Rehabilitation and Restorative Care


Objectives:

At the end of this class, you will be able to:

  1. Describe restorative and rehabilitation care.
  2. Discuss physical therapy, occupational therapy and speech therapy.
  3. List some of the devices used in this kind of care.
  4. Incorporate rehabilitation and restorative care into one’s role.


Introduction

When a patient or resident gets restorative and rehabilitation care they most often get physical therapy, occupational therapy, and/or speech therapy. This care helps a patient or resident:

  • to get back, or restore, their lost abilities, or
  • to keep their abilities at the level that they are and to prevent further loss of ability.

This special care is planned by a group of people including doctors, physical therapists, occupational therapists, speech therapists, nurses and other people. It helps patients and residents to be independent as possible and to be able to get around. It helps them to leave the hospital and return to their home or another healthcare place in a shorter period of time. It increases the quality of life for many people and it also prevents problems such as contractures and decubiti, or bedsores.

Who Gets This Kind of Health Care?

People of all ages get this kind of care. Young children and infants may get this care when they are born with a deformity such as one that affects their legs or hip.

Older children, teens and young adults may get this care when they have broken a limb, such as an arm or a leg. They may also need help with a speech problem.

Older children, adolescents and young adults often get this care if they get injured doing a sport like football or snow skiing.

They may hurt a part of their leg or knee and need an operation and follow up rehabilitation after an operation, for example.

Adults also receive this care when they have had a serious accident, operation or disorder. For example, a 45-year-old woman who has had heart surgery may need physical therapy to increase her strength and endurance so that she can return home or to a cardiac rehabilitation program near her home.


Older adults, on the other hand, are in the age group that most often gets restorative and rehabilitation care. This care is very often used for older patients and residents who have had a stroke, a hip fracture, a cardiac disorder, a limb amputation or who have been on a bed rest for a long time. Some of these patients may have had a serious illness or a major surgery, such as heart or chest surgery.



Many people, including older people, can often be helped with this kind of health care even when the person is weak or confused. It may be more difficult and time consuming to give restorative and rehabilitation care to these patients and residents, but it can be done when we all work together and stick to the plan of care.

Nursing assistants play a very important role in this care. They play a part in the care whenever the person is not with a physical therapist, occupational therapist or a speech therapist. This care must be followed up and practiced in the person’s room throughout the course of the day by the nursing assistant and nurses.

What Are the Goals of This Care?


A doctor writes an order for this treatment and care. After this, the physical therapist, occupational therapist and/or speech therapist see the patient or resident so that they can:

  • · think about and find the best way to go about the care that the doctor has ordered and
  • · decide on the goals of the care for the patient or resident.

Older adults and younger people often have different goals of treatment.

For example, the goal of care for the older person may be to help the person to be able to do one or more of the basic activities of daily living, such as walking with a cane or a walker. Other goals of treatment for the older person can include such things like being able to:

  • · Eat on their own using special plates and utensils if needed,
  • · Get in and out of the bath tub or shower using a special shower chair and grab rails if needed,
  • · Climb up stairs safely,
  • · Grip items with a hand that has been weaken by a stroke,
  • · Have increased strength and endurance after heart surgery or another serious operation or illness,
  • · Cook meals using special cooking utensils if needed,
  • · Communicate with others with the spoken word or using a special word board if needed after the person has had a stroke

Younger patients usually have different kinds of treatment goals because their physical problems are quite different from those of the older person. Restorative and rehabilitative care for the younger person most often aims to restore the person to full, normal function after an accident or injury.

Some of the goals for the younger person may be to help the person to:


  • · Return to work and school being able to perform their usual routines and activities of daily living,
  • · Have full mobility of a fractured joint, such as a knee, after surgery or a cast,
  • · Regain body strength after a period of illness and/or hospitalization

Patients and residents work with the healthcare team to decide on their goals. They must be encouraged to reach these goals on a daily basis. Progress, or lack of progress, toward these goals is documented on a flow sheet, progress note or another tool, as required at your place of work.

Where is This Care Given?


Restorative and rehabilitation care can be given to the patient in the hospital, in the nursing home, in an assisted living home, in a rehabilitation hospital, in an outpatient community rehabilitation center and in the person’s own home or apartment.

The choice of location is usually based on the patient or resident, their needs and the availability of choices in the area where the person lives. For example, an elderly person who has been in the hospital for a long period of time may be sent to an inpatient rehabilitation center for care after they have left the hospital or they may go to their own home with the help of family members and home care services. A nursing home resident who has had a stroke may stay in the nursing home for treatment and care. A young person may go to an outpatient rehabilitation near their home or workplace after a knee surgery.

Who Gives This Care?


