Rehab Nursing Series : Intro to Rehabilitation · Rehab Nursing Series™: Intro to Rehabilitation iii THE REHAB NURSING SERIES INTRODUCTION TO REHABILITATION & REHABILITATION NURSING

Rehab Nursing Series™: Intro to Rehabilitation i

Rehab Nursing Series™: Intro to Rehabilitation ii

Rehab Nursing Series™: Intro to Rehabilitation iii

TH E R E H A B NU R S IN G SE R I E S

INTRODUCTION TO REHABILITATION &

REHABILITATION NURSING

Pamela Masters-Farrell, MSN, RN, CRRN

This workbook is for use with the course Introduction to Rehabilitation

& Rehabilitation Nursing, which is part of the Rehab Nursing Series

published by Rehab ClassWorks, LLC®.

Notice: The clinical information and tools used in this course are based on current literature,

research, and consultation with nursing, medical, and legal authorities. To the best of our

knowledge, it reflects current practice. However, appropriate information sources should be

consulted, especially for new or unfamiliar procedures.

This course contains many references and resources using internet addresses. Although these

sites were current at the time of the research, writing, and/or publication, many internet postings

are dynamic and subject to expiration or deletion over time. Therefore, Rehab ClassWorks, LLC

cannot guarantee currency of electronic references. Please check for the latest information on a

cited topic using online search engines.

©2017 Rehab ClassWorks, LLC 14330 S. 2200 W. Bluffdale, UT 84065

Phone: (888) 294-0412 Fax: (801) 253-7520 Email: [email protected]

Web Address: http://www.rehabclassworks.com

All rights reserved. This document, the associated computer course, or any part thereof, may not

be reproduced or transmitted in any form or by any means, electronic or mechanical, including

photocopying, recording, storage in an information retrieval system or otherwise, without prior

written permission of Rehab ClassWorks, LLC. Licensing of this course and workbook are non-

transferable without prior written permission of Rehab ClassWorks, LLC. Purchasers of a registered

multiuser license for the course are granted permission for copying of the workbook and computer

course for use by staff covered by said license.

mailto:[email protected]

http://www.rehabclassworks.com/

Rehab Nursing Series™: Intro to Rehabilitation iv

TH E R E H A B NU R S IN G SE R I E S

The Rehab Nursing Series™

Second Edition

NOVICE COURSES—NEW TO REHABILITATION

Introduction to Rehabilitation & Rehabilitation Nursing

Take Care! Safe Patient Handling Works!

1, 2, Buckle My Shoe… Functional Skill Development

Not Documented? Not Done! Documenting Professional Rehabilitation Nursing Care

Got a Plan, Man? Patient-Centered Care Planning in Rehabilitation

See One, Do One… Patient & Family Education in Rehabilitation

Go HOM! Preventing Complications from Immobility

Pediatric Rehabilitation

INTERMEDIATE COURSES—CORE REHABILITATION NURSING SKILLS

Get Going! Mobilize Your Patients

Gotta Go Right Now! Bladder Management in Rehabilitation Nursing

Full of It! Bowel Management in Rehabilitation Nursing

An Apple a Day… Nutrition & Dysphagia Management

He Said/She Said? Disorders of Communication, Speech, & Language

Wandering, Confused, & Agitated? Cognition & Behavior Management

A Little Romance? Providing Sexuality Education & Counseling in Rehabilitation

Down, Not Out! Providing Psychosocial Support in Rehabilitation

ADVANCED COURSES—APPLICATION OF CORES SKILLS TO SPECIFIC POPULATIONS

Rehabilitation of Stroke

Rehabilitation of Brain Injury

Rehabilitation of Spinal Cord Injury

Cardiopulmonary Rehabilitation

Certification Review for Rehabilitation Nurses

I N T E R A C T I V E E D U C A T I O N · N O V I C E T O E X P E R T · W O R K I N G S M A R T E R

Registration is required for continuing education credit. Register your course by going

to www.rehabclassworks.com/reg.html.

http://www.rehabclassworks.com/reg.htm

Rehab Nursing Series™: Intro to Rehabilitation v

A C K N O W LE D G E ME N T S

A C K N O W LE D G E ME N T S

This course could not be completed without the help and expertise of our associates and

reviewers, some of which are listed below. In the interest of privacy, we list only those who desire

to be listed. Their contributions are gratefully acknowledged.

Reviewers

Irin Daniel, BSN, RN

Robin Decker, MSN/Ed, RN, CRRN

Melissa Grann, RN

Tanja Hagen, MS, RN, CRRN

Chris Hayball, RN

Sharon P. Jacobson, RN

Brook Jimenez, MBA, BSN, RN, CRRN

Judy Kiefer, BSN, RN

Janet Pratt, RN

Ann Rogers, RN

Patricia Safford, RN, CRRN

Timothy Walsh, BSN, RN

Elizabeth Woodrich, BSN, RN, CRRN

Editor:


Planning, Research, & Development:


Michelle Edwards, MSN, RN

Sherry Adkins, BSN, RN, CRRN

Carolyn Schultz, RN, CRRN

Art:

Shantel Pilcher

Programming & Quality:

Suzanne Bawden

Cheryl Micheel, BS

Janet Plackemeier, BS Ed

Yuliya Lange, BS-BA

Individuals in a position to control content for this educational activity have nothing to disclose.

This educational activity does not include any content that relates to the products and/or services

of a commercial interest that would create a conflict of interest, and there is no commercial

support being received for this activity.

Visit us at www.rehabclassworks.com to learn more about our course offerings, course expiration

dates (http://www.rehabclassworks.com/FAQ.htm), and quick tips. Visit our rehab nursing blog at

http://www.rehabclassworks.com/Blog.htm. We would love to hear from you regarding your

rehabilitation nursing needs and questions. Contact us via email to [email protected].


http://www.rehabclassworks.com/FAQ.htm

http://www.rehabclassworks.com/Blog.htm


Table of Contents Rehab Nursing Series™: Intro to Rehabilitation vi

TABLE OF CONTENTS

Getting Started .................................................................................................... ix Launching the Course ...................................................................................................... ix Logging In ..................................................................................................................... ix Functions of the Main Menu .............................................................................................. x Continuing Education Hours ............................................................................................. x Using the Course ............................................................................................................ xi Workbook and Computer Course ...................................................................................... xi Quizzes ........................................................................................................................ xii Links ............................................................................................................................ xii Functions of the Navigation Bar ....................................................................................... xii Page Numbers ............................................................................................................... xii Reference ..................................................................................................................... xii Main Menu .................................................................................................................... xii Index .......................................................................................................................... xiii Help ............................................................................................................................ xiii Read ........................................................................................................................... xiii Progress Report ............................................................................................................ xiii Other Features ............................................................................................................. xiii Notes Books/Feedback .................................................................................................. xiii

Chapter 1 Introduction & Overview .......................................................................... 1 Chapter Objectives or What Is Your Job in This Chapter? ..................................................... 1 Course Goal ................................................................................................................... 2 Rehabilitation Nursing and YOU! ....................................................................................... 2 The History of Rehabilitation ............................................................................................ 3 Before Rehab ................................................................................................................. 3 Rehab Is Born ................................................................................................................ 3 Rehab Comes Into Its Own .............................................................................................. 4 You Make a Difference! .................................................................................................... 6 Where Are We Now? ....................................................................................................... 7 What Does This Mean to Me? ........................................................................................... 7

Chapter 2 What Is Rehab? ...................................................................................... 8 What Is Your Job in This Chapter? .................................................................................... 8 Just What Is Rehabilitation? ............................................................................................. 9 Trends in Rehabilitation ................................................................................................... 9 The Continuum of Care ...................................................................................................10 Philosophy of Care .........................................................................................................11 Problem Lists ................................................................................................................11 Goals ...........................................................................................................................12

Chapter 3 The Rehabilitation Nurse ....................................................................... 17 What Is Your Job in This Chapter? ...................................................................................17 What Makes a Good Rehab Nurse? ...................................................................................18 The Rehab Nurse Is… .....................................................................................................18

Table of Contents Rehab Nursing Series™: Intro to Rehabilitation vii

Professional Roles of Rehabilitation Nurses........................................................................20 Professional Standards ...................................................................................................20 Myths of Rehab Nursing ..................................................................................................22 Rehabilitation Work Is Teamwork! ...................................................................................24 Jargon ..........................................................................................................................26 Professional Resources ...................................................................................................26

Chapter 4 The Rehabilitation Team ........................................................................ 28 Chapter Objectives or What Is Your Job in This Chapter? ....................................................28 Why Should You Care? ...................................................................................................28 Rehabilitation Team—Synergy in Action ............................................................................30 Other Team Members .....................................................................................................32 Team Structure and Organization ....................................................................................32 Rehabilitation Team Functions .........................................................................................34 What Makes a Good Team Work Well Together? ................................................................34 Team Development ........................................................................................................35 Characteristics of Effective Teams ....................................................................................36 Learn About Your Team ..................................................................................................36

Chapter 5 Rehabilitation Populations ...................................................................... 42 What Is Your Job in This Chapter? ...................................................................................42 Rehabilitation Populations & Their Needs ..........................................................................43 Activity Limitations ........................................................................................................43 Knock! Knock! Who’s There? ...........................................................................................44 Stroke ..........................................................................................................................45 Spinal Cord Injury .........................................................................................................46 Brain Injury ..................................................................................................................47 Other Patient Populations ...............................................................................................47 Common Problems .........................................................................................................48 Population-Specific Care .................................................................................................49 Impact of Disability ........................................................................................................50 Aging ...........................................................................................................................51 Access to Care ..............................................................................................................51

Chapter 6 Therapeutic Milieu ................................................................................ 52 What Is Your Job in This Chapter? ......................................................................... 52

Creating a Therapeutic Milieu ..........................................................................................53 A Therapeutic Environment .............................................................................................53 More Than Physical Barriers… ..........................................................................................56 From Admit to Reintegration ...........................................................................................58 Those Unwritten Rules and Expectations ...........................................................................58 Creating Expectations ....................................................................................................59 Resource Allocation vs. Personal Productivity ....................................................................60 Patient's Rights and Confidentiality ..................................................................................60 Teaching Patients and Families ........................................................................................61 Issues of Change in the Rehab Setting .............................................................................63 What Next? ...................................................................................................................63 I Am My Own Best Advocate ...........................................................................................63 Ethical Issues in Rehabilitation Settings ............................................................................64

Chapter 7 Regulatory Issues ................................................................................. 65 What Is Your Job in This Chapter? ...................................................................................65 Regulatory Issues ..........................................................................................................66 Accreditation .................................................................................................................66 Quality Improvement .....................................................................................................66 Program Evaluation ........................................................................................................67 Funding Sources ............................................................................................................67 Meeting Medicare Regulations .........................................................................................68 Changing Medicare Regulations .......................................................................................68 The MDS Data Collection Tool ..........................................................................................69 The OASIS-C2 Data Collection Tool ..................................................................................69 The IRF-PAI Data Collection Tool .....................................................................................70

Table of Contents Rehab Nursing Series™: Intro to Rehabilitation viii

60% Rule for Acute Inpatient Rehabilitation Facilities .........................................................71 Answer Key ........................................................................................................ 73

Getting Started Rehab Nursing Series™: Intro to Rehabilitation ix

GETTING STARTED

This course is designed to assist nurses new to the

specialty field of rehabilitation nursing to transition into

this specialty. This workbook is intended to be used with

the Rehab ClassWorks computer course: Introduction

to Rehabilitation & Rehabilitation Nursing.

Launching the Course

Single User License: After installing the course, launch it on the computer by

selecting it from your Windows menu or by using the desktop icon.

Multiuser License: Follow your organization’s instructions for accessing the

course.

Logging In

Enter your login name as the name you want to see on the CE certificate. Select

your own password and keep track of this information so you can use it in

the future to enter the course. (Support cannot access this information.) Click

the Start button on the login page to view the menu.

Getting Started Rehab Nursing Series™: Intro to Rehabilitation x

Functions of the Main Menu

The course is navigated from its Main Menu.

1. You can roll your mouse onto a chapter title to display information

about a given chapter.

2. Click on the chapter title to enter the chapter.

3. Start with the Overview chapter for an introduction to the course and

access to Course Help tools.

