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58 Cards in this Set

  • Front
  • Back
Rehabilitation nursing
- The diagnosis and treatment of
Human responses of individuals and groups to actual or potential health problems
relative to altered functional ability and lifestyle
Rehabilitation Goals
• To assist the individual who has a disability and/or chronic illness in restoring, maintaining, and promoting his or her maximal health
Rehabilitation Principles
• Client centered
• Client centered
- Emphasizes the client's unique needs and deemphasizes the medical diagnosis
- Families are an integral part of achieving client-centered care
- The client has the ultimate right to make decisions regarding outcomes
Rehabilitation Principles
• Goal-oriented approach
Rehabilitation Principles (cont.)
• Goal-oriented approach
- Individual goals are mutually agreed upon
- Goals are established to support an increase in
functional ability in physical, social, emotional, and vocational areas
Rehabilitation Principles
• Team approach, including the client
• Multidisciplinary teams may include:
• Team approach, including the client
• Multidisciplinary teams may include:
- Physical therapist; occupational therapist; registered nurse; physician; dietitian; chaplain; orthotist, case manager; audiologist; speech therapist;
recreational therapist; social worker, etc.
Rehabilitation Principles
• Quality of life
Rehabilitation Principles
• Quality of life
- Must be defined in terms of the client
- The rehabilitation plan facilitates the maintenance
or restoration of an acceptable quality of life
- Issues to be considered when discussing quality of life include spiritual, cultural, financial, social, emotional, and well as physical
Rehabilitation Principles
• Coping with change
Rehabilitation Principles
• Coping with change
- Identify factors that influence coping
- Support client and families in coping
- Assess for denial, grieving, uncertainty,
hopelessness, hopefulness, and adaptation in response to changes
Rehabilitation Principles
• Client and family education
Rehabilitation Principles
• Client and family education
- Pivotal concept for successful rehabilitation
- Collaborative effort of all team members
- Requires assessment of unique learning needs
- Requires teaching involving unique strategies
Rehabilitation Process
Rehabilitation Process
• Multidisciplinary team assessment
• Team conference held to set goals
• Multidisciplinary plan is established
• Implementation of rehabilitation plan
• Ongoing evaluation
World Health Organization (WHO) Framework
• WHO international classification of functioning, disability and health
- Describes the relationship among body functions and structures, activities and participation, environmental factors, and personal factors
WHO Classification System
Comprehensive assessment
- Determines impairments that may occur as a result of changes to body function or structure
- When impairments lead to a decline in ability to participate and engage in activities, rehabilitation services are needed - Determines the impact that a health condition or disease may have on an individual
Rehabilitation Settings
• Wide variety of settings - Outpatient services
- Home setting
- Day treatment program
- Inpatient setting
- Subacute program
- Long-term care setting
Medicare Requirements of Rehabilitation Units
• Patients discharged must have one of the following discharge diagnoses:
- Stroke; spinal cord injury; brain injury
- Congenital deformity; amputation
- Multiple major trauma; hip fracture
- Polyarthritis; burns
- Neurologic disorders (e.g., Parkinson's; multiple
sclerosis; muscular dystrophy)
• To be eligible for rehabilitation patients must: - Be able to participate in at least 3 hours of primary therapy daily
- Require at least two therapeutic modalities in addition to nursing and medicine
Home Health Nursing
• Home health nursing care
Home Health Nursing
• Home health nursing care
- Skilled services needed to treat an individual's disease and disability in collaboration with their families and designated caregivers
Home Health Nursing
Trends
Trends
• Explosive growth related to: - Medicare reimbursement
- Aging population
- Consumer demand
- Escalating health care costs
- Managed care
What home healthcare nurses like about their jobs
Autonomy and independence

Relationship with peers

Relationship with organization

Relationship with patients

Salary and benefits

Professional pride

Relationship with physician
Competencies HHC Nurses need to Develop
Competencies HHC Nurses need to Develop