Most rehabilitative and restorative care is provided by physical therapists, occupational therapists and speech therapists. Some hospitals, nursing homes and rehabilitation centers also have physical therapy assistants, occupational therapy assistants, and restorative and rehabilitation aides who help with this care. These people are given special training and education so that they are able to help the physical therapist, occupational therapist and speech therapist in reaching the goals of care.

The Role of Physical Therapy

Most patients and residents who get restorative and rehabilitation care need at least some physical therapy.

Physical therapists provide:

  • · Range of motion exercise,
  • · Muscle strengthening,
  • · General conditioning exercises,
  • · Coordination exercise,
  • · Transfer training,
  • · Ambulation assistance,

Range of Motion Exercise


Physical therapy provides range of motion exercise to increase the patient’s or resident’s ability to move their joints fully after a long period of bed rest, or immobility, and after the person has a disorder that affects range of motion. Pain and the lack of functional ability occur when a joint does not have normal range of motion.

After a stoke, a patient or resident may get physical therapy to restore some motion to weak or paralyzed extremities, such as the right arm. A young person may need range of motion exercises after a leg cast has been removed because the knee may be stiff or weak and the muscles of the leg may have shortened and are not flexible enough to bend the knee in the correct way.

There are three (3) kinds of range of motion exercise. They are:

  • · Active Range of Motion. Active range of motion is used when the patient or resident is able to do full range of motion to one or more parts of their body without the physical help of another. Nursing assistants and other members of the healthcare team may simply have to remind the person to do these exercises and to watch the person to make sure that they are doing these exercises in the right way.
  • · Active Assistive Range of Motion. Active, assistive range of motion is used when a patient or resident needs some help doing full range of motion to one or more parts of the body because their muscles are too weak or stiff to do these exercises on their own. For example, a person that is physically weak or cannot move a weak limb after a stroke needs active assistive range of motion. The nursing assistant and other members of the team will have to help this person with their range of motion.
  • · Passive Range of Motion. Passive range of motion is used for patients and residents who cannot move one or more parts of their body at all. For example, a patient that is in a coma needs passive range of motion to all joints. The nursing assistant and other members of the team will have to do full range of motion for the person without any help from the patient or resident.


At times weights are used with active range of motion and active assistive range of motion.

Active assistive and passive range of motion exercises are done in a gentle, slow way so you do not hurt or harm the joints and bones. If the person gets pain, stop. These exercises are NOT done to the point of pain. They should also NOT be done to an area that has an untreated fracture.

Muscle Strengthening


Muscle strengthening exercises are used for patients and residents of all ages.

For the older person, the goal of these exercises may be to get the person strong enough to perform some basic activities of daily living, such as combing one’s hair.

For the younger person, the goal of these exercises may be to restore weak muscles to their full strength. For example, a baseball pitcher may need muscle strengthening exercises after they have had an injury to their arm so that they can return to the game. Muscle strengthening exercises are sometimes done with weights.

General Conditioning Exercises

General conditioning exercises are most often used after a long period of bed rest and immobility in order to:

  • · increase the function of the heart and lungs,
  • · to maintain range of motion and
  • · to increase muscle strength.

Nursing assistants and other members of the team often help and/or remind the patient or resident to perform these exercises.

Coordination Exercises


Coordination exercises are mostly used for patients and residents that need help to use their hands properly or to walk with good balance and gait.

For example, a person that has had a stroke may need these exercises in order for them to be able to pick up a spoon and place it in their mouth. Or, they may need coordination exercises to be able to walk in a balanced and safe manner after a stroke.

Transfer Training

Many people get physical therapy in order for them to be able to transfer safely from the bed to the chair, from the bed or chair to the commode or from a sitting to a standing position. When a person is not able to do these transfers they must depend on others for help.


The goal of this transfer training is to help the person move about in a safe way without the help of others. Many people who have had a stroke or a bone fracture need transfer training.

Some people can bear weight on both legs. Others can not. When a person is not able to bear full and strong weight on both legs, they may need a cane, a walker, a chair with a high seat and/or a self lifting chair for some transfers.

Ambulation Exercises


Ambulation exercises are a frequent form of therapy for many patients and residents. A young person may need this form of exercise after they have had surgery. An older person may need this form of exercise after a long illness and bed rest.

The purpose of these exercises is to help the patient or resident to walk safely without the help of another person. Some are expected to use some sort of device, such as a cane, crutches or a walker. The goal of this therapy for the older person may be to take short and safe steps to the bathroom or around their own home. The goal of this therapy for a younger person may be to walk the same way they did before they had their illness, accident or surgery.


It is often necessary for the patient or resident to have range of motion, balance, and muscle strengthening and/or coordination exercises before ambulation exercises can be started. At times a splint or brace may also be needed. Many people also practice with parallel bars, like the ones above, and/or a gait or ambulation belt.


Once the person is able to walk safely on a flat and level surface, they may then practice how to walk up and down stairs using a handrail. When a person walks up the stairs they should put their good leg up on the stair and then bring up the weak one.