Continuing Education Hours

In order to receive continuing education contact hours, complete the course and

workbook activities, pass the course posttest with a score of 80% or better, and

complete the course evaluation per instructions provided at the conclusion of the

posttest.

This course is worth 8.7 contact hours.

The posttest is in the computer course that accompanies this workbook. Your

results are displayed on the computer when you complete the exam. Print or

create a screen shot of your results page. Verify that the page has printed

or the screen shot has been saved successfully before closing this screen

because you will not be able to return to this page once you have left it

without taking the test and passing it again.

To receive contact hours you must submit both the Score Page and the Course

Evaluation form.

Instructions at the end of the posttest direct you to either print OR create

a screen shot of your Score Page. (Save this image to attach to an email

or paste it into the email.) This document must be manually sent to RCW.

There is no way to electronically submit it from the course.

You are then given the option to go to the Course Evaluation web page

for electronic submission at www.rehabclassworks.com/CEData.html OR,

if you do not have web access, to complete and print (or create a screen

shot of) your Course Evaluation form in the course. (Three pages will

need to be processed.)

http://www.rehabclassworks.com/CEData.html

Getting Started Rehab Nursing Series™: Intro to Rehabilitation xi

Send your documents to Rehab ClassWorks, LLC using one of the

methods listed below.

o Send by email to [email protected] (include screen

shots and/or scan and attach print documents)

o Send by fax to (801) 253-7520

o Send by mail to RCW, PO Box 1306, Riverton, UT 84065

Only persons with valid, registered serial numbers will receive

continuing education credit. Go to www.rehabclassworks.com/reg.html to

register the purchase of your course! (NOTE: Those with multiuser licenses are

only required to register once for the group via the person managing the

course.)

The expiration date for this course can be found at

http://www.rehabclassworks.com/FAQ.htm.

Rehab ClassWorks, LLC is an approved provider of continuing nursing education

by the Western Multi-State Division, an accredited approver by the American

Nurses Credentialing Center’s Commission on Accreditation.

Using the Course

Listed below are features of the computer course and how to best use them.

Workbook and Computer Course: To get the most out of this course, you should

use this workbook concurrently with the computer course. There is a great

deal of audio in the course, so be sure your speakers are on. There are

exercises in the workbook and in the computer course to help you learn and

remember the material. When you see the following, you should go to the

designated section of the course on the computer.

On the Computer

mailto:[email protected]?subject=CE%20Request

http://www.rehabclassworks.com/reg.html

http://www.rehabclassworks.com/FAQ.htm

Getting Started Rehab Nursing Series™: Intro to Rehabilitation xii

Note that each chapter in the workbook matches the chapter of the same name

in the computer course. Answers to questions in the workbook are in the back of

the workbook for your reference.

This course is a lengthy course and should therefore be approached in small

chunks of time for best retention. Each chapter in the computer course has a

bookmarking feature so that you can return to the page you last viewed when

you return to the chapter. Be sure to exit the course using the EXIT button on

the bottom right of the course navigation bar (not the X on the top right corner

of the window) to initiate the bookmark.

Quizzes: There are quizzes at the end of each chapter of the computer course to

help you assess your understanding of the information in that part of the course.

Links: There are links in the computer course that take you to more information

when you click on them. They appear in blue underlined text. If your internet

security system allows you to do so, you will be able to jump to external web

pages as well as internal links while in this course. Otherwise, type the address

in your web browser to view those resources.

Functions of the Navigation Bar

The Navigation Bar at the bottom of the screen allows access to information,

return to the Main Menu, or the ability to go to a specific page in the course.

Page Numbers: Page numbers in the computer course are located on the left

side of the Navigation Bar.

Reference: The Reference link displays definitions of terms and additional

reference material.

Main Menu: Return to the Main Menu by clicking that item on the Navigation

Bar.

Getting Started Rehab Nursing Series™: Intro to Rehabilitation xiii

Index: You can use the Index link to display the electronic pages of the chapter.

Click on the page you want to go to when this tool is open.

Help: This item provides information on using and navigating the course. If you

do not find your answer there, contact technical support at

[email protected] or call (888) 294-0412.

Read: This item opens a window that allows you to read the audio that occurs in

a given frame.

Progress Report: The Progress Report summarizes your scores on quizzes in

the course. The posttest score also is recorded, but not the subset scores you

will see at the end of the posttest. Only posttest scores are reported in a

learning management system. Quizzes are for self-assessment of content

learned in each chapter and are not reported in a learning management system.

Other Features

Notes Books/Feedback: Some screens contain a Notes Book icon in

the top right corner. You can click on this icon for feedback or more

information. The Notes Book icon is pictured here on the right.


Overview Rehab Nursing Series™: Intro to Rehabilitation 1

Chapter Highlights

Course goal: Your goal in this course is to learn about the specialty of rehabilitation nursing.

Rehabilitation nursing is a specialty practice with standards of care and professional behavior.

Why should you care about specialty practice issues?

Because, with impactful practice, we make a huge difference in the quality of life for our patients.

An understanding of some of the history of the specialty will help

you to better grasp issues impacting practice today.

CHAPTER 1

INTRODUCTION & OVERVIEW Rehabilitation is a rather new field in the big picture of life. Its

development spans the last century or so and is closely

associated with social and scientific advancement. This course

introduces you to our specialty field, helps you understand

where it has come from and where it is going, and introduces

you to the patients and team members with whom you will be

working.

Chapter Objectives or What Is Your Job in This Chapter?

In this chapter, your job is to learn about how the history of the specialty

impacts our practice today. Each chapter will start with a description of the

objectives or the job to be accomplished in the chapter.


As a result of participating in this activity, you, the learner, should be able to

pass the posttest with a score of 80% or better, demonstrating knowledge of:

The key characteristics and behaviors of the specialty practice of

rehabilitation and rehabilitation nursing

The key characteristics and needs of typical patient populations

receiving rehabilitation care, including types of patients and some of the

safety precautions that will need to be applied to them

The roles of fellow team members and strategies for learning about

their therapeutic interventions and how to incorporate them into care of

the patient

A therapeutic milieu and how to support and facilitate it in the care

environment

The impact of regulatory agencies on the care of patients in

rehabilitation settings

Course Goal: The goal of this course is to introduce nurses new to the

specialty of rehabilitation nursing to its goals, roles, and philosophies and

to familiarize them with fellow team members, common regulatory

standards, and patient populations.

Rehabilitation Nursing and YOU!

Rehabilitation nursing is an important specialty practice dedicated to helping

those with disability maximize their skills and maintain quality of life.

Rehabilitation relies heavily on teamwork, coordination, and continuity of care to

facilitate goal achievement within the limitations of today's healthcare systems.

In order to be successful within the regulatory and fiscal parameters in which we

work, it is important that all staff quickly learn about the field and the forces

driving it.


On the Computer: Overview, pages 3-11

(Page numbers are on the bottom bar of the frame.)

The History of Rehabilitation

Rehabilitation is about adapting and creatively surviving, using all the resources

available.

1. What factors influence the development and practice of rehabilitation?

Before Rehab

The technological advances which brought rehabilitation into a high-demand

practice for those with disability did not occur until the 20th century.

2. What changes in healthcare had to occur before rehab could fully

develop as a specialty practice?

Rehab Is Born

Rapid change in the delivery of healthcare has

been the standard during the last few centuries.

Community health, emergency medicine,

intensive care, and the management of chronic

conditions have influenced the development of

rehabilitation as a specialty practice.

3. Why did the industrial age and increased recreation time increase the

numbers of people in need of rehab services?


Rehab Comes Into Its Own

Research, stimulated by recent wartime needs and the rapid development of

technology, is fueling new innovations in recovery from injury/illness and new

ways of living with disability.

4. What do you think may potentially limit access to many of the

innovations potentially available to persons with disability?

For more information on finding reliable health information on the internet,

consider one of these sites.

Patient 101: How to Find Reliable Health Information at

http://www.jointcommission.org/assets/1/18/patient_101.pdf

Finding and Evaluating Online Resources on Complementary Health

Approaches at http://nccam.nih.gov/health/webresources

A User's Guide to Finding and Evaluating Health Information on the Web

from Medical Library Association at

http://www.mlanet.org/resources/userguide.html

Some of the sites below may be of assistance as you look for rehabilitation-

related information.

Medlineplus.gov: Sponsored by the National Institutes of Health and

managed by the U.S. National Library of Medicine, MedlinePlus provides

information on more than 900 diseases and conditions in their Health

Topics section and links to other trusted resources.

It also provides a directory of hospitals, clinics, and healthcare providers;

a medical encyclopedia and medical dictionary; tutorials on common

conditions, tests, and treatments; extensive information on prescription

drugs, supplements, and herbs; and links to thousands of clinical trials. It

even offers a senior-specific health site (nihseniorhealth.gov) that makes

age-related health information easier to get.

http://www.jointcommission.org/assets/1/18/patient_101.pdf

http://nccam.nih.gov/health/webresources

http://www.mlanet.org/resources/userguide.html

http://medlineplus.gov/

http://nihseniorhealth.gov/


MayoClinic.com: Owned by the Mayo Foundation for Medical Education

and Research, this site is produced by more than 3,300 physicians,

scientists, and researchers from Mayo Clinic, and provides in-depth, easy-

to-understand information on hundreds of diseases and conditions, drugs

and supplements, tests and procedures.

There are also dozens of sites dedicated to specific diseases and conditions.

Here are a few that are directly related to rehabilitation populations.

Brain Injury

Brain Trauma Foundation: https://www.braintrauma.org/

Traumatic Brain Injury Information Page from the National Institute of

Neurological Disorders and Stroke at

http://www.ninds.nih.gov/disorders/tbi/tbi.htm

Brain Injury Association of America: http://www.biausa.org/

Spinal Cord Injury

Spinal Cord Injury Model System Information Network from the UAB

School of Medicine: http://www.uab.edu/medicine/sci/uab-scims-

information/sci-infosheets

United Spinal Association: http://www.spinalcord.org/

Paralyzed Veterans of America:

http://www.pva.org/site/c.ajIRK9NJLcJ2E/b.7516843/k.6FC/Paralyzed_Ve

terans_of_America_Publications.htm

Stroke

National Stroke Association:

http://www.stroke.org/site/PageNavigator/HOME

American Stroke Association:

http://www.strokeassociation.org/STROKEORG/#

A quick search will show that there are sites for almost any disease/injury that

can result in disability.

http://mayoclinic.com/

https://www.braintrauma.org/

http://www.ninds.nih.gov/disorders/tbi/tbi.htm

http://www.biausa.org/

http://www.uab.edu/medicine/sci/uab-scims-information/sci-infosheets

http://www.uab.edu/medicine/sci/uab-scims-information/sci-infosheets

http://www.spinalcord.org/

http://www.pva.org/site/c.ajIRK9NJLcJ2E/%20b.7516843/k.6FC/Paralyzed_Veterans_of_America_Publications.htm

http://www.pva.org/site/c.ajIRK9NJLcJ2E/%20b.7516843/k.6FC/Paralyzed_Veterans_of_America_Publications.htm

http://www.stroke.org/site/PageNavigator/HOME

http://www.strokeassociation.org/STROKEORG/


5. Identify at least three things to look for to determine if a website is a

credible, reliable, and objective resource for rehabilitation and health-

related information? For example, how would you know if a source

offering stem cell therapy is trustworthy?

You Make a Difference!

The patient’s success in rehabilitation is often dependent on the quality

of the teamwork among the patient’s caregivers. Continuity of care is as

critical as developing a plan that considers the patient’s abilities, resources,

preferences, and responses to care strategies.

You are an essential tool in the rehabilitation process. Your attitude, affect,

approach, support, encouragement, discouragement, dress, distractibility, and

attentiveness all influence your patient's responses. You are a therapeutic

tool every time you interact with a

patient.

6. How will you approach this role? Why

do you want to be a rehabilitation

nurse?


One More Time!

Coordination and continuity of care matter!

YOU make a difference in each patient’s quality of life.

Where Are We Now?

Rehabilitation settings face the same challenges everyone else in healthcare is

facing.

What Does This Mean to Me?

You need to be invested in delivering care that moves the patient toward

goals every day that you are providing care.

You need to document in a manner that reflects progress toward goals

or strategies used to manage barriers to progress.

