Nociception Coma Scale (NCS): Was recently validated in patients with disorders of consciousness (MCS/VS). This scale includes the observation of motor, verbal, and visual responses as well as facial expression. The total score varies from 0 to 12 [7].

• Treatment

Use multimodal therapy to provide pain relief while limiting drug side effects, thereby minimizing their effects on cognitive recovery.

Nonpharmacologic therapies include heat, cold, repositioning, diversion, relaxation techniques, acupuncture, massage, and behavioral management. Maximize use of these modalities.

Use analgesics for analgesia, not to control behavior. Taper or discontinue drugs that are not effective.

Consistency of caregivers (nurses, unlicensed personnel, and family) is very beneficial in identification of signs of pain in cognitively impaired patients.

ASSESSMENT AND PREVENTION OF SKIN BREAKDOWN

Assessment

• This is a high-risk population for development of pressure ulcers. Risk factors include decreased sensation/movement, agitation/nonpurposeful movement (e.g., spasticity/dystonia), nutritional impairment, and incontinence.

• Extrinsic factors causing pressure ulcers include pressure, shear, friction, moisture, and equipment/positioning devices.

• An estimated 1.6 billion dollars is spent annually on care of pressure ulcers. Cost per hospital stay ranges from $200 up to $7,000 (for complex stage IV) [8].

• The Centers for Medicare and Medicaid Services (CMS) has tightened regulations related to reimbursement surrounding pressure ulcers and wounds. If pressure sores develop that were not present at admission to a facility, they are considered “hospital acquired” and hospitals may not receive payment for care.

• Most frequently used risk assessment tools are the Braden and Norton scales. Risk for skin breakdown should be initially assessed on admission and then on a routine frequency; at minimum daily.

Norton-5 parameters scored/assessed: physical condition, mental state, activity, mobility, and incontinence. Lower scores indicate high risk. Risk onset begins at 12 or less.

Braden-6 parameters scored/assessed: sensory perception, skin moisture, physical activity, nutritional status, friction/shear, and ability to change body position. Lower scores indicate high risk. Risk onset begins at 16 or less [9].

Preventative Interventions

• Reduce/limit moisture: Establish a program to enhance continence. Use pH-balanced soaps/cleansers. Use moisture barrier as needed to prevent skin breakdown. Perineal areas open to air when in bed.

• Optimize nutrition/hydration: Calorie counts, mineral/vitamin supplements.

• Shear/friction prevention: Use of lifting aids/equipment when repositioning. Raise knee gatch of bed when the head of the bed is elevated to decrease shear/friction forces from additional sliding.

• Pressure relief aids: Bed surfaces, chair cushions, adequate padding of orthotics, and padding of rigid surfaces in bed and wheel chair. Specialized chairs such as tilt-in-space chairs also relieve pressure in immobilized patients.

• Repositioning/pressure relief programs: Establish an individualized turning program when patient is in bed, use of log to track. Prone positioning, when appropriate, can be very useful to off-load pressure points when patient is in bed. The use of timers with an alarm can be used to establish a repositioning program for wheelchair-bound patients who cannot weight shift independently to off-load bony prominences (due to immobility or cognitive impairments). The timers can be placed on wheelchair. Timer set for 20 to 30 minutes based on patient need for repositioning. When timer alarms, it signals patient/care givers to reposition in chair.

• Pressure mapping: A computerized clinical tool that involves using sensors to assess pressure distribution between two contacting objects, such as a person and his or her support surface. It is commonly used by clinicians to determine the suitability of a wheelchair cushion or other support surfaces, and optimal positioning (when sitting or lying) to off-load pressure [10].

PROMOTION OF SLEEP/WAKE PATTERN

• Assessment: A log maintained by caregivers is recommended due to limited ability of patients to self-report sleep patterns. Document sleep onset and duration of sleep periods. Include patient/family assessment of quality of sleep. Actigraphs provide another means of assessing sleep duration [11].

• Interventions

Control environmental factors such as noise, light, and temperature. Employ nonpharmacologic sleep aids—music, evening showers, soothing scents, or TV (may assist with promoting onset of sleep, not to be left on after sleep is established).

Establish a “bedtime routine;” this can be advantageous in promoting sleep onset.

Be aware of patient’s preinjury sleep behavior; hours of sleep per night, bedtime, and usual time of awakening and shift work. Do not force sleep.

Schedule nursing care so as not to interfere with sleep.

Use of pharmacological agents. Timing of administration early enough to enhance sleep but not affect ability to participate actively in therapy is important. Use sleep aids to promote sleep—not to control behavior.

Regulation of the patient’s sleep-wake cycle has been shown to have a positive impact on agitation and other negative behaviors. (See also Chapter 54 for a more detailed discussion of management of insomnia in TBI.)

CONTINENCE OF BOWEL AND BLADDER

Continence is a major area of nursing focus. Functional Independence Measure scores that quantify bowel and bladder continence are an externally reported outcome measure/benchmark for rehab programs. Continence is also a primary goal for families/caregivers. Incontinence may present a burden of care that prevents home discharge. Incontinence can also increase agitation in TBI patients.

• Bladder incontinence

Cause—

Incontinence is most often due to uninhibited neurogenic bladder, signs and symptoms include reduced bladder capacity, frequency/urgency, nocturia, and voiding as soon as urge is perceived. Sensation and the bulbocavernosus and micturition reflex arcs are intact. The bladder empties completely [12].

Transient, acute functional incontinence, often of precipitous onset, is typically reversible. It is related to impaired physical/cognitive/communication/behavioral function.

Assessment—monitor postvoid residual; review medications, consider age, presence of premorbid incontinence issues, and urinary tract infection.

Interventions to reestablish continence:

Prior to initiating any program, assess patient’s behavior, core strength, balance, and level of assistance with transfers. Continence can be achieved using bedpans, urinals, commodes, or condom catheters. Consistency of caregiver adherence to the continence program is very important. Regulate fluid intake. Ensure privacy. Provide positive reinforcement [13].

Scheduled/timed voids—assess patients voiding patterns and replicate (usually every 2–4 hours). Patients are often unaware of the need/urge to void.

Prompted voiding—it is useful when the patient recognizes the need/urge to void. It requires intense caregiver intervention. Three steps to program; (a) monitor the patient for incontinence at regular pre-established intervals, (b) prompt the patient to toilet if dry, and (c) provide positive reinforcement for successful toileting.

• Bowel incontinence

Cause—uninhibited neurogenic bowel—reflexes, spinal reflex arc, and bowel and saddle sensation are typically intact. Decreased awareness of the need to defecate and decreased control of external sphincter result in inability to inhibit defecation. May have a sense of urgency (perceived). [12].

Assessment: consider preinjury bowel habits. Identify date of last bowel movement. Review current diet, hydration status.

Interventions to promote bowel continence: assess patient’s ability to transfer to/use the toilet. Be consistent in administering a bowel program. Promote an upright sitting position, with knees bent for defecation. Avoid use of a bedpan; utilize shower or toileting chair. Consider an abdominal binder to increase abdominal pressure. Ensure adequate hydration/fiber intake. Initiate program after food intake to activate gastrocolic reflex. Plan bowel program so as not to interfere with participation in therapy. Provide privacy [13].