Assessment skills

Technical skills

Critical Thinking Skills

Documentation Skills

Computer skills

Client Teaching/Communication Skills
Home Health Care
• Home care client projections
Home Health Care
• Home care client projections
- 35 million people age 65 and older
- People age 65 and older spend
one third of health care dollars
- 60% of older adults take medications improperly
- 4 million people older than 85 years of age
Home Health Care
Perspectives
Perspectives
• 1877: Francis Root was the first visiting nurse in New York
• 1893: Lillian Wald and Mary Brewster established the Henry Street Settlement
• Today
- 600,000 community health nurses
- Standards exist for agencies and nurses
- Multidisciplinary collaboration is essential
Home Health Care
Philosophy
Philosophy
• The client is the individual and family
• The client is "in charge" and has power
• The health care team includes family
• Respect for cultural, spiritual, and ethnic differences is vital
• Nurses are guests in the home
• The client "owns" the health-related problem
What home healthcare nurses like about their jobs
What home healthcare nurses like about their jobs
• Autonomy and independence
• Relationship with patients
• Relationship with peers
• Relationship with organization
• Salary and benefits
• Professional pride
• Relationship with physician
Competencies HHC Nurses Need to Develop
Competencies HHC Nurses Need to Develop
• Assessment Skills
• Technical Skills
• Critical Thinking Skills
• Documentation Skills
• Computer Skills
• Client Teaching/Communication Skills
OASIS (Outcome and Assessment Information Set Requirements)
OASIS (Outcome and Assessment Information Set Requirements)
OASIS is a group of data items developed, tested, and refined over the past decade.
The OASIS items were designed for the purpose of enabling the rigorous and systematic measurement of patient home health care outcomes, with appropriate adjustment for pt risk factors affecting these outcomes.
Home health care challenges
Home health care challenges
Increased complexity of clients
Increase in number of clients
Demand for economical service
Declining reimbursement rates
Declining staff availability
Increasing regulatory demands
What home healthcare nurses like least about their jobs
What home healthcare nurses like least about their jobs
Stress: Poor benefits: poor salary not commensurate with education, experience, specialty, lack of fairness and comparability
Constant change
Car maintenance/wear and tear
Lack of control/authority/role in decision-making
Not respected/valued.
Home Health Care and the Nurse
Home Health Care and the Nurse
• Recognize risks - Be prepared
- Always consider safety
• Use available resources
• Become educated and knowledgeable
• Utilize your life experiences
• Use common sense
Hospice and Palliative Care
Terms
Terms
• Hospice care
• Palliative care
- Root word in Latin is Palliare meaning to cloak or shield
- Emphasis on symptom management with no effort to prolong or hasten death
• End-of-life care
Palliative Care
Disease trajectory
• Disease trajectory
- Identified from the onset of a life-limited diagnosis until death
Palliative Care
• Quality of life
Palliative Care
• Quality of life
- Socioeconomic status
- Physical health
- Relationships with friends and family
- Satisfaction with self
Symptoms at the End of Life
Symptoms at the End of Life
• Pain
• Dyspnea
• Lethargy, generalized weakness, and fatigue
• Dry mouth
• Anorexia
• Depression
• Insomnia
Imminent Death: Objective Indicators
Imminent Death: Objective Indicators
Cognition/orientation
- Not always nonresponsive, may be agitated or restless, cannot subjectively respond to verbal stimuli
Cardiovascular
- Tachycardia, irregular heart rate, lowered blood pressure or significant widening between systolic and diastolic pressures, dehydration
Pulmonary
- Tachypnea, dyspnea" use of accessory muscles, acetone breath, Cheyne-Stokes breathing, pooling of secretions or noisy respirations
• Gastrointestinal
- Diminished appetite, smaller amounts of feces (despite not eating), incontinence
• Renal
- Diminished urine output, incontinence, concentrated urine
• Mobility
- Limited mobility, bed bound, and requires frequent position changes
Imminent Death:
Food and Water
Food and Water
Give food and fluids by mouth by request
Provide ice chips or small sips to relieve dryness
Use an artificial saliva or oral moisturizer
Good/frequent oral care
Soothe dry, chapped lips
End-of-Iife is a Memory Maker
End-of-Iife is a Memory Maker
• These are the last precious moments families/friends have with their loved ones and the care you give can affect these moments
Families
• Accept them where they are
• Care for the patient and the family
Issues Important to Patients
Issues Important to Patients
• Maintain one's dignity
• Being kept clean
• Be free of pain
• Be free of SOA
• Be free of anxiety
• Have physical touch
• Presence of family
• Not die alone