You need to be very conscientious of your responsibilities to manage

costs of care for both the patient and the organization for which you

work. If this is not managed well by all of us, many of us will not have

access to these very necessary rehabilitation services in the future.

You need to provide high-quality care every single day.

You need to incorporate regulatory and accreditation requirements for

safe patient care into your daily care practices.

You need to learn continuously about this specialty field and to

incorporate new evidence-based care strategies into your practice as they

are developed. This includes the use of technology for both treatment and

functional adaptation.

You need to take seriously your role as teacher and advocate of patients

with disability and use yourself as a therapeutic tool to help your

patients maximize their potential.

On the Computer: Complete the Overview quiz, page 12.

Then, return to the Main Menu and start the next chapter: What Is Rehab?

Watch for the page that tells you to return to the workbook.

What Is Rehab? Rehab Nursing Series™: Intro to Rehabilitation 8

Chapter Highlights

Rehabilitation is a process and philosophy. Rehabilitation care can be delivered in any setting.

The field of rehabilitation is heavily impacted by laws and

regulations and the number of people needing rehabilitation care.

You need to develop strong skills in setting goals with your

patients and measuring progress toward them.

CHAPTER 2

WHAT IS REHAB? Rehabilitation is a simple concept. The hard part is the art of

pushing, prodding, coaching, supporting, and releasing patients

day after day. It is almost like rearing a child over and over

again, giving them the tools to make them successful in the

world we live in and then sending them off.

What Is Your Job in This Chapter?

Your job in this chapter is to learn about the philosophy and

goals of rehabilitation. Think about how you will demonstrate

this philosophy in your day-to-day practice in this specialty field.

On the Computer: What Is Rehab?, pages 3-22


Just What Is Rehabilitation?

The World Health Organization has defined disability according to limitations in

body structure, activity, and participation in community life. This

paradigm promotes a focus on empowering persons with disability so that they

can equally and fully participate in community-level activities.

1. What is the definition of rehabilitation?

Trends in Rehabilitation

Change continues to impact rehabilitation services as it does others in the

healthcare industry. The Balanced Budget Act of 1997 and the Health Care and

Education Reconciliation Act (amending the Patient Protection and Affordable

Care Act) of 2010 have dramatically impacted rehabilitation services in all

settings through its action on Medicare documentation and

reimbursement. Other issues impacting the field include:

Insurance companies continue to pick and choose the disciplines for which

they will pay, leading to restructuring and the development of alternative

treatment models that focus on smaller teams, alternative settings, and

increased use of unlicensed assistive personnel.

The number of disabled and elderly in our communities continues to grow.

Our ability to meet their needs will depend on technological and

sociological advances, and the outcome of healthcare reform efforts.

Increased survivorship and improved health in those with disability will

lead to the need to care for them as they age, a relatively new issue for

the field.


2. What trends are impacting your work setting? Interview fellow team

members who have worked in rehabilitation for more than several

years to learn about the impact of local trends on your rehabilitation

setting.

The Continuum of Care

With all of the changes impacting the rehab industry, the continuum of care has

become very important to effective rehabilitation care. The process of care and

adaptation is usually a lifelong event.

3. What two items are important when using the continuum of care if

teams are to reduce duplication of effort and decrease the risk of

relocation stress in patients?

Caregivers should be aware of the stresses placed on the patient and family

when they are moved from setting to setting. The effort required to learn and

trust the new team is tremendous, especially when it occurs in an unfamiliar

environment with many unwritten and unknown rules of conduct.

The newly-arrived family group must learn to adapt to the new environment and

the new team members, while trying to cope with losses and the reality of the

situation. Team members must make every effort to be flexible and supportive.

The best method of care for this problem is good planning and prevention.

Symptoms of relocation stress include:

Apprehension, depression, or increased confusion

Changes in sleep patterns, eating patterns, or gastrointestinal

disturbances


Expressions of distress or need for excessive reassurance

Vigilance and withdrawal

4. What interventions can you think of that could prevent relocation

stress from developing when a patient is transferred to your care?

Philosophy of Care

Philosophies are the principles that guide and shape healthcare delivery. They

provide focus for the rehabilitation team. In rehabilitation, this means that

patients, families, and caregivers have the right to become experts in

their own care.

5. What must the team provide in order for patients and families to

become experts in their own care?

Problem Lists

It is easier to write a good goal if the problem is clearly identified. Problems are

often documented as a single word or simple phrase depending on the tools

used for the care planning process. You learned in the course that many

assumptions can occur that may or may not be accurate when shorthand is used

to identify a problem.

What would happen if the problem was descriptive of the data found in the

assessment? What if the problem explained the issues of the problem to others

using the plan of care, making the plan more meaningful? Let’s review the

example from the course again.


Instead of:

Nutrition or Altered nutrition

A descriptive problem might say:

Altered nutrition related to:

Increased nutrition needs due to excess energy expenditure

because of agitation (Rancho IV brain injury)

Decreased oral intake due to distractibility

Mild oral motor control problems from jaw and facial injuries

Difficulty sustaining nutritional support via tube feedings due to

frequent pulling of tube

Which of these do you think gives the oncoming caregiver the best picture of

what is going on with this patient?

Goals

Most of us who spend any significant time in the practice of rehabilitation

become experts in goal writing and goal development. Goal development should

not be done simply to meet standards or requirements; it should be done to

focus and guide care delivery and patient effort.

The goals of rehabilitation focus on facilitating function and independence

through adaptation and therapeutic intervention.

6. On what do most patient/family goals focus?

Remember, goals should be specific, measurable, attainable, relevant, and

time-related. Well-written goals will present a target for each caregiver. They

should be written clearly enough to present the same picture to each person

reading them—including the patient and family.


Short-term goals build step-by-step to the final outcome you are working to help

the patient achieve. What would be the likely outcome (or long-term goal) to

be achieved for a patient with the above problem? How about the following?

Patient meets nutritional needs (lab values within normal limits,

weight at baseline) with oral intake without aspiration.

This is the first week of the patient’s care by the rehabilitation team. The team is

working on short-term goals to move the patient toward the desired outcome.

This week, they want to establish a safe way for the patient to eat so that the

tube feedings are not needed and there is no aspiration. A short-term goal for

this week may be:

Patient able to eat finger foods without aspiration and tube

feedings discontinued by Thursday.

Perhaps next week’s goal will be:

Patient meets caloric target of 2200 kcals and a protein target of

60 g per day by Thursday.

Remember not to confuse goals with interventions such as type of diet, safe

swallowing strategies, removal of distractions, or need to complete an

assessment or plan.

In the following questions, write short-term goals for these examples of

problems that are common to patients in rehabilitation settings. Feel free to

make up any assessment information you may need to complete the picture for

yourself as you work on this exercise. (Answers in the back of the workbook are

suggested responses; evaluate your responses for completeness.) While this

process may not match the process in your work environment, it will help you

learn to develop goals.

Use these steps, or remember: who will do what, to what degree, by when?

Identify the goal Make it relevant

Make it measurable Make it time-specific

Make it specific


Problem: Impaired physical mobility

Right hemisphere stroke with left hemiparesis

Limits in bed mobility, coming to sit, and transfers

Dependent for wheelchair mobility

Very poor endurance, but does try to follow cues and participate

7. Goal:

Problem: Bowel incontinence

Frequent oozing of stool

Lack of voluntary or reflexive emptying because of spinal shock following

spinal cord injury

8. Goal:

Problem: Impaired verbal communication

Stroke with expressive aphasia

Inability to accurately indicate yes/no or to use call light

9. Goal:


Problem: Fluid volume deficit

Cranial nerve damage from traumatic brain injury

Dysphagia

Negative intake and output balance

Concentrated urine, weight loss, poor skin turgor

10. Goal:

Problem: Risk for injury

Brain injury

Poor balance, though tries to ambulate

Poor judgment

Tries to leave unit when up in wheelchair

11. Goal:

It is important that those new to rehabilitation care spend some time with the

appropriate person(s) on your team to learn your care planning and discharge

planning processes.

(The Rehab Nursing Series™ provides additional training on this topic in the course Got a Plan,

Man? Patient-Centered Care Planning in Rehabilitation. You can find information at

www.rehabclassworks.com/CarePlan.htm)

http://www.rehabclassworks.com/CarePlan.htm


One More Time!

Rehabilitation is a process of providing coordinated care aimed at improving health,

reducing future risks, and improving function.

Transitions between settings can be difficult for patients. Be

proactive in reducing stresses associated with them.

Develop skills in writing and tracking the patient’s progress

toward goal achievement.

Documentation of individualized plans of care and progress toward goals is

simply good rehab nursing practice. Remember that documentation of the team

is audited by payers to evaluate if a patient is receiving the appropriate level of

care.

On the Computer: What Is Rehab?, pages 23-24, Case Study and Quiz

Then, return to the Main Menu and start the next chapter: The Rehabilitation Nurse.


The Rehabilitation Nurse Rehab Nursing Series™: Intro to Rehabilitation 17

Chapter Highlights

You are a therapeutic tool central to the process

of rehabilitating the patients in your care.

The rehabilitation nurse wears many hats and changes them frequently. The art of rehabilitation nursing revolves around wearing the right hat at the right time.

Rehabilitation nursing is about teamwork and the delivery of

patient-centered care.

CHAPTER 3

THE REHABILITATION NURSE The nurse is the pivotal point of all inpatient rehabilitation care. In

addition to facilitating self-management of healthcare needs, the

nurse is active in blending all that the patient learns in therapy

into daily care, driving the success (or failure) and efficiency of the

program. With limited lengths of stays and shrinking resources, it

is imperative that the nurse understands the pivotal role he or she

plays and aggressively acts on it each and every day.


In this chapter you will identify the roles of the rehabilitation nurse. You will

learn to differentiate fact from fiction when it comes to rehabilitation nursing

practice. You also will be introduced to the Association of Rehabilitation Nurses

and the process for becoming certified as a rehabilitation nurse.


On the Computer: The Rehabilitation Nurse, pages 3-18

What Makes a Good Rehab Nurse?

Rehabilitation nursing can be very rewarding. It can be the most important

job you have ever done in your life.

You will touch the very hearts and souls of those in your care. Never forget that

you are a tool which will influence the way they will live the rest of their lives.

Rehabilitation nursing combines medical/surgical nursing with additional skills in

functional skill development.

1. Identify at least three traits evident in

great rehab nurses.

The Rehab Nurse Is…

A rehab nurse has many roles and uses them all on almost any given day. The

challenge is in learning to be good at all of them.

Most nurses new to the field of rehabilitation are comfortable with the caregiving

role. However, they may be challenged by the educator role that often requires

that they coach or sit on their hands and allow the patient the opportunity to

struggle through a skill, solve a problem, or learn a process on their own.

The art is in determining when the patient has been pushed enough and

needs assistance and when to push the patient for more. This skill is

developed through experience and role-modeling by other team members.


Match the following roles to their descriptions.

a. Educator b. Caregiver c. Advocate

d. Collaborator e. Coordinator f. Counselor

2. ____ Nurses provide care that is consistent, thorough, and supportive

of the patients' and caregivers' efforts to learn their own care.

Caregiving is integrated with education and identification of the

tools and resources needed to reduce the burden of care and

transfer skills and responsibilities to the patient or caregiver.

3. ____ Together, the team facilitates positive coping and assists patients

and families to plan, practice, and problem-solve community

reintegration issues.

4. ____ In order to do this well, the nurse must know the patient's

wishes and desires well enough to be an effective and true

representative. The nurse often spends more time with the

patient than other team members and may have more insight

into the patient's desires.

5. ____ This is one of the most important roles of the nurse in a rehab

setting. One of our basic principles is that every nursing

encounter is a potential teaching opportunity, an opportunity to

teach them how to live, not just survive, in the community. Your

job is to teach, to coach, and to give them the skills they need to

solve their problems and use the resources in their community.

6. ____ Effective and efficient care results from the efforts of all team

members working together to be creative, problem-solve, and

promote functional gains in each patient. This work across and

between disciplines increases the potential of each interaction

through shared knowledge and resources.

7. ____ The rehab nurse has responsibility for the patient around the

clock. Practicing skills repeatedly throughout the day, in a

coordinated and consistent manner, will help patients acquire

effective problem-solving skills and become experts in their own

care. This also requires support, listening, and advising for

optimum health and well-being in the community.