Some of the treatments that physical therapist use are:

  • · Heat therapy,
  • · Cold therapy,
  • · Water therapy,
  • · Electrical nerve therapy,
  • · Traction
  • · Massage therapy,

Heat Therapy


Heat performs several roles. Heat:

  • · Increases the flow of blood to a body part,
  • · Helps joint stiffness and pain,
  • · Decreases spasms of the muscles, and
  • · Halts swelling and inflammation.

Heat therapy is often used for short term and chronic problems such as arthritis, strains, sprains, spasms and neurological problems.

Heat can be given in one of two (2) ways:

  • · Superficial
  • · Deep

Superficial heat is given by using a heating pad, hot pack, a wax bath to a limb, like a hand, a warm water bath or whirlpool and with infrared heat using a lamp. Hot packs are used very often for heat therapy. When you apply a hot pack it must be wrapped in towels to protect the skin from a burn.

Deep heat is given with ultrasound and diathermy. There are two (2) kinds of diathermy, short wave and microwave. Short wave diathermy is used to relieve pain, decrease inflammation. Both forms of diathermy are NOT used for patients and residents that have a prosthesis that cannot be removed such as a heart pacemaker, and metal implants like metal rods, plates and screws. Heating rods, plates and screws can cause serious burning. Pacemakers can be damaged or completely destroyed with this kind of heat. Microwave diathermy is deeper than the short wave form. It also causes less skin damage and discomfort than the short wave form of diathermy.


Ultrasound is done with sound waves. These sound waves go deep into the body’s tissues and it produces heat. This form of therapy is used when the patient or resident has:

  • · Poor range of motion caused by shortened muscles,
  • · A disorder like bursitis and tendonitis, and
  • · Back pain.

Ultrasound is NOT used on areas that have dead tissue, such as a pressure ulcer, a malignancy or an area that is infected. It is also NOT used on eyes, ears, spinal cord heart, brain or broken bones.

All heat must be given very carefully. Heat can burn the skin of the person, especially when the patient or resident does not feel heat because of poor nerve sensation and when they are not mentally able to tell a person that they feel burning.

Cold Therapy

Sometimes cold is used right after an injury occurs. For example, the doctor may order cold for 48 or 72 hours after a person strains or sprains their ankle.

Cold performs the following roles. It:

  • · Decreases blood flow to the area and
  • · Halts swelling just after an injury has occurred.

Cold must also be given with care. It, too, can cause tissue damage (frost bite) and a lowered body temperature. Cold may be applied locally using an ice bag, a cold pack, or some fluids like ethyl chloride. Cold is NOT placed over areas of the body that do NOT have a good blood supply.

Water Therapy


Water therapy, also called hydrotherapy, uses moving water to:

  • · apply heat to an area,
  • · help wound healing,
  • · relieve pain and to
  • · relax muscles.

This therapy is often used along with range of motion exercises so that the muscles are relaxed and the patient can be free of pain while going through range of motion.

Some water therapy is given using a Hubbard tank that is a very large whirlpool bath. The water is usually heated to from 96° to 104° F. Some patients and residents may feel weak and tired after water therapy so safety must be maintained. At times the person’s blood pressure may drop while in the whirlpool

Electrical Nerve Stimulation


Muscles do NOT work in the correct way when nerves that contract muscles get damaged. Electrical nerve stimulation, using small electrodes, contracts these muscles to keep them from going into a spasm, something that often happens when a person has hemiplegia as the result of a stroke or another disorder. It also prevents muscles from shrinking, or atrophy, when they are not being used for one reason or another.

Some patients are given transcutaneous electrical nerve stimulation (TENS) by the physical therapist, according to the doctor’s orders. This small machine can even be used by the patient in their own home after they, or a family member, is taught about how to use it. They are often used for back pain, arthritis, sprains and other disorders. TENS is usually not used if the person has a heart pacemaker or very severe cardiac disease because it may lead to an irregular heart beat.

Traction

Traction is the use of a weight and pulley system to decrease muscle spasm and to keep bones in proper alignment so they can heal. Traction can be used for spine problems, neck disorders, and lower back problems. Traction can be used in all settings, including the home. Some traction is used on a continuous basis and other traction is used just for short periods of time.

For example, a person with a fractured hip may need continuous traction before surgery is done to repair it. People with a neck injury, on the other hand, may use traction two or three times a day in their own home.

Massage


Massage is also done by physical therapists. Massage helps to reduce pain and swelling. It is used for patients and residents that have a fracture, sprain, strain or nerve injury. Many people with low back pain, arthritis, bursitis, neuritis, hemiplegia, paraplegia, multiple sclerosis, and cerebral palsy are helped with massage.