Educate Families/friends
• Education eases the fear of the unknown.
Knowledge is power.
Language with Unintended Consequences
Language with Unintended Consequences
• There's nothing more we can do.
• Do you want everything possible?
• Do you want to stop treatment?
• Do you want to stop aggressive therapy?
• We want to make it so he won't suffer.
Language that Works
Language that Works
• What is most important in your life right now?
• As you think about the future, what is most important to you?
• What are you hoping for?
• What is it that you hope I can do for you?
Empathy
Empathy
• Verbal communication
• Nonverbal communication
• Paying attention and being present to the patient's experience.
Communication Issues
Communication Issues
• Nursing role
- Establish trust
- Be available
- Be nonjudgmental and nonthreatening
- Listen and advocate
- Empower
• Support the caregivers
Support of the Grieving Family: Tasks of Mourning
Support of the Grieving Family: Tasks of Mourning
• Accepting the reality of the loss
• Experiencing the pain of the loss
• Adjusting to the environment in which the deceased is missing
• Finding a way to remember the deceased while moving forward with life
Complicated Grieving and the Role of the Nurse
Complicated Grieving and the Role of the Nurse
• Chronic grief
• Delayed grief
• Exaggerated grief
• Masked grief
End-of-Life Symptom Management:
Pain
• Pharmacologic management
End-of-Life Symptom Management:
Pain
• Pharmacologic management - Opioid and adjuvant analgesics
- Analgesic dosing
- Analgesic rescue dosing
End-of-Life Symptom Management:
Delirium
End-of-Life Symptom Management:
Delirium
• Etiology and assessment
• Pharmacologic management
• Nonpharmacologic management - Hydration
- Oxygenation
End-of-Life Symptom Management:
Fatigue/Weakness
End-of-Life Symptom Management:
Fatigue/Weakness
• Etiology and assessment
• Pharmacologic management
• Nonpharmacologic management
- Modify exercise, activity, and rest patterns
- Self-care activity assistance
End-of-Life Symptom Management:
Dyspnea
End-of-Life Symptom Management:
Dyspnea
• Assessment
• Pharmacologic management
- Opioids, anti-anxiety agents, bronchodilators, corticosteroids
• Nonpharmacologic management - Oxygen therapy
End-of-Life Symptom Management: Depression
End-of-Life Symptom Management:
Depression Etiology and assessment
• Pharmacologic management
• Nonpharmacologic management - Psychotherapy
- Cognitive-behavioral techniques
End-of-Life Symptom Management:
Sleep Disturbances
End-of-Life Symptom Management:
Sleep Disturbances
• Etiology and assessment
• Pharmacologic management
• Nonpharmacologic management - Avoid stimulants and interruptions
- Establish a regular sleep schedule
- Keep mentally and physically active
End-of Life symptom Management
Cachexia-Anorexia Syndrome
Etiology and assessment
Pharmacological management
progestational agents, corticosteroids, cannabinoids, Central Nervous system stimulants, prokinetic agents

Nonpharmacologic strategies
Dietary supplements
Describe hospice care and palliative care
Describe hospice care and palliative care
These terms are sometimes used interchangeably.
Palliative care should be considered early in the course of advanced illness rather than restricted to the end of life.
Hospice care was initiated on the basis of a quality-oriented alternative to the traditional biomedical model of health care with the intent to ensure that clients and their families could have appropriate care at the end of life.
Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problem, physical, psychosocial, and spiritual.
Kubler-Ross’s Stages of Dying
Kubler-Ross’s Stages of Dying