Professional Roles of Rehabilitation Nurses

Role descriptions of many subspecialists in rehabilitation nursing are available

from the Association of Rehabilitation Nurses (ARN). These roles were developed

by consensus of the ARN Special Interest Groups and include:

Gerontological Rehabilitation Nurse

Home Care Rehabilitation Nurse

Pain Management Rehabilitation Nurse

Pediatric Rehabilitation Nurse

Rehabilitation Nurse Manager

The Rehabilitation Admissions Liaison Nurse

The Advance Practice Rehabilitation Nurse

The Rehabilitation Nurse Case Manager

The Rehabilitation Nurse Educator

The Rehabilitation Staff Nurse

The Rehabilitation Nurse Researcher

LPN/LVN on the Rehabilitation Team

Access these role descriptions at http://www.rehabnurse.org/pubs/role/Role-Descriptions.html.

Professional Standards

The Association of Rehabilitation Nurses (ARN) publishes the following as the

definitions and scope of practice for rehabilitation nursing.

Definitions and Scope of Practice

Rehabilitation nursing is a specialty practice area within the scope of

professional nursing. It involves the diagnosis and treatment of human

responses of individuals and groups to actual or potential health problems

resulting from altered functional ability and altered lifestyle.

http://www.rehabnurse.org/pubs/role/Role-Descriptions.html


The goal of rehabilitation nursing is to assist individuals with disabilities and

chronic illness in the restoration, maintenance, and promotion of optimal health.

The rehabilitation nurse is skilled at treating alterations in functional ability and

lifestyle resulting from injury, disability, and chronic illness.

Association of Rehabilitation Nurses (ARN), n.d.

As noted in the computer component of the course, the Association publishes

Standards of Care and Standards of Professional Performance in a booklet

called Standards & Scope of Rehabilitation Nursing Practice, 6th Edition (2014).

See ARN bookstore at http://apps.rehabnurse.org/Store/ProductDetails.aspx?productId=2993183.

8. Define the standard of practice for planning noted in the synopsis of

Standards & Scope of Rehabilitation Nursing Practice.

It is not uncommon to hear that

rehabilitation nurses address primarily

bowel, bladder, and skin issues. The

Association of Rehabilitation Nurses defines

the practice of rehabilitation nursing in

a much broader manner, as noted in their

position statement sent to the Centers for

Medicare & Medicaid Services (Rehabilitation

Nursing Criteria for Determination and Documentation

of Medical Necessity in an Inpatient Rehabilitation

Facility, http://www.rehabnurse.org/advocacy/content/pcriteria.html).

http://apps.rehabnurse.org/Store/ProductDetails.aspx?productId=2993183

http://www.rehabnurse.org/advocacy/content/pcriteria.html


Rehabilitation nurses address all of these areas and more in daily practice.

Rehabilitation diagnoses, course of treatment, plan of care, and expected

outcomes

Bladder and bowel management

Skin care management

Medication and pain management

Reinforcement of self-care and mobility skills

Cardiovascular, autonomic, and pulmonary management

Energy conservation and sleep

Intimacy and sexuality

Nutrition and lifestyle adaptations

Role changes and psychosocial manifestations

Primary prevention and adoption of health and wellness

Aftercare, including community resources, physician and ancillary

services, durable medical equipment procurement, and emergency

procedures

What are the standards and scope of practice for

rehabilitation nursing in your setting? If you cannot

define them, review them with your mentor.

Myths of Rehab Nursing

Myths abound regarding how hard it is, physically, to

work in rehab and that it is an unrewarding, even

depressing, area in which to work.

Reality is that most rehab nurses are seldom injured if

they use the techniques taught to them. And rehab


nursing is as rewarding as any other area of nursing, if you are vested in

assisting your patients in achieving the best possible quality of life.

(The Rehab Nursing Series™ provides additional training on moving and handling patients in the

course Take Care! Safe Patient Handling Works! You can find information at

www.rehabclassworks.com/sph.htm)

9. Identify the best way to avoid back injuries while caring for patients.

Rehab nursing is impacted by the same issues impacting the rest of healthcare.

Changing demands in the industry with a constant stream of new

regulations intended to improve the quality and reduce the cost of care

Recruitment and retention issues impacting the supply of rehabilitation

professionals, including the loss of seasoned staff and mentors in the field

Changes in the role of the nurse on the team—variable from setting to

setting and heavily impacted by regulatory requirements

Reflecting on what you learned when you reviewed the Standards & Scope of

Rehabilitation Nursing Practice, answer the following questions True or False.

10. ______ In order to provide quality and cost-effective care, each nurse

is accountable to stay current regarding trends in the

healthcare industry.

11. ______ The nurse's role may vary from setting to setting and even

from year to year depending on the impact of industry trends

and regulatory directives.

12. ______ The nurse can participate proactively in meeting industry

demands by being creative, collecting data, and supporting

improvement efforts.

http://www.rehabclassworks.com/sph.htm


13. ______ The nurse should not lose sight of the patient and quality of

care when faced with changing demands of the industry.

14. ______ The experienced nurse should actively mentor and teach those

new to the team to enhance skill development.

Rehabilitation Work Is Teamwork!

If you are new to the field of rehabilitation, you will quickly learn that you need

to meet others on your team and establish your role with them. The rehab nurse

and assistant at the bedside in inpatient settings are the ones who, 24 hours a

day and 7 days a week, reinforce teaching and training done by other

disciplines.

Continuity becomes critical. One hour of therapy can be undone

repeatedly each day or reinforced throughout each day.

Successful rehabilitation inpatient programs are heavily dependent on the

commitment and efforts of a solid rehab nursing team.

Here are some tips to help you assimilate your experiences as a nursing team

member:

Arrange opportunities for observation of your fellow team members as

part of your continuing education in your role.

Avoid storytelling and focus on problem solving to meet goals when

discussing the care of patients in team meetings.

Communicate results back to the nurses who will care for the patient after

you.

Focus on integration and continuity

of care! Remember that it is easier

to undo previous training by failing

to follow through than it is to

reinforce it.

It is difficult enough for a patient with

cognitive and perceptual deficits to learn


without the nurses and therapists being inconsistent, changing expectations, or

offering new solutions each time a task is approached. It is a little like taking

advanced math classes with a different teacher each day and no communication

between them. What would your learning curve be?

Remember, you have a very limited amount of time to teach survival skills to

each patient.

Listed below are the tips for building rapport with team members. Fill in the

blanks to complete the statements with words from this list.

clarify educate prepare listen reliable

needs support respect humor impression

15. Be visible and create a good ______________. Be aware of when you

are on stage.

16. Anticipate ________________. Volunteer, pick up the phone and

answer it, help cover call lights, etc.

17. Be ________________.

18. ________________, really listen.

19. Act with confidence, and ________________ in advance for the worst-

case scenario or the unexpected crash of a patient. Rehearsal always

pays off.

20. ________________ yourself and ask appropriate questions. Keep a

small notebook handy to write down questions when you think of

them.

21. Use ________________ appropriately.

22. ________________ and share perspectives. Find a mentor.

23. Treat others with ________________. Learn their names and their

roles.

24. Say thank you and show ________________. Develop a team spirit

that supports the unit’s morale.


Jargon

Jargon can be very confusing, but using common language facilitates

communication among team members. To get you started on familiarizing

yourself with jargon common to rehab settings, you completed jargon exercises

in the computer component of the course. This was just a sampling.

Keep learning! When you see an unfamiliar term, ask what it means or

look it up.

Be consistent with the team in use of terms that describe the amount of

assistance required when a patient is completing a task. The terms reflect

the amount of assistance provided (e.g., set up, minimum, moderate,

maximum, or total assistance).

Learn the names of the equipment used in rehabilitation settings and how

to use it.

Define the terms below.

25. ADLs:

26. Hemiplegia:

27. Paraplegia:

28. Tetraplegia:

Professional Resources

The Association of Rehabilitation Nurses (ARN) is your nursing organization.

There are journals, newsletters, user groups, and conferences to help you

network and develop your professional role.


One More Time!

Incorporate the many roles of rehabilitation nursing into your practice. You will need them all almost

every day.

Learn the jargon of your team so that you are communicating

accurately with each other.

Learn strategies from therapists that you can incorporate into daily care to improve patient function.

These ARN web pages can provide you with more information on these topics.

ARN home page: http://www.rehabnurse.org/

List of local chapters:

http://www.rehabnurse.org/chapters/content/Chapter-List.html

Join the list serve or electronic discussion group:

http://membercircle.rehabnurse.org/home.

Information about why to become certified:

http://www.rehabnurse.org/certification/content/About-CRRN.html

You can also continue to develop your skills in rehabilitation nursing by working

your way through the Rehab Nursing Series™. This course is the first course

in this series. All titles in the series are listed in the front of the workbook. You

can access more information on these courses at www.rehabclassworks.com.

On the Computer: The Rehabilitation Nurse, pages 19-21,

Review, Case Study, and Quiz

Then, return to the Main Menu and start the next chapter: The Rehabilitation

Team. Watch for the page that tells you to return to the workbook.

http://www.rehabnurse.org/

http://www.rehabnurse.org/chapters/content/Chapter-List.html

http://membercircle.rehabnurse.org/home

http://www.rehabnurse.org/certification/content/About-CRRN.html


The Rehabilitation Team Rehab Nursing Series™: Intro to Rehabilitation 28

Chapter Highlights

An inpatient rehabilitation nursing team has 24/7 accountability for patients and must, therefore,

incorporate the skills that patients learn with the therapists into the patients’ daily routine.

Outcomes are improved with tight coordination and continuity of care between nursing and therapy team

members.

Quality and safety are enhanced when appropriate delegation to

assistive personnel occurs.

CHAPTER 4

THE REHABILITATION TEAM The most critical tool each team member should have is a great

skill in communicating…including good listening skills!

Chapter Objectives or What Is Your Job in This Chapter?

Your task in this section is to learn about your fellow team

members and how to interface with them to improve the care

provided to your patients.

Why Should You Care?

You have already been introduced to the concept that rehab work is team work.

This concept should be

embraced by all

members of the

rehabilitation

team.


When the team does not collaborate, coordinate, and communicate effectively,

the patient, the organization, and the community suffer. Perhaps you think that

is a bit far-fetched. It is not.

For every patient who does not receive coordinated, collaborative care there is a

domino effect impacting all of us.

The patient does not maximize his potential in the time allotted to him in

rehabilitation care because of variable support, training, expectations, and

education.

The patient/family begin to pick and choose what is important to them

and what they will implement on their return to the community,

increasing the risk of needing more healthcare services in the future.

Increased use of the continuum results when a patient does not reach full

potential at any one point in the continuum. While this is what the

continuum is for, we should work hard to maximize benefits at each level

of care.

Increased use of services due to inefficiencies in the work of the team

increases the cost of care.

Increased costs require payers to restrict access to services and to raise

amounts paid by all of us in insurance premiums or by federal deductions

from paychecks.

Restricted access eventually means that you or one of your loved ones

may have difficulty getting the care needed when faced with a healthcare

need.

Rehabilitation teams MUST collaborate, coordinate, and communicate so that

there is continuity of care between all team members and the patient is

supported in achieving the best possible outcomes in the most efficient manner.

On the Computer: The Rehabilitation Team, pages 3-10


Rehabilitation Team—Synergy in Action

There is some variability in team membership across the continuum of care. As

a new member of the team, you will need to meet others on your team

and establish your role with them. This is

easier if you have some basic understanding of

their roles and backgrounds.

Remember that integration of care is a key

responsibility of nursing team members.

Integration and continuity are dependent on

communication and the understanding of each

other's roles and expertise. Make an effort to get

involved with your patients and fellow team

members and all will benefit.

Complete the statements with names of

rehabilitation team members from the list below.

Terms may be used more than once.

patient physiatrist physical therapist

occupational therapist social worker neuropsychologist

speech-language pathologist rehabilitation nurse

1. The ___________________ is generally considered to be the most

important member of the team.

2. The professional ___________________________ (2 words) is a

pivotal member of the team, responsible to coordinate care from many

disciplines while maintaining health and preventing complications in

assigned patient groups.

3. The ___________________________ (2 words) recommends and

adapts equipment and the environment to facilitate independence.

4. The _____________________________ (2 words) creates a

therapeutic milieu and provides education and reinforcement of prior

learning.

