REHABILITATION

Neurorehabilitation
● INTRODUCTION
Rehabilitation is defined as “a set of interventions designed to optimize functioning
and reduce disability in individuals with health conditions in interaction with their
environment”. Put simply, rehabilitation helps a child, adult or older person to be as
independent as possible in everyday activities and enables participation in education,
work, recreation and meaningful life roles such as taking care of family. It does so by
working with the person and their family to address underlying health conditions and
their symptoms, modifying their environment to better suit their needs, using assistive
products, educating to strengthen self-management, and adapting tasks so that they
can be performed more safely .

●DEFINITION
Rehabilitation is the process of maximizing the patients capabilities and resources to
promote optimal functioning related to physical, mental, and social well-being.
● Goals of Stroke Rehabilitation

• To lessen physical and cognitive impairments

• To increase functional independence

• To lessen the burden of care provided by significant other

• To reintegrate the patient into family and community

• To restore the patient’s health related to quality of life

• To prevent complications

• To achieve maximal self-sufficiency

• To modify social and vocational environment

● INDICATIONS
• Patients with the following conditions:

• Hemiplegia resulting in spasticity and aphasias

• Neurological fatigue syndrome

• Lacunar stroke

• Pure sensory stroke

● NURSING PROCESS

ASSESMENT
A baseline comprehensive assessment is performed on admission. Assess the
following:

• Rehabilitation potential of the patient

• Physical status of all body systems.

• Presence of complications caused by stroke or other chronic conditions.

• Cognitive status of the individual.

• Family resources and support.

• Expectations of the patient and family regarding rehabilitation. Various tools can be
used as follows:

• Functional Independence Measure (FIM) scale .

• It is used to examine the degree of dependence in performing 23 items in various

activities such as mobility, locomotion, and communication.

• The items include 13 motor and 5 cognitive measures.

• A 7-point scale is used to estimate the severity of disability and need for assistance.

• An FIM score of 18 points represents the need for total assistance compared with
(126 points representing complete independence

• Barthes Index

• To evaluate the level of independence in ADLs)

• The National Institutes of Health Stroke Scales (NIHSS)

■The NIHSS is a 15-item neurological examination stroke scale used to evaluate the
impact of acute cerebral infarction on the levels of consciousness, language, neglect,
visual field loss, extra ocular movement, motor strength, ataxia, dysarthria, and
sensory loss.

■ A trained observer rates the patient’s ability to answer questions and perform
activities.

■ Ratings for each item are scored with 3-5 grades with 0 as normal

● NURSING DIAGNOSIS
• Ineffective cerebral tissue perfusion

• Impaired swallowing

• Impaired physical mobility

● EXPECTED OUTCOME
◇ The patient demonstrates:

• Signs of stable or improved cerebral perfusion.

• Effective swallowing without choking, coughing, or aspiration

• Increased muscle strength and ability to move.

• Use of adaptive equipment to increase mobility

● IMPLEMENTATION
◇The components of stroke rehabilitation are as follows.

Nutritional Therapy
• Assist in determining the appropriate daily caloric intake based on weight and
activity level.

• Assess the ability to swallow with dietician; plan the diet type, texture, caloric count,
and fluids to melt the nutritional needs.

• Evaluate the ability for self-feeding and recommend assistive devices to allow
independent eating.

● INTERVENTIONS

• Encourage to use unaffected upper extremity to eat.

• Employ assistive devices such as rocker knives, plate guards, and nonslip pads for
dishes.

• Remove unnecessary items from tray or table to redo spills.

• Provide a no distracting environment to decrease sensory overload.

• Evaluate in terms of maintenance of weight, adequate hydration, and patient

satisfaction.

●BOWEL FUNCTION
This is implemented for problems with bowel control constipation, or incontinence.

Interventions
• Recommend a high-fibre diet and adequate fluid intake.
• Encourage the following:

☆ Fluids: 2500-3000 ml. daily, unless contraindicated

☆ Prune juice daily (120 mL)

☆ Cooked fruits three times a day

☆ Cooked vegetables three times a day

☆ Whole grain cereal or bread three to five times a day

• For incontinence:

■ Place the patient on bedpan or bedside commode or take the patient to bathroom
daily at a regular time to re-establish bowel regularity.

■ Regular practice of using bedpan or bedside commode 30 minutes after breakfast

should be initiated because eating stimulates gastro colic reflex and peristalsis.

■ Adjust time according to individual bowel habits.

■ Sitting on commode or toilet promotes elimination through both gravity and

increased

■ Abdominal pressure.

■ Administer stool softeners or suppositories as ordered to stimulate anorectal reflex.