The Role of Occupational Therapy



Occupational therapists, like physical therapists, are part of the rehabilitation and restorative care team. A patient’s or resident’s doctor writes an order for occupational therapy when the person can be helped in terms of their functioning, particularly in terms of performing the activities of daily living.

Some of the activities of daily living that the occupational therapist helps the person do are:

  • · Dressing
  • · Grooming
  • · Mouth care
  • · Bathing and/or showering
  • · Feeding self
  • · Cooking meals
  • · Getting around and caring for the home



Some people need special assistive devices to do the activities of daily living. For example, a person may need special gripping devices to pick items up off the floor. Others may need special forks and eating utensils to better pick up food from their plate. Some may need special plates with high sides to hold food on the plate when a person has trouble with a spoon or a fork. Still others may need to have their clothing made with larger buttons or Velcro strips when they cannot dress using small buttons and zippers on their clothes.

Occupational therapists teach residents, patients and their family members how to use these special assistive devices so the person can be as independent as possible with the activities of daily living.

Nursing assistants should help their patients and residents with their activities of daily living, as planned by the occupational therapist and other members of the rehab team. For example, nursing assistants should help their patients and residents with dressing, brushing their teeth and using any special devices that they have.

The Role of Speech Therapy

Speech therapists help their patients with communication. They also help patients with a swallowing disorder, something that often happens after a stroke.

These therapists also use assistive devices. For example, they may use a word board so that a patient who cannot speak can communicate their needs to others.



Doctors write orders for speech therapy when the person is not able to talk with and communicate with others. Many older people who have had a stroke get speech therapy so that they can speak after their speech center has been damaged by the stroke. This lack of speech is often very upsetting to the person. Some of these patients or residents are not even able to make their own basic needs known to those that care for them. For example, a patient or resident knows that they are hungry or have to use the bathroom but they are not able to say it.

Nursing assistants should encourage the patient or resident to speak whenever this is possible. When the person cannot speak, the nursing assistant and other team members should give the patient or resident the communication tool that they have been given by the speech therapist. For example, if a person has a word board, encourage them to use it.


Some of the Devices Used for Restorative and Rehabilitation Care

Splints

Splints are specially made items for a patient or resident to prevent a deformity, such as a contracture and to promote function. Some examples of splints are hand splints, a wrist splint and a foot drop splint.

Self-help Devices

Self-help devices help the patient or resident to be able to function in a safe way and independent way even though they have a disorder or a physical problem.


Some examples of self-help devices are:

  • · walkers,
  • · canes,
  • · shower chairs,
  • · grab bars on the side and the back of the bathtub or toilet,
  • · graspers or reachers to lift items up from the floor,
  • · special eating utensils with built-up handles to help the person feed themselves,
  • · special combs and brushes so that the person can groom themself,
  • · shoehorns to help a person get dressed even though they do not have full range of motion,
  • · raised sitting chairs, raised toilet seats, and chair leg extenders help people safely transfer without the help of another person and
  • · cups with lids and special plates with deep centers and weight helps people eat their meal without spills.


When a person is not able to see, large print and audio taped books and large calendars can be used. Large clocks and large telephone dials also help.


A flashing light instead of a telephone ring helps people that are able to see but not hear. Some people with limited hearing can also sometimes be helped when the loudness of the telephone ring is moved to its highest level.

Summary

Rehabilitation and restorative care play a very important part of healthcare. People of all ages get this special care in the hospital, nursing home, assisted living home, rehabilitation hospital, an outpatient center and in the person’s own home.

Physical therapists, occupational therapists and speech therapists provide a lot of this care, according to the patient’s or resident’s doctor’s order.

Nursing assistants, patient care technicians, physical therapy assistants, occupational therapy assistants, restorative and rehabilitation aides, nurses and other members of the healthcare team support the work of the physical therapist, occupational therapist and speech therapist by following the plan of care and working with the person in the nursing care unit so that they can meet their restorative and rehabilitation goals.

References

Berman, Audrey, Shirlee Snyder, Barbara Kozier and Glenora Erb. (2010). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice. 8th Edition. Pearson Prentice Hall.

Merck & Co. (2010). The Merck Manual of Medical Information- Home Edition. “Stroke”. [online]. http://www.merck.com/mmhe/sec06/ch086/ch086a.html?qt=stroke&alt=sh

Merck & Co. (2010). The Merck Manual of Medical Information- Home Edition. “Rehabilition”. [online]. http://www.merck.com/mmhe/sec01/ch007/ch007a.html?qt=rehabilitation&alt=sh

Monahan, Frances Donovan and Wilma J. Phipps (2007). Phipps’ Medical-Surgical Nursing: Health and Illness Perspectives. 8th Edition. Elsevier Mosby.

Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.

Wold, Gloria Hoffmann. (2008). Basic Geriatric Nursing. Elsevier Mosby.

 

Copyright © 2010 Alene Burke


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