5. A ___________________ is a physician who has special training in

physical medicine and rehabilitation.


6. The __________________________________ (3 words) addresses

cognition, information processing, and memory deficits along with

other team members such as a neuropsychologist and occupational

therapist.

7. The ________________ identifies medical diagnosis and prognosis,

manages medical needs, and prescribes therapies, testing,

medications, therapeutic aids, and adaptive equipment.

8. The ___________________________ (2 words) facilitates the

development of functional skills related to activities of daily living at

home, work, or school.

9. The ___________________________ (2 words) addresses mobility

issues through the use of exercise, strengthening, inhibition of

abnormal reflexes and tone, positioning strategies, gait training, use of

orthotics and prosthetics, and facilitation of sensorimotor function.

10. The ___________________________ (2 words) also works closely

with the prosthetist and orthotist to ensure the correct fit and use of

prosthetic and orthotic devices.

11. The __________________________________ (3 words) evaluates

receptive and expressive communication skills.

12. The __________________________________ (3 words) also

evaluates the patient at risk for swallowing disorders, making

recommendations for diet, food, and fluid consistency, and adaptive

eating techniques to decrease the risk of aspiration.

13. A _______________________ specializes in the treatment of

cognitive disorders associated with brain injury or disease. He or she

can be very helpful in identifying cognitive process impairments and in

advising the team and significant others regarding interventions and

coping strategies.

14. The _________________________ (2 words) focuses on coping,

adapting, and facilitating a return to the community. This role is also

active in assisting patients and significant others in addressing the

impact of the disease or disability on the living arrangements, roles,

and finances of the family.


Other Team Members

Membership and responsibilities of the team may vary greatly from setting to

setting according to the needs of the patient. Any number of other specialists

may be involved in the patient's care. These experts generally are pulled into

the team according to need. They are excellent resources; get to know them

and incorporate them into your network.

Chaplain: provides emotional and spiritual support

Driving Instructor: assesses driving abilities and retrains in driving

with adaptive equipment

Vocational Specialist: assesses vocational aptitude and abilities and

facilitates return to productive employment

Prosthetist: designs, fits, and prescribes prosthetic devices

Orthotist: designs, fits, and prescribes supportive devices used for

joint stabilization

Additionally, you will be working with a variety of assistive personnel.

Answer the following as True or False.

15. ______ Unlicensed assistive personnel are unskilled labor.

16. ______ Unlicensed assistive personnel have bad jobs and are stuck

doing all the grunt work.

17. ______ Stress and burnout are no worse for unlicensed assistive

personnel than for other professionals.

18. ______ Patients are concerned about the healthcare, food, and

environment, not about the unlicensed assistive personnel

caring for them.

Team Structure and Organization

Teams may be organized in a hierarchical or matrix reporting system and the

variations are numerous.


Interdisciplinary teams are at risk for ineffectiveness

and turmoil if there is not an

organizational framework that addresses

issues of territoriality, overlapping roles,

and communication processes. This may

be further compounded when groups

change due to staff turnover or

reassignments. Ultimately, this may leave

team members in different stages of

development.

Teams can remain in a given stage of development for extended periods of time

or may fluctuate wildly through stages due to external forces.

Scholtes, Joiner, & Streibel, 2003

19. List at least 5 things that drive team structure and composition.

Match the type of team organizational pattern to its description.

Multidisciplinary Interdisciplinary Transdisciplinary

20. _____________________ A limited number of team members interact

with the patient and significant others. The

rest of the team functions as consultants to

the identified caregivers.

21. _____________________ Team members are accountable for their

own area of expertise, but also are

accountable to work toward common goals

with the rest of the team. Problem solving

crosses discipline boundaries and goals are

common to the patient rather than to

individual disciplines.


22. _____________________ Each team member is accountable for their

own specialty area and works in a

coordinated manner with fellow team

members (though focused primarily on

their own discipline) to facilitate the

patient’s return to the community.

Rehabilitation Team Functions

The Commission on Accreditation of Rehabilitation Facilities (CARF) has

established the core functions of the rehabilitation team. These functions should

sound familiar because they are very similar to the nursing process.

23. List the core functions of the rehabilitation team.

What Makes a Good Team Work Well Together?

What makes a good team? And what makes them work so well together? If you

could bottle this and sell it, you would make a million dollars. Good teams

develop from the dynamics of leadership, respect, and collaboration. They work

well together when their processes and goals are clear and the members are

motivated.

Answer the following questions as True or False.

24. ______ Good leadership means that energy will be put into building

the team's skills and relationships, improving their ability to

meet their goals, and avoiding stagnation.


25. ______ Competition can occur between disciplines and lead to turf

issues. This is particularly difficult when one discipline feels

that it is less important or when it is being affected by

reimbursement and cost issues that it feels are unfair.

26. ______ All team members should be adept at conflict resolution,

addressing issues in a timely manner before they interfere

with the team's function.

27. ______ Collaboration is the foundation on which teamwork is built.

28. ______ Advocacy keeps the team focused on the patient's goals rather

than the goals of individual team members.

Team Development

Teams grow and develop like any other group.

Match the following to the description of team development that best matches

the stages listed below.

Forming Storming Norming Performing

29. ____________ Members demonstrate dependency on the designated

leader, anxiety about roles, and may participate in

pseudo-work (telling stories about patients that are

not relevant to the treatment decisions at hand).

30. ____________ The team is highly productive and effective during this

stage, and members understand each other's

strengths and weaknesses.

31. ____________ The team works harmoniously together. Trust and

structure increase, facilitating cohesion and dynamics.

32. ____________ Conflict is obvious. Members are less dependent on the

leader and more vested in own views, often

questioning the process or procedures they are

required to follow.

Teams do not stay in any one stage but rather move back and forth through

various stages as members and the industry change.


One More Time!

You will quickly become involved in team processes, so learn about them early on and

prepare yourself for professional interactions.

Continuity matters! One hour of therapy can be undone

repeatedly each day or reinforced throughout each day.

If you delegate care, make sure you spend adequate time with

patients so that you actually know what is going on with them.

Characteristics of Effective Teams

Effective teams share a common set of traits. A relaxed environment that

supports balanced participation and respectful disagreement helps to avoid

uncomfortable conflict that can interfere with the effectiveness of the team.

33. List at least 5 traits that are characteristic of effective teams.

On the Computer: The Rehabilitation Team, pages 11-13,

Review, Case Study, and Quiz

Complete the exercises on the next several pages in the workbook with your mentor.

Then, return to the Main Menu and start the next chapter: Rehabilitation Populations.



Learn About Your Team

Much can be learned about your team and how it functions through observation

and reflective thinking/discussion. Use this worksheet to learn about your team

and its functions. You can further your understanding by discussing your

observations with your manager, educator, or preceptor.

Identify your fellow team members:

Patient/Significant Others

Nursing Staff

Physiatrist/Physician

Physical Therapists

Occupational Therapists

Speech-Language Pathologists

Clinical Dietitians

Respiratory Therapists

Recreational Therapists

Other (list):

Identify your team's structure:

Multidisciplinary

Interdisciplinary

Transdisciplinary

Other:


Identify your role in the patient's assessment:

Identify your role in patient/family education:

Identify your role in identifying the patient's goals:

Identify your role in planning the patient's care:

Identify your role in communicating and coordinating the plan of care:


Identify your role in evaluating the effectiveness of the plan of care:

Who is the formal leader of your team?

If there is an informal leader, who is it?

What kind of competition is there among team members?

How is conflict resolved?

Describe at least one situation in which you have observed team

members advocating for the patient:


What stage of development is your team at?

Forming Storming Norming Performing

Which of the following characteristics are evident in your team?

Clear rules

Defined goals and roles

Comfortable and relaxed environment

Nurture and develop each other

Effective communication

Well-defined decision making procedures

Beneficial team behaviors and balanced participation

Awareness of group processes

Are you evaluated for your participation in the team process? How is

this measured? What is your plan for achieving a high score in this

area?


Are you able to do the following on your team?

Identify overall team goals and determine if you understand them, can

support them, and feel ownership of them.

Place the patient’s goals ahead of your individual goals within the team.

Get to know and understand fellow team members; build trusting,

respectful relationships.

Communicate openly and honestly.

Respect differences and value diversity in people, thoughts, and ideas.

Willingly listen to all team members and try to understand the others’

point of view.

Facilitate team development through participation, constructive use of

conflict, reaching consensus, maintaining good relationships with fellow

team members, and compromising when necessary.

Avoid group think and encourage divergent views by voicing honest

opinions and presenting pertinent facts and by respecting others for

doing the same.

Network with your fellow team members.

What are you most concerned about regarding team relationships and

the team’s care planning process?

Rehabilitation Populations Rehab Nursing Series™: Intro to Rehabilitation 42

Chapter Highlights

Stroke, brain injury, and spinal cord injury are

the most common neurological diagnoses found in typical rehabilitation care, though a variety of less common diagnoses may be addressed.

Debility from a variety of health problems and orthopedic

problems are a second common subset of patients receiving rehabilitation care.

Care must be delivered with consideration of age, culture,

resources, and functional ability.

CHAPTER 5

REHABILITATION POPULATIONS Funding continues to have a significant impact on access to

and utilization of services. Legislation continues to urge

creative and economical approaches to care.


Your job in this chapter is to identify the types of patients

commonly found in rehabilitation care. Using this as a basis, you will consider

how approaches to disability, population-specific care, and cultural sensitivity

need to be incorporated into your care strategies.

On the Computer:

Rehabilitation

Populations, pages

3-15


Rehabilitation Populations & Their Needs

The practice of physical medicine and

rehabilitation provides care to those with

disabilities in an effort to minimize

handicaps. During assessment, the

rehabilitation team determines the patient’s

strengths and assets as well as his

limitations and devises a plan to improve

activity and participation levels.

CARF, 2015

Match the following WHO definitions to the correct term.

Impairment Activity Participation

1. ________________ The nature and extent of functioning at the level

of the person; may be limited in nature, duration,

and quality (e.g., taking care of oneself)

2. ________________ The nature and extent of a person's involvement

in life situations in relation to impairment,

activities, health conditions, and contextual

factors; may be restricted in nature, duration,

and quality

3. ________________ A loss or abnormality of a psychological,

physiological, or anatomical structure or function

Activity Limitations

The rehabilitation team reduces impairment and improves environmental factors

in an effort to increase activity and participation. The rehab nurse incorporates

techniques for improving function into care. There were some tips to this end

provided in the computer component of the course.

Indicate True or False for the following to see what you remember.

4. ______ In most circumstances, it generally is easier for a patient to

don both pants and shirt while lying in bed.


5. ______ Allow adequate time for a patient to remember, process, and

problem-solve before offering another cue to help with self-

care.

6. ______ Address healthcare regimens separately from other functional

activities.

Knock! Knock! Who’s There?

Each rehabilitation setting has its own pattern of admissions. The patterns of

admission and the regulatory requirements shape patterns of practice.

Answer these questions for your setting.

7. What types of patients are commonly admitted to your program?

8. What are their lengths of stay?

9. What is the average workload or acuity? This is often reported as

hours of care per day per patient (hours per patient day) in inpatient

settings.

10. How are decisions made regarding who gets admitted to your unit and

who does not?


Stroke

Stroke is one of the most common diagnoses found in rehabilitation settings.

(The Rehab Nursing Series™ provides additional training on this population in the course

Rehabilitation of Stroke. You can find information at www.rehabclassworks.com/stroke.htm.)

Patient safety, management of comorbidities, maximizing functional

skills, and providing training and support to the caregiver are important

to successful stroke rehabilitation.

11. Why is stroke incidence increasing?

Patterns of deficits following stroke are directly related to the type of stroke and

vessel (part of brain) involved.

12. List 5 deficits common to left hemisphere stroke.

13. List 5 deficits common to right hemisphere stroke.

http://www.rehabclassworks.com/stroke.htm


Spinal Cord Injury

Spinal cord injury results in various levels of disability. Deficits are directly

related to the site and amount of damage sustained by the spinal cord and

often include motor and sensory impairment; alterations in bowel, bladder, and

sexual function; and, in those with higher injuries, alterations in autonomic

nervous system functions.


Rehabilitation of Spinal Cord Injury. You can find information at

www.rehabclassworks.com/SCI.htm.)