■ Use bisacodyl suppository when other measures are ineffective.

● Bladder Function
Often the patient may have functional incontinence which is associated with
communication difficulties, mobility problems, and dressing and undressing
difficulties.

INTERVENTIONS
• Assess bladder distension by palpation.

• Offer bedpan/urinal/commode every 2 hours during day time and every 3-4 hours
during night time.
• Focus the patient on the need to urinate voluntarily or when instructed.

• Assist with clothing and mobility.

• Schedule majority of fluid intake between 7 am and 7 pm.

• Encourage usual position for urinating.

• Other short-term interventions include:

◇ Indwelling catheters

◇ Intermittent catheterization.

Sensory-Perceptual Function
For patients with stroke on right side of brain:

• Directions for activities are best given verbally for comprehension.

• Break down the task into simple steps for easy understanding.

• Remove clutters and obstacles; use good lighting.

• Assist or remind to dress the weak or paralyzed side first for patients with
unilateral neglect.

For patients with stroke on left side of brain:

• Use nonverbal cues and instructions for better comprehension.

Coping
• Support communication between the patient and the family.

• Discuss the lifestyle changes resulting from stroke deficits.

• Discuss changing roles and responsibilities within family. Be an active listener to

allow expression of fear, frustration, and anxiety.

• Include the patient and family in short- and long-term goal planning and patient care.

• Support family conferences.

• Encourage family therapy.

• Encourage to join in stroke support groups.

Sexual Function
• Initiate the topic with the patient and spouse with significant others.

• Educate on:

■ Optional positioning

■ Patient and partner counselling.

● Communication
• Provide frequent, meaningful communication.

• Allow time for the patient to comprehend and answer.

• Use simple short sentences.

• Use visual cues.

• Structure conversation to permit simple answers by the patient.

• Praise the patient honestly for improvements with speech.

● Community Integration
• Provide a review of patients’ health, social care, and secondary stroke prevention
needs, typically within 6 weeks of leaving hospital, after 6 months, and then annually
to enable access to further advice, information, and rehabilitation when needed.

• Give written information about the patient’s diagnosis and management plan.

• Train the family/caregivers on the practical aspects of home care for stroke patients.

• Persons with very severe stroke may be given active end of life care by skilled
personnel.

● Evaluation

• Patient (and) caregivers verbalized awareness of home care management of stroke.

• They cope adequately according to the level of disability of the patient.

• They demonstrate satisfactory skills in caring for stroke patients.

SPINAL CORD INJURY REHABILITATION

● DEFINITION
Spinal cord injury rehabilitation is a comprehensive term including a holistic approach
in meeting functional, emotional, medical, vocational, educational, environmental,
and spiritual needs of a patient who had spinal cord injury

● PRINCIPLES OF SPINAL CORD INJURY REHABILITATION

• It uses holistic approach

• It encourages continuity of care and lifetime access to a specialized care

• It facilitates community integration and education regarding spinal cord injury

● INDICATIONS
• Spinal and neurogenic shock

• Central cord syndrome

• Autonomic dysreflexia

• Neurogenic bladder

● CONDRAINDICATIONS

• Conditions which interfere with rehabilitative process

● REHABILITATION POTENTIAL AMONG INJURIES IN SPECIFIC LEVELS OF
SPINAL CORD
◇ C2 or C3: Completely dependent for all care
◇ C4: It needs a ventilator and is dependent for all care

◇ CS: To breathe without a ventilator

◇ C6: To push themselves on wheelchair indoors

◇ C7: To drive a car with special adaptations

◇ T1-T6: To become independent with self-care

◇ T7-T12: To improve sitting balance

◇ L1-L5: To walk short distances with assistive devices

● NURSING PROCESS
• Rehabilitation potential of the patient

• Physical status of all body systems

• Family resources and support

• Personality factors

• Patient and family expectations of treatment.

• Educational background

• Sexual concerns

• Ethnic, culture, and religious factor

• Financial status and resources

• Legal issues

● NURSING DIAGNOSIS
• Impaired gas exchange

• Impaired urinary elimination Risk for autonomic dysreflexia

• Deficit knowledge

● IMPLEMENTATION

• Respiratory Rehabilitation

• Neurogenic bladder

• Neurogenic bowel

• Maintaining skin integrity

• Physical mobility

• Spasticity

• Pain implications

• Sexuality

• Grief and depression

• Driving

• Education

● EVALUATION
• Patient maintained adequate

• Patient reported no episodes of dysreflexia

• Patient demonstrated adequate adaptability to suggested lifestyle modification

changes

● BIBLIOGRAPHY
Manual of Nursing procedures and practices: 2 nd edition; Wolters Kluwer