Denial
Anger
Bargaining
Depression
Acceptance
What is the Palliative care philosophy?
What is the Palliative care philosophy?
• Palliative care provides support and care for persons facing life-limited illness across all care settings.
• Palliative care identifies death as normal and natural
• The dying process is profoundly individualized and occurs within the dynamics of family.
• Palliative care enhances the quality of life and integrates the physical, psychological, social, and spiritual aspects of care.
• The interdisciplinary team addresses the multidimensional needs of the dying clients and his or her family.
• Palliative interventions affirm life and neither hasten nor postpone death.
• Appropriate palliative care and a supportive environment promote quality of life and health closure for the client and family.
What actions are included in a comprehensive assessment, which helps determine the disease trajectory.
What actions are included in a comprehensive assessment, which helps determine the disease trajectory.
1. Defining the nature of the clinical finding and symptoms
2. Performing a thorough history and physical examination, reviewing current and tried medications, and evaluating a minimal set of diagnostic procedures to differentiate underlying pathophysiologic disorders from a reversible symptom
3. Evaluating the problem within the context of the clients situation and allowing for prioritization. For example, the priority assigned a urinary tract infection (UTI) in a cognitively impaired, dehydrated, and bedridden client will be different from that given to a UTI in a cognitively intact client with good symptom control.
4. Defining the "cost" of diagnostic and therapeutic interventions and the varying differences between clients-for example, what may be considered appropriate therapy for one client may be inappropriate for another-when evaluating the risk versus benefit of treatment and the financial burden of unnecessary interventions.
5. Discussing the various care options with the client and the family and encouraging informed decision making.
What determines quality of life
What determines quality of life

1) socioeconomic status,
(2) physical health,
(3) relationships with friends and family, and
(4) satisfaction with self.
What are some of the most distressing symptoms at the end of life?
What are some of the most distressing symptoms at the end of life?

1. Pain
2. dyspnea
3. asthenia (lethargy, generalized weakness, and fatigue)
4. dry mouth
5. anorexia
6. depression
7. insomnia
Name some mu agonists that relieve pain
Name some mu agonists that relieve pain

Morphine (MS Contin)
Hydromorphone (dilaudid)
Fentanyl (duragesic)
Oxycodone (oxycontin)
Name some behavioral indicators of pain in the nonresponsive client
Name some behavioral indicators of pain in the nonresponsive client Restlessness: Agitation, frequent moving, an inability to get comfortable, fidgety, picking at things.
Vocalizations: Moaning, groaning, crying out
Muscle tension: Tense muscles, not relaxed, clenched teeth, tightened fists, guarded movements.
Facial expression: Frowning, grimacing, distressed
Physiologic indicators: Fast heart rate, frequent and labored breathing, sweating.
Adjuvant Analgesics-Name adjuvant meds and how do they alleviate pain
Adjuvant Analgesics-Name adjuvant meds and how do they alleviate pain
NSAIDS-can be helpful when the inflammatory process is involved and is initiating the pain impulse, such as in bone or soft-tissue damage.
Examples: Ibuprofen, Naproxen, Indomethacin

Tricyclic antidepressants and anticonvulsants
can be effective analgesics in the management of pain syndromes that have a neurologic component, TCAs appear to be most helpful for pain described as burning or aching;

anticonvulsants are useful in the treatment of shooting and shock-like neurologic pains.
The effective analgesic dose of a TCA is much lower
than the dose required for an antidepressant effect.
TCA examples: Amitriptyline, Doxepin
Anticonvulant examples: Carbamazepine, Phenytoin, Valproic Acid, Gabapentin.

Clients who report "colicky" pain may be experiencing the discomfort of smooth-muscle spasm. Cramping or grabbing pains (intermittent) This type of pain is best treated with an anticholinergic medication.
Examples: scopolamine, hyoscyamine, oxybutynin, dicyclomine

Benzodiazepine medications are frequently used for anxiety in the palliative care setting. Examples: Lorazepam, Diazepam
Haloperidol, a butyrophenones, may also be used
What disease processes are commonly associated with dyspnea?
What disease processes are commonly associated with dyspnea?
1. acute and chronic pulmonary disorders
2. heart failure
3. neuromuscular disorders
What medications are used to treat dyspnea
What medications are used to treat dyspnea
Opioids
Antianxiety agents
Bronchodilators
Corticosteroids
Oxygen Therapy