14. What population group sustains the most spinal cord injuries?

15. What is the most common cause of spinal cord injuries in older adults?

16. When does rehabilitation begin for the patient with a spinal cord

injury?

17. What is the purpose of early rehabilitative interventions for patients

following spinal cord injury?

18. List at least 5 deficits common to spinal cord injury.

http://www.rehabclassworks.com/SCI.htm


Brain Injury

Brain injury remains an all-too-common result of motor vehicle accidents,

violence, and recreational activities. Regular and consistent use of helmets, seat

belts, and other safety devices can dramatically decrease the incidence of

traumatic brain injury. Cognitive deficits are some of the most devastating

problems following brain injury.


Rehabilitation of Brain Injury. You can find information at

http://www.rehabclassworks.com/Brain%20Injury.htm.)

19. How severe are the majority of brain injuries?

20. List at least 5 deficits common to brain injury.

Other Patient Populations

Depending on the environment in which you work, you may see a number of

other diagnoses.

21. What other types of patients do you see in your environment?

http://www.rehabclassworks.com/Brain%20Injury.htm


Common Problems

There are some problems that occur regularly in the rehabilitation care of

patients. The computer component of the course addressed medication safety,

elimination, dysphagia, cognitive problems, communication disorders, and skin

care. This is only a basic introduction to these care needs.

Answer the following questions to see what you remember.

22. What type of medications should not be crushed?

23. Should you use applesauce to help a patient with dysphagia to swallow

medications? Why or why not?

24. Why should the bladder be emptied within 6-8 hours?

25. What is wrong with simply using incontinence products to manage

elimination accidents?

26. Is there such a thing as a silent aspirator in patients with dysphagia?

27. Should patients with dysphagia lie down and rest after meals?


28. What strategy can be used to increase a confused patient’s ability to

focus on the task at hand?

29. What must be remembered if a patient requires 1:1 care due to

confusion and risk for injury?

30. Is it likely that a patient with receptive aphasia will be able to read?

31. How do you evaluate yes-no reliability?

32. Should turning schedules for patients on rehabilitation units routinely

be every 2 hours? Why or why not?

33. What is the first thing that should be done if the patient develops a red

area?

Population-Specific Care

Patients of different age groups and maturity

levels have different physical,

psychological, and social needs.

There are four populations that often need

population-specific care related to their

developmental level: infants, children,

adolescents, and elders.


Remember the following regarding population-specific care.

Adapt the way you perform a task to the physical and social needs of the

patient.

Interactions are more effective when they are developmentally

appropriate.

Explain procedures to patients at a developmentally-appropriate level and

allow a suitable amount of time, if possible, for understanding and

assimilation.

Accommodate for changes in physical skills and cognitive function.

34. List at least 5 situations that require a developmentally-appropriate

response.

Impact of Disability

Disability impacts developmental tasks.

Answer these questions regarding care of children.

35. What should be incorporated into care for children?

36. Should teens be encouraged to participate in problem solving and

decision making?


One More Time!

Learn about the needs of the patient populations typically cared for by your team. This will help

you develop expertise for most patients.

Provide care in a developmentally-appropriate and functionally-appropriate manner. Involve family members too!

Learn about issues related to patient access to care both in the

organization and in the community.

Aging

Complete these phrases reminding you of issues to remember when caring for

the elderly.

37. Cardiac output ________________.

38. About _________ times the light is needed to see.

39. Tolerance for _____________ debt is low.

40. GI motility ________________.

41. Diminished renal function increases the risk of __________________.

Access to Care

Rehabilitation services are more prominently available in urban regions than

rural. Rural access to long-term care and home health services is also more

limited. Technology will provide options and opportunities in the future.

42. List one reason why access to care may be limited.

On the Computer: Rehabilitation Populations, pages 16-18,

Population-Specific Review, Case Study, and Quiz

Then, return to the Main Menu and start the next chapter: Therapeutic Milieu.


The Therapeutic Milieu Rehab Nursing Series™: Intro to Rehabilitation 52

Chapter Highlights

The milieu creates support and opportunity for the patient. It also provides rules and expectations for behavior for patients and team

members alike.

The team creates, supports, and maintains the milieu

through patient/family education. Consistency in team members reduces stress in patients/families.

The team must earn the trust of the patient and help them to manage limited resources.

CHAPTER 6

THERAPEUTIC MILIEU Milieu: the physical or social setting in which something

occurs or develops


In this chapter you will learn what a therapeutic milieu is,

identify ways you can facilitate it, and evaluate the

importance of education in maintaining it in your unit. Your first job is to define

the term milieu. A milieu is a powerful therapeutic tool, just as you are a

powerful tool as you use different personas with different patients to gain their

trust and cooperation. The use of self and milieu is as important as the use of

any other tool to promote positive coping and functional gain in the

rehabilitation process.


On the Computer: The Therapeutic Milieu, pages 3-18

Creating a Therapeutic Milieu

Many rehabilitation professionals are unaware of the difficulties and stresses of

life in the community in a wheelchair or of life caring for a family member

24/7 without relief or a change of shift. In our current healthcare world,

those working in acute settings have a lack of exposure to the long-term effects

of disability; there are shorter lengths of stay in each stage of the continuum,

and there often is a lack of training regarding the realities of life in the

community with a disability. At times, rehab personnel do not ask critical

questions about the environment and lifestyle to which the patient will be

returning. This lack of exposure limits their ability to help patients and

caregivers rehearse and prepare for worst-case scenarios following discharge.

The creation of an effective milieu in inpatient settings can help to

bridge this gap.

1. What is the definition of a milieu?

2. List at least 3 attributes that contribute to the milieu of a rehabilitation

setting.

A Therapeutic Environment

Creating an environment that facilitates community skill development

requires planning, thought, and understanding of the transitions most patients

in your care will face.


Failure to provide opportunities to learn and practice skills required in the

community is a significant injustice for rehab patients, leaving them to struggle

on their own without support. All too often, the team assumes that skills

practiced in the gym are readily transferred into other settings. Patients will tell

you that this is not as easy as it seems. There is a huge difference between

being successful in the rehabilitation environment and being successful in the

community.

The rehab program should be incorporated into the real world in a manner

that facilitates application of learned skills to the community environment. Staff

can improve their ability to facilitate transitions and provide appropriate

coaching and training with the ideas below.

Evaluate the environment, in relation to the type of patients cared for, to

determine how close it is to the conditions of the real world. Make

appropriate changes or identify a way to provide opportunities to practice.

Ask questions of patients regarding the environment to which they

will be returning and problems they anticipate having. Encourage and

praise practical problem solving.

Use passes into the community

to provide opportunities to

practice skills and identify

problems. This allows patients

to be introduced into reality in a

gradual and supportive manner.

(While this is a valued practice

in rehabilitation care, insurance

companies may not support the

activity. Thus, it must be used

selectively, and the therapeutic

value must be documented.)*

Hold forums or discussions with patients who have been in the community

for some time for ideas and suggestions for support and training of

newer patients.


Critically assess discharge plans for opportunities to facilitate

rehearsal of worst-case scenarios and transference of skills to life in the

community.

Make sure there is a follow-up plan to support the patient and caregiver

on return to the community.

*(The Rehab Nursing Series™ provides additional training on the use of therapeutic community

passes to improve discharge planning in the course Got a Plan, Man? Patient-Centered Care

Planning in Rehabilitation. You can find information at

www.rehabclassworks.com/CarePlan.htm.)

Consider your organization and determine their effectiveness in meeting the

challenge of creating an environment that is a) supportive to those newly

admitted, but b) representative of reality for those close to discharge.

Identify actions your team needs to take (if any) to more aggressively meet the

patient's needs in each of the following areas.

3. The patient’s immediate room (including the patient's bed, bathroom,

doorways, dining and eating facilities, flooring, closets, cabinets, etc.):

4. The community areas of the unit and facility:

5. The environments used for transition or community-level training:

http://www.rehabclassworks.com/CarePlan.htm


More Than Physical Barriers…

Society's views of disability and chronic illness are not always kind. As a result,

many laws have been implemented to protect the rights of and provide

opportunities to those with disabilities. Quality of life is improving for many

through the use of education, technology, and media support.

What are your feelings about quantity versus quality of life? Perceptions of

the quality of life are personal and very individual. Rehab team members are

expected to provide support, education, counseling, and respect to the patient

and significant others as they traverse this path. It is difficult to acknowledge

that, for some, improving their quality of life

may not include extending the length of it.

What are your beliefs about the healthcare

process and issues of care versus cure? In

spite of the fact that the media portrays

healthcare as curing almost everything,

rehabilitation seldom cures anyone. Instead,

the focus is to address the residual deficits of

a disease or injury in the effort to minimize its

effects.

How comfortable are you in allowing your patients to have more control—self-

care versus caregiving? Nurses and many family caregivers are conditioned to

take care of others in need. However, we do a significant injustice to our

patients if we consistently do for them and fail to prepare them for the realities

of the community in which they are going to be living (limitations of funding,

time, and resources).

Staff with negative attitudes toward disability may feel helpless when facing

persons with significant limitations. What do you feel—empathy or sympathy?

Empathy will help you develop solutions; sympathy will limit your ability to

prepare your patients for the real world.

Consider your team’s interactions with patients, and answer the following

questions for your setting.


6. What messages are sent to your patient population regarding attitudes

toward disability?

7. Are there good and bad disabilities, or some that are preferred by the

team over others? Which types of patient does everyone want to be

assigned to, and which types do they avoid?

8. What kind of reactions do you see when you watch visitors interacting

with your patients?

9. What are your feelings about quantity versus quality of life?

10. What are your beliefs about the healthcare process and issues of care

versus cure?


11. How comfortable are you in allowing your patients to have more

control—self-care versus caregiving?

12. What do you feel when caring for your patients—empathy or

sympathy?

From Admit to Reintegration

A therapeutic milieu facilitates the processes of rehabilitation.

13. List at least 3 premises that support the development of a therapeutic

milieu.

Those Unwritten Rules and Expectations

All inpatient units have some sort of milieu. Some of this is formalized in

orientation materials for patients and families, informing them of the processes

and resources of the unit. Even those in community settings are informed of the

rules of the game.


14. What informal rules exist in your environment regarding how patients

are expected to act?

Creating Expectations

From the moment a patient and his or her family enters our world, we are

consciously and unconsciously sending messages that provide them with

information and feedback. By being consciously aware of this, the team can

define and create expectations for participation and success.

15. List at least 5 expectations your team has of patients and family

members which are directly or indirectly communicated to them and

describe how you know that the message is received.

16. How does your team care for the caregiver?


Resource Allocation vs. Personal Productivity

Resources are limited and most rehabilitation professionals have very high

productivity requirements. Access to care is limited, and the team is expected to

use the patient’s limited resources wisely.

17. Each day that you are delivering care, you are using up some of the

patient's resources. How is the patient getting his money’s worth?

Patient's Rights and Confidentiality

Protection of the patient's rights and confidentiality is not only common sense,

but it is also mandated by regulations and laws. One of the most common

confidentiality problems on the rehab unit is the question of how much

information should be given to fellow patients and friends of the patient.

Confidentiality rules do apply in these situations, and failure to follow the

guidelines of your organization can result in legal action. When fellow patients

ask what is going on with another patient, you may suggest that they

ask the patient or even go so far as to remind them of confidentiality

requirements.

If you must tell other patients and family members of a patient at risk on a unit

(such as an agitation or elopement risk), you can simply say, "One of our

patients is having a very hard time and is at risk for leaving the unit. Would you

please be very cautious going in and out of the doors?"

There are many polite ways both to maintain confidentiality and to meet the

needs of the patients on the unit as a group. They will talk amongst themselves

and share information. You do not need to be the bearer of it.

18. Where are your weak links in protecting patient confidentiality?


19. How will you reply to a patient who is asking pointed questions about

another patient's situation?

Teaching Patients and Families

In rehabilitation settings, every interaction with the patient and family is a

potential learning situation. The rehab team is consistently role modeling

and reinforcing (or failing to reinforce) the messages they are sending

to patients and their caregivers. Use the nursing process to assess, plan,

implement, and document.

