When our disabled or elderly patients are admitted to either an acute or sub-acute rehab, the focus is typically on therapy. This is appropriate because these patients have probably just spent time in an acute stay hospital for something like stroke, pneumonia, a fracture, surgery, urinary tract infection, or injury from a fall. Since they likely spent most of their hospitalization in bed and are now weaker than before they were admitted, they need therapy to get them back to at least their prehospital level of activity and hopefully better.
The problem is that these patients are only in acute or sub-acute therapy a few hours per day so that leaves over 20 hours each day that they are the responsibility of nursing. A few hours of therapy each day without continued mobility support from nursing is very likely not enough for the patient to reach their rehab potential. Unless they are encouraged and assisted by nursing to walk and exercise, they tend to remain immobile — and immobility results in weakness and adversely effects every system of the body. The reasons for immobility are numerous: loss of the use of a body part, pain, fear of falling, weakness, depression, feelings of hopelessness, and lack of balance, to name a few.
After a stroke, as an example, the patient may be dealing with multiple issues. They may have difficulty swallowing, loss of center of gravity that can make them more prone to falls, left or right sided neglect, vertigo, loss of self-image, loss of use or weakness of at least one body part, loss of bowel or bladder control, and potential for increased muscle tone or lack of muscle tone (flaccid body part) that may require intermittent appropriate splinting to reduce the incidence of deformity.
Pain is a significant reason a patient may desire to limit their movement so nursing must monitor their pain and be consistent with pain-relieving measures. This might be a cold or warm pack to an area, pressure relief and other positioning and repositioning strategies, and pharmaceutical pain relievers (given before therapy to decrease the potential for pain during their therapy session but not enough medication to adversely affect their ability to do quality therapy). Sometimes just reassuring them the pain medication will help does wonders. Patients do better when they have trust that they will be given the best care.
Adequate nutrition and hydration are important for healing and for energy — and energy is required to safely exercise and take part in therapy. A weak patient may have greater fears of falling and require more assistance and encouragement with transfers, standing, toileting and walking. They must feel confident that the staff person will support them and not allow them to fall. These patients are frequently dehydrated or close to it. Nothing in your body works properly if it is not adequately hydrated.
If not contraindicated, encourage fluids at mealtimes and with any contact. Just sitting a glass full of water near them will most likely not be successful. Their thirst mechanism is decreased, they may not have a steady hand to maneuver a glass, and they may forget to drink. Choosing the best size and shape of glass for the individual patient, how much liquid to put into the glass, learning if they like room temperature or cold drinks, and if they like a bit of flavor in their water can encourage them to drink more. If a hot beverage, discover the best shape of mug/cup and the style of handle. These specifics may sound insignificant but can make the difference in them feeling comfortable that they can handle the weight and not spill the beverage.
If a patient seems to be confused, especially if they are part of the older population and especially if they are female, it is recommended to check their urine for infection. The longer an infection might be allowed to grow, the more confused they may become and the UTI can become a very serious situation even reaching sepsis. Even “mild” UTIs can waste therapy days as the patient will not be as compliant or productive. If the infection is not recognized and addressed, they could even be discharged from therapy for lack of improvement when they may have been successful if not for the infection.
Importance of rest and sleep
Adequate rest and sleep are vital to overall health and definitely for success with therapy. After the patient has worked in therapy, consider assisting them to lie down and even nap for 30-60 minutes but then get them back up, straighten their clothes and hair and, if appropriate, bring them to an area where they can have socialization or a comfortable place to watch TV or read. They are getting over some insult to their body anyway and the extra exertion of exercise can be exhausting. Once they know they can rest after their efforts, they may be more inclined to push themselves.
Quality sleep at night is a must! If they are intermittently awakened and not allowed to go through complete sleep cycles, they can actually become sleep-deprived and may become confused and even depressed. Drawing blood for labs and doing bed checks (especially for incontinent persons) should be scheduled as much as possible when they do not disrupt sleep. Using a flashlight instead of turning on the overhead light when possible is a much better option.
Make sure you have physician orders to cover whatever nursing might do to work with these patients. Therapy can decide when it is safe for nursing to transfer and walk with patients — and how far. Therapy should also train nursing on the appropriate way these activities should be done.
These nursing measures need to be on the patients’ overall plan of care and scheduled on their daily task list or they will not be accomplished. Make sure the patient and their family are kept informed.
In order to assist these sometimes frail and fragile patients to their highest potential, we have to train staff to automatically think of all of the holistic needs of their patients and the importance of follow-through with patience, kindness and respect. Care plans and schedules must reflect all needs and potential needs of the patient. Assignment changes must be carried over from shift to shift. Therapy is vital to “get people back on their feet” and as independent as possible, but it is nursing that is the glue that makes true rehabilitation a success.
Karen Bonn founded and incorporated Restorative Medical Inc. (RMI) in January 1992. Today she is the company’s clinical specialist.