(The Rehab Nursing Series™ provides additional training on this topic in the course See One, Do

One… Patient & Family Education in Rehabilitation. You can find information at

www.rehabclassworks.com/PtEd.htm)

Assess: Identify needs, concerns, current perceptions, beliefs, attitudes,

skills, and readiness to learn. Are there barriers to learning? Don't work

from assumptions. Establish rapport and find out about the patient's

support systems, limitations, and cultural history. Understand the

patient's beliefs and knowledge level regarding his diagnosis. Be attentive

to age, cognition, and perceptual skills. Verify literacy level. Be attentive

to emotional or health factors that may interfere with the ability to learn.

Plan: Plan with the patient/family. Use appropriate tools and stay

organized. Prioritize education, starting with the information that is critical

to the patient's survival.

Implement: Stay organized; make sure the patient stays on track. Allow

enough time for the patient to practice and experiment.

Document: Check off objectives as completed. Keep current records to

avoid duplication of work. Document return demonstrations, ability to

feed back information that has been shared, or other responses.

http://www.rehabclassworks.com/PtEd.htm


If your patient does not speak English, be certain to use a certified healthcare

translator according to your organization’s processes.

Providing a good learning environment includes your body language, the

environment, and privacy. Make sure patients know what they should do and

why, when they should expect results, danger signs to watch out for, what to do

if there are problems, and whom to contact for referrals.

The Joint Commission (TJC) requires that an assessment be completed prior

to implementing a teaching plan. This should be plain old common sense but

requires regulation because care providers short-cut this step and assume they

know the patient’s needs. Plans are expected to be based on identified needs

and should include the following.

Education on appropriate medication administration

Use of medical equipment

Information on potential food/drug interactions

Counseling on nutrition and modified diets

Information on healthcare management, further treatments, and

rehabilitation needs

Appropriate information should be provided to the discharge setting and

caregivers, and documentation should include responses to teaching. The TJC

surveyor may ask you how you assess and identify what your patient needs to

learn, may ask to see the materials you use, and may ask to see

documentation of your work.

20. List at least 5 strategies to enhance patient and family education.


Issues of Change in the Rehab Setting

Much of the learning required of persons with acquired disabilities under our

care will result in extreme demands to change family roles and lifestyles.

21. When does change occur?

What Next?

Discharge planning is a key component of maintaining continuity of care and

alleviating anxiety over transitions. There are a myriad of resources available to

patients and their families. These resources range from community support

services to volunteers and support organizations.

22. What is the discharge planning process in your setting, and how is it

communicated to your patients?

I Am My Own Best Advocate

One of the hardest things to teach a patient or caregiver is how to be one's own

best advocate. We do our patients no favors by doing everything for them. They

will not always have the team at their side. Be cautious and avoid creating a

codependency that further handicaps them in the community.

23. How does your team teach patients and families self-advocacy?


One More Time!

A therapeutic milieu requires consistent nurturing

by all team members. Remember that you are a therapeutic tool when interacting with patients.

Creative approaches are used to improve quality of life within

the limits of resources.

Learn effective patient/family education strategies and use them

to prepare patients for self-management in the community.

Ethical Issues in Rehabilitation Settings

Ethical issues come in many shapes and sizes in rehabilitation settings. Many

rehabilitation organizations have access to resources to help them solve ethical

dilemmas.

24. What would happen if a patient under your care chose to refuse care in

an effort to die rather than live with a disability?

On the Computer: The Therapeutic Milieu,

pages 19-21, Review, Case Study, and Quiz

Then, return to the Main Menu and start the next chapter: Regulatory Issues. Watch for

the page that tells you to return to the workbook.

Regulatory Issues Rehab Nursing Series™: Intro to Rehabilitation 65

Chapter Highlights

Your practice in rehabilitation (just like any other

healthcare setting) is impacted by regulatory and legal requirements. They change frequently and

influence care delivery.

Practice according to regulatory/legal guidelines every day to protect yourself and reduce the risk of compromising the patient’s care or the organization’s status.

Invest in understanding and improving outcomes and quality of care.

CHAPTER 7

REGULATORY ISSUES Minimal standards are defined by regulations and accreditation

standards. The trick is to understand the intent of them so that

you can incorporate them into your daily care.


In this chapter you will learn who the regulatory bodies are that

drive rehabilitation practice. You will be introduced to a few of the regulations

that apply to the continuum of care and will take a quick look at your possible

involvement in quality and outcomes management. Regulations are different at

different levels of care. Pay particular attention to the information related to the

setting in which you work.

On the Computer:

Regulatory Issues,

pages 3-16


Regulatory Issues

Regulations impact every facet of your care in one way or another. The vast

majority of regulations are designed to facilitate safe patient care. Yes,

we have earned them. Many regulations have been written because we, as an

industry, have failed to keep patients safe without them.

Accreditation

Accreditation standards have been redesigned over recent years to focus on

quality, effectiveness, and efficiency of care. All staff members should

practice as if the accreditors were going to walk in that very day and

evaluate your care and documentation. If this was true, and staff were well-

informed of requirements, there would be almost no work required to get ready

for a survey.

TJC issues patient safety goals as part of their standards of care. These goals

are mandatory for all organizations accredited by them.

1. Who accredits your team?

Quality Improvement

All staff should be involved in quality improvement activities. Reflection on best

practices, analysis of data, and use of root cause analysis to prevent the

recurrence of an adverse event are examples of how to be involved. You can

anticipate that surveyors will expect you to know performance

measures for quality initiatives your team has undertaken.

2. List current quality improvement activities being undertaken by your

team.


Program Evaluation

Rehabilitation care providers throughout the continuum of care are being asked

to justify the cost of their programs in relation to the benefits by providing data

related to the amount of functional gains made and the significance of decreased

dependence on the healthcare system.

3. How does your team evaluate the effectiveness and efficiency of care?

Funding Sources

Cost containment and healthcare reform are receiving significant attention. This

brings more concerns regarding rationing and access to care than those we face

today. (Recognize that Medicare already rations care by limiting who can get

what services and by determining what will and will not be covered for a

Medicare beneficiary.) Healthcare providers must do their part in managing the

costs of care. Understanding the funding a patient has, if any, is part of good

fiduciary responsibility.

Answer the following questions True or False.

4. ______ Any worker is eligible for Medicare coverage.

5. ______ Medicare Part A covers hospital, skilled, and home health care.

6. ______ Any worker is covered by Workers’ Compensation for injury or

illness when employed.

7. ______ Each state determines eligibility for Medicaid, though some

groups are required to be covered by federal government

mandate.


Meeting Medicare Regulations

Medicare requirements and limitations drive many of the activities done by

rehabilitation teams. If you want more information regarding the Centers for

Medicare & Medicaid Services (CMS) requirements and services, visit the CMS

website at www.cms.gov. Note that there are specific admission, care, and data

collection requirements for each level of care in the continuum.

Changing Medicare Regulations

The Balanced Budget Act (BBA) of 1997 mandated the implementation of

prospective payment systems (PPS) for post-acute services. The intent of

this legislation is to control Medicare expenditures.

Prospective payments systems were first utilized in acute care settings in the

1980s and controlled costs by dividing patients into 470+ Diagnosis-Related

Groups (DRGs). Spending was quickly shifted to units exempt from this

legislation, such as skilled nursing facilities and rehabilitation settings, and

patients were moved more quickly out of acute settings.

It is important to understand the CMS regulations and the impact that they have

on services for our patients because Medicare is the largest payer in many

settings. Payment for rehabilitation care has moved from a cost-based (bill for

services) reimbursement system to a designated payment disbursement based

on patient needs and utilization. More changes are coming with the shift to

value-based care and a continued emphasis on patient outcomes due to the

Affordable Care Act (2010).

It should also be noted that the BBA resulted in the initiation of the Acute Care

Transfer Rule, which stipulates that hospitals will receive only a prorated

portion of a DRG payment if a patient's length of stay is less than the DRGs

average length of stay. Ten DRGs are targeted in the ruling in an attempt to

prevent hospitals from increasing revenues by discharging patients early and

then earning more reimbursement in other levels of care.

For post-acute settings, CMS requires a significant amount of documentation

compiled in data collection tools. Admit and continued care criteria vary across

the continuum. Documentation and scoring in data collection tools is used to

http://www.cms.gov/


determine prospective payment based on medical diagnosis and functional

status.

Careful and accurate documentation is critical. CMS believes that the

amount of therapy time for each patient should be tailored to individual needs.

Progress should be clearly documented; functional improvement must

be shown.

The MDS Data Collection Tool

For use in skilled nursing settings

The Minimum Data Set (MDS) assessment includes more than 583 items in 13

domain areas (past medical history and medically-defined conditions, medical

status, functional status, physical and sensory impairments, nutritional status,

special treatments or procedures, psychosocial status, discharge potential,

dental condition, activities potential, rehabilitation potential, cognition, and drug

therapy).

MDS data is collected, updated per regulations, and encoded and transmitted

electronically to state and federal governments and used for a variety of

purposes, including calculation of payment, establishment of quality indicators,

and development of quality report cards for public information.

The OASIS-C2 Data Collection Tool

For use in home health agencies

The Outcome and Assessment Information Set (OASIS) is a group of data

elements that are part of a comprehensive assessment for adult home care

patients. The data is ultimately used to measure patient outcomes for outcome-

based quality improvement (OBQI).

The OASIS-C2, the current version of the OASIS data set, includes

sociodemographic, environmental, support system, health status, and functional

status information, as well as selected attributes of health service utilization.

Home health agencies are required to submit OASIS data to their state survey

agency. It is ultimately transmitted to CMS for use in calculating payments per

the regulations associated with the home health agency prospective payment

system. This data also is used for evaluation of the home health agency.


The IRF-PAI Data Collection Tool

The Inpatient Rehabilitation Facility – Patient Assessment Instrument (IRF-PAI)

was designed to manage the IRF prospective payment system (IRF PPS). Data is

used for the items below.

Objective assignment of Medicare payment for inpatient rehabilitation

services

Development of a system to monitor the effects of IRF PPS on patient

care and outcomes*

Calculation of adjustments to the IRF payments

Development of an integrated system for post-acute care in the future

*Remember to provide the appropriate amount of care for the appropriate (not the

shortest) length of time in order to keep this data truly reflective of patient needs.

Assessments are completed at admission and discharge. The IRF-PAI consists of

nine sections, including identification and demographic information, medical

information, and information related to quality of care and basic patient safety.

The functional status section of IRF-PAI utilizes the FIM-PAI™ instrument. As

has occurred with the MDS and OASIS, CMS is expanding quality measures

(catheter-associated urinary tract infections, pressure injuries, influenza

vaccine, unplanned readmissions) based on items contained in the IRF-PAI.

(The FIM® instrument has been used in rehabilitation settings for quite some

time to objectively measure functional gains. It has expanded over the last

several decades to include pediatric (WeeFIM II®), outpatient (LIFEware®), and

acute care (AlphaFIM®) tools and databases. These allow for benchmarking to

occur in long-term acute care hospitals and subacute/skilled nursing

environments as well as in the acute rehabilitation setting. The adult FIM®

scoring component is the same in each tool, but the databases compare the

functional gains of like settings.)

Additional quality and outcomes items are being added to all of these data

collection sources in order to comply with the IMPACT Act’s mandate to compare

outcomes across the post-acute settings.


60% Rule for Acute Inpatient Rehabilitation Facilities

Acute inpatient rehabilitation admissions must meet the 60% Rule, which states

that 60% of patients admitted must have a diagnosis that falls within

the following categories, as defined by CMS:

Stroke

Spinal cord injury

Congenital deformity

Amputation

Major multiple trauma

Fracture of femur (hip fracture)

Brain injury

Burns

Neurological disorders (multiple sclerosis, motor neuron disease,

polyneuropathy, muscular dystrophy, and Parkinson's disease)

Polyarthritis if: a) bilateral hip or knee replacement immediately

preceding inpatient rehabilitation facility admit, or b) extremely obese

with BMI of at least 50, or c) age 85 or older.

In addition, patients must meet the following medical necessity guidelines.

The patient requires rehabilitation medical supervision.

The patient requires and receives at least 3 hours of therapy per day—

at least 5 days per week .

The patient requires a coordinated plan of care with specialized

professional rehabilitation nursing as part of the care planning team.

The patient is expected to achieve significant improvement.

Goals are realistic and targeted at maximum function.

Length of stay is reasonable.

Documentation must support the need for 24-hour-per-day specialized

professional rehabilitation nursing care!


One More Time!

Learn what you must do to meet regulatory

requirements in your organization and follow those guidelines consistently.

Become involved in the quality improvement process. It

takes all of us to do the job better.

Document thoroughly and in a manner that describes the impact

you are having on the patient as a rehabilitation specialist.

Answer these questions for your setting.

8. What percentage of your patient population is comprised of Medicare

patients?

9. What Medicare data collection tool do you use?

10. What documentation requirements do you need to meet?

(The Rehab Nursing Series™ provides additional training on this topic in the course Not

Documented? Not Done! Documenting Professional Rehabilitation Nursing Care. You can

find information at www.rehabclassworks.com/Documentation.htm.)

On the Computer: Regulatory Issues,

pages 17-20, Review, Case Study, and Quiz

Study any areas in the course you feel weak in. Then, return to the Main Menu and

complete the posttest. A score of 80% on the posttest is required to obtain continuing

education credit. Print the score sheet at the end of the test—you will not be able to

retrieve it later.

http://www.rehabclassworks.com/Documentation.htm

Answer Key Rehab Nursing Series™: Intro to Rehabilitation

73

ANSWER KEY Chapter 1 Overview

1. The current interests and pressures of society, technological advances, and the consequences of war

2. There had to be methods for

increasing survivorship of injuries and illness.

3. These developments coincided with the development of improved healthcare strategies. Industrial inventions and recreation activities

provided the opportunity for new

injuries. The result was more severe injuries (speed-related injuries had never been an issue prior to fast cars) and more survivors.

4. There are both ethical issues (e.g., stem cell research) and cost issues

that may limit access to new innovations in rehabilitation care.

5. The source (websites sponsored by the U.S. government, not-for-profit health or medical organizations, and university medical centers are typically the most reliable resources on the

internet), certification by Health on the Net (HON), and date

6. This answer should reflect your personal expectations of this role. Remember that you are a therapeutic tool that can make a significant difference in another’s quality of life

through what you teach and how you help solve the problems of community living.

Chapter 2 What Is Rehab?

1. Rehabilitation is a process of care

addressing the needs of those with

functional disability. It is both comprehensive and coordinated. It focuses on the individual's potential rather than his limits.

2. This answer varies from setting to setting and may include changes in

reimbursement, staffing shortages, patient mix issues, referral trends,

etc. Discuss it with your manager or preceptor.

3. Effective coordination and communication by the teams in different settings.

4. Strategies to decrease relocation

stress include:

Reduce environmental differences between old and new settings; promote continuity of care in new environment.

Transfer all personal items (e.g., mobility aids, eyeglasses, hearing

aids, dentures, prostheses, and belongings) with the person.

Transfer during daytime hours.

Offer decision-making opportunities throughout the relocation experience.

Offer help in maintaining contact with significant others by telephone calls, writing letters, or visits with previous roommates.

5. It is the duty of the team to provide appropriate education and

opportunities for practicing skills and

problem solving. This, in fact, is what you are there for!

6. Improving function, promoting quality of life, promoting independence, preserving self-esteem, and maintaining health

7. Possible goal for next week: Able to

bridge and turn self during care in bed with cues; able to perform pivot transfer to the left with moderate assist, set-up, and coaching by [date].

8. Possible goal for next week: No oozing of stool with evacuation of stool each

day in a.m. before therapy by [date].

9. Possible goal for next week: Able to indicate yes/no with head gestures and use call light appropriately 50% of time by [date].

10. Possible goal for next week: Intake of 2000 mL fluid (combination of oral,


74

tube, or IV supplements) daily and no

signs of fluid volume deficit by [date].

11. Possible goal for next week: Factors that increase risk for injury are

controlled and no injury occurs while patient is impaired in judgment and motor skills.

Chapter 3 The Rehabilitation

Nurse

1. Solid base in medical-surgical and

neurological nursing, empathy, good teaching and coaching skills, creative with good problem-solving skills,

open-minded, and good at collaborating in care with other team members.

2. b

3. f

4. c

5. a

6. d

7. e

8. Participates in development of an individualized plan of care that

includes interventions targeted toward

attaining expected outcomes. The plan supports continuity of care, is documented, and is congruent with patient/family priorities and resources.

9. Facilitate the development of a safe

patient handling environment according to the national standards and recommendations. Use the correct transfer technique and equipment, proper body mechanics, and appropriate safety devices, such as shoes, gait belts, and wheelchair

brakes.

10. True

11. True

12. True

13. True

14. True

15. impression

16. needs

17. reliable

18. listen

19. prepare

20. educate

21. humor

22. clarify

23. respect

24. support

25. Activities of daily living: Activities such as grooming, dressing, bathing, etc., that are part of everyday life

26. A condition of paralysis of the right or

left half of the body—worse than hemiparesis

27. Loss of motor and/or sensory function of the lower half of the body

28. Loss of motor and/or sensory function

in all 4 extremities and trunk (also known as quadriplegia)

Chapter 4 The Rehabilitation Team

1. Patient

2. Rehabilitation nurse

3. Occupational therapist

4. Rehabilitation nurse

5. Physiatrist

6. Speech-language pathologist

7. Physiatrist

8. Occupational therapist

9. Physical therapist

10. Physical therapist



13. Neuropsychologist

14. Social worker

15. False

16. False

17. False

18. False


75

19. The market, costs, patient needs,

reimbursement, practice regulations

20. Transdisciplinary

21. Interdisciplinary

22. Multidisciplinary

23. Assessment, identification of patient's goals, development of a plan of care, implementation of a plan of care, evaluation of the effectiveness of the plan, and discharge planning

24. True

25. True

26. True

27. True

28. True

29. Forming

30. Performing

31. Norming

32. Storming

33. Clear rules, defined goals and roles, comfortable and relaxed environment, nurture and develop each other, effective communication, well-defined decision making procedures, beneficial

team behaviors and balanced

participation, awareness of group processes.

Chapter 5 Rehabilitation

Populations

1. Activity

2. Participation

3. Impairment

4. False

5. True

6. False

7. Discuss this with your manager, educator, or preceptor.



10. Discuss this with your manager,

educator, or preceptor.

11. Due to aging of the population and noncompliance with hypertension

management

12. Right hemiparesis; language (written, spoken, and receptive) deficits; problems with math and logical functions; reasoning deficits; slow, cautious behavior

13. Left hemiparesis; spatial/perceptual

deficits; decreased creativity; poor pathfinding; and lack of insight with impulsive behavior

14. Young adult males

15. Falls

16. After spinal stabilization

17. To decrease the risk of secondary complications such as pneumonia, skin breakdown, and deep vein thrombosis

18. Paralysis; sensory deficits; alterations in bowel and bladder function; alterations in sexual functioning; alterations in the function of the

autonomic nervous system leading to difficulties with blood pressure and temperature regulation

19. Mild

20. Motor impairments; sensory-perceptual deficits; communication deficits; dysphagia and alterations in

nutritional intake; alterations in cognition and behavioral control


22. Time-released or enteric-coated

23. No. It disperses too easily in the

mouth. Use pudding or yogurt instead. (The Rehab Nursing Series™ provides additional training on dysphagia in the course An Apple a

Day… Nutrition & Dysphagia Management. You can find information at

www.rehabclassworks.com/nutrition.htm)

24. This is done to prevent stagnation of urine, which increases UTI risk. (The Rehab Nursing Series™ provides

http://www.rehabclassworks.com/nutrition.htm

http://www.rehabclassworks.com/nutrition.htm


76

additional training on bladder

management in the course Gotta Go Right Now! Bladder Management in Rehabilitation. You can find

information at www.rehabclassworks.com/Bladder.htm)

25. They are expensive, increase risk of skin breakdown, and decrease self-esteem.

26. Yes. In these patients there are no

overt signs of aspiration.

27. No. They should rest before so they can attend to eating and sit up for 30 minutes after.

28. Control noise and distraction in the environment. (The Rehab Nursing

Series™ provides additional training on care of patients with cognitive dysfunction in the course Wandering, Confused, & Agitated? Managing Cognition & Behavior Management. You can find information at www.rehabclassworks.com/Cog.htm)

29. Do not leave the patient unattended.

30. No. Written words will likely be difficult as well. (The Rehab Nursing Series™ provides additional training on care of patients with

communication disorders in the course He Said/She Said? Disorders of

Communication, Speech, & Language. You can find information at www.rehabclassworks.com/communication.html)

31. Ask several questions that are

obviously a yes or no response, e.g., “Is it snowing in your room?”

32. No. They should be adjusted to the patient’s tolerance on the bed surface to enhance sleep. Additionally, plans should be made to maximize time between turns so that the home

caregiver can get adequate sleep. (The Rehab Nursing Series™ provides additional training on preventing complications of immobility in the course Go HOM! Preventing Complications of Immobility. You can find information at

www.rehabclassworks.com/Immobility.htm)

33. Keep the pressure off of it until it

resolves.

34. Situations requiring a developmentally-appropriate

consideration include, among others: comfort and support; dietary needs; vulnerability to fluid and heat loss; beliefs and understandings of the causes of illnesses; variations in responses to medications based on body size and ability of the body to

process and excrete them. (The Rehab Nursing Series™ provides additional training on care of pediatric patients in the course Pediatric Rehabilitation. You can find

information at

www.rehabclassworks.com/peds.htm)

35. Play

36. Yes. This facilitates achievement of developmental tasks.

37. Diminishes

38. Three

39. Oxygen

40. Decreases

41. Dehydration

42. Finances; lack or type of insurance coverage; preferred provider

relationships; lack of services within the community

Chapter 6 Therapeutic Milieu

1. Milieu: the physical or social setting in which something occurs or develops

2. Physical environment; attitudes of caregivers; expectations; written and unwritten rules of the system

3. Answers should reflect your practice setting.



6. Answers should reflect your personal

experience.

7. Answers should reflect your personal experience.

http://www.rehabclassworks.com/Bladder.htm

http://www.rehabclassworks.com/Bladder.htm

http://www.rehabclassworks.com/Cog.htm

http://www.rehabclassworks.com/communication.html

http://www.rehabclassworks.com/communication.html

http://www.rehabclassworks.com/Immobility.htm

http://www.rehabclassworks.com/Immobility.htm

http://www.rehabclassworks.com/peds.htm


77


experience.





13. View the environment from the

patient's perspective. Build a rapport. Maintain continuity of care. Avoid depersonalization. Learn tough love.



experience.


17. Answers should reflect your personal experience. Ask yourself: Are education and practice in functional skills included every shift? Are

patients provided with ample time to practice self-healthcare management?


experience.

19. When fellow patients ask what is going on with another patient, you may suggest that they ask the patient or

even go so far as to remind them of confidentiality requirements.

20. 1) Make it clear in actions and words, from the beginning, that the patient/family are to be active, participating team members.

2) Remember the principles of adult learning: Adults learn on a need-to-know basis.

3) Be alert to and anticipate the

impact of adaptation and grieving issues on the patient and significant other's ability to learn.

4) Involve the patient in the learning process; make sure you understand previous knowledge and experience before providing new information, and

repeat information while providing

multiple opportunities to practice.

5) Take advantage of questions and opportune moments for teaching.

Know your information or how to quickly access it so that when they are interested or ready, you are too.

6) Make sure you are teaching and working with the same equipment the patient will be using at home.

7) Make sure the patient knows that

education is happening.

8) Remember that your attitude and body language will convey your willingness to answer questions and

assist in problem solving.

21. When a person recognizes a need to

make a change and believes that the status quo should not continue.


23. Answers should reflect your personal experience. What do you do to teach your patients about how to access

supplies, interact with insurance companies and the healthcare system, or find support systems in the community?

24. Answers should reflect your personal experience. Does your organization have an ethics committee? How do

you access it?

Chapter 7 Regulatory Issues

1. Answers should reflect your situation.



4. False—The worker must have worked the minimum number of quarters required to be eligible. The spouse of a qualified worker or person who has

been disabled for 2 years is also eligible.

5. True

6. False. They are only covered if injured while on the job and the employer carries this type of coverage.

7. True


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8. Answer should reflect your situation.



Documents

Rehab Nursing Series : Intro to Rehabilitation · Rehab Nursing Series™: Intro to Rehabilitation iii THE REHAB NURSING SERIES INTRODUCTION TO REHABILITATION & REHABILITATION NURSING