Rehab Observation From The Nurse Perspective

Rehab Observation

This paper describes the experiences and learning objectives at a recent rehabilitation observation experience. The student nurse observed the roles of the physical therapy, speech therapy, and occupational therapy. The roles were explained as the processes went on, and the integration of the whole care team was observed and explained. An RN interview was conducted to better explain the occupational workload of RN compared to an acute patient setting. The focus on the system of care as a whole, and roles of each individual were all observed.

The role of the therapy team as a whole is to help the patient regain physical strengths to the best of their abilities to live their life with the fullest potentials. The Therapy team consists of occupational, physical, and speech language pathologists. Along with the therapy team the nurses play a big role in the care of these patients as well. Observing all these different aspects in rehabilitation care shows the network style of care that each patient is given. The members of the team communicate well, and each have a special role in the physical rehabilitation, but all combine for a whole concept of care for each patient. Each therapist is educated in specialties for each patient, but their practices will overlap each other’s making rehabilitation forming a very webbed center of care. Spending this time as an observer was very informative, and eye opening. A total of two hours was spent at the rehab inpatient unit at Tuomey Hospital in Sumter, SC. Upon arriving to the unit therapists were helpful in dividing our times the best they could, for the best educational experience for the student nurses.

The first hour of the day was spent with the OT (occupational therapists). The role of the occupational therapist is summarized by the WFOT website as, “Occupational therapy practice is focused on enabling individuals to change aspects of their person, the occupation, the environment, or some combination of these to enhance participation.”(wfot.org). The therapists explained the work she does as helping the patient regain their ability for the occupations of their daily life. Examples of this are the tasks such as brushing teeth, combing hair, and daily oriented tasks such as these. The patient we worked with was working on balance and fine motor movements. The patient stood, and we played connect-four. As he stood and played the game it worked the fine motor movements of the hand to play the game, and balance as the patient stood. The therapist timed the patient and let him rest after certain amount of time was reached. It was interesting how the therapist worked on physical activity such as standing and balance when that seemed more of physical therapy task. When the patient was tired, we changed to a different activity. She used the resistance bands to help him with arm strength and had him count each repetition as well. This was interesting because, not only was she working with physical needs, she also was working on cognitive needs. Asking the patient what day, and season it was, and asking him to keep track of what repetition they were on in the exercise. She explained this helped with his memory, and by working day after day it would help with over all cognition. When his time was up, he retired back to his room, and rested. The frequency of the therapy sessions occurs every day. They rotate between disciplines during the days work.

Physical therapists work can be defined as, “Their job revolves around promoting their patients’ ability to “move, reduce pain, restore function, ,and prevent disability (APTA).””(Peterson, Bryanne). The therapist was working on helping a patient with a hip replacement stand and walk. It was a painful time for this patient, but the therapy had to be done to preserve the hip. This took physical strength of both the therapist and the patient. The therapist utilized the parallel bars to help support the patient and ambulate. To remain safe the therapists utilized a gait belt and explained the importance of safety for himself and the patient by using it to help support the patient when standing and walking. Once tired from standing and walking the therapists worked with the patient to perform range of motion on the hip while the patient was sitting. He utilized the rolling logs to help the patient moved his foot back and forth working muscles surround his hip joint in the leg. He then moved to a skateboard which was interesting to watch. He used the skate board to again work with range of motion of the hip joint without extending over the 90-degree limitation from the waist. Physical therapy work demands a physical aspect of not only the patient, but therapist as well.

The last portion of the therapy was spent with a speech pathologist. “The speech therapist is primarily responsible for the assessment, and intervention of patients with swallowing dysfunctions.”(Mok,Jagadish,Yiap,Yu,Lim,Ker). Along with physical needs of rehabilitation often times patients need the therapists to also help with swallowing, and speech needs. This care is vital to patients needing this type of rehabilitation. The ability to swallow can affect the outcomes of patients tremendously. They need the abilities to eat, drink, and take meds. It is vital to sustain life. Interventions may come into play if the patient is unable to swallow correctly. The treatment from the speech pathologist was interesting as it didn’t go along with a swallow evaluation or swallowing training. The therapist worked with cognition. She showed the patient two different items, (example: umbrella, and cane), and then asked the patient to state two differences and two similarities. Patients suffering from cognitive illnesses would struggle to perform these tasks, but it shows improvement when able to comprehend these questions asked. It was interesting to watch the interaction between the patient and the speech pathologist. A different scenario of treatment was viewed than anticipated but showed how the treatments can once again integrate with each other. The OT worked with cognition as well combing these two therapies. Each therapist also included the role as educator. This is important in a patient’s physical recovery. They all were sure to educate the patient when necessary and stated how important it was to build a rapport with these patients. They expressed how it was different from an acute care setting. They see these patients every day, and the relationship built is crucial to their outcomes.

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The importance of rehab is important for these patients. Along with the therapy there is also skilled nurses who work with these patients whenever they are not with therapy. The nurses play a significant role in the wellness of these patients. When speaking with nurses on this floor about the differences from the rehab setting to an acute care setting they insisted not much was different. They were still nurses who cared for patients passing medications, assessing head to toe, and normal responsibilities within the hospital. The nurse then stated, “We wear many hats on this unit. The responsibility and patient care load can be very demanding. We play the role of physical, emotional, and spiritual support.” (Deela RN) The patient load can vary on this floor. The criteria needing to be met to be on the rehab floor plays a role in their census. The nurse can take anywhere from four patients to ten. Not only does the therapy teams aid in the physical aspects of patient care, but what the patients learn while working with therapy, the nursing staff is to implement as well. The therapists are only on the floor for eight to nine hours working with every patient on a set schedule. The patient is to take what they have learned from their therapy work to apply it to their lives. The nurse plays the responsibility of enforcing that education and helping them to keep on their scheduled activities. The nurse also expressed the emotional toll it can take on a patient. Her role as a nurse can be very psych oriented. To comfort these patients who have gone through some hard diagnosis, and rehab they need the emotional support in recovery which the nurse can also provide to these patients. Nurses can also play a role as a patient cheer leader. Helping to provide that positive feedback for the patient to continue support throughout the process.

The integrated care team of therapists and nurses is imperative for the patient’s outcome. The roles of each individual are each a piece of a building block for patients’ wellness. Each therapist, and nurse are trained to specific skills settings, and workload. They all overlap in a sense that they can all work together for the patient, and each therapy has something the other therapy doesn’t, but has similarities as well. By having each member of the team with a special skill set the patient benefits as a whole. This is the best way to approach a rehabilitation setting. Each team member plays an imperative role that without the job would be much harder for the team, and perhaps not complete. It is important for the patient that care team work together and communicate about patient care.

While interviewing the RN of the floor she discussed the FIM scores of patients. She expressed the importance of having completed a FIM assessment within three days of the patient’s arrival to the unit. “The FIM is a minimum data set measuring 18 self-care items including eating, bathing, grooming, dressing upper body, dressing lower body, toileting, ,bladder management and bowel management.”(Hinkle, Cheever). Assessing these things is important to the patients care. This allows staff to understand where the patient is at in the rehabilitation process, and what still needs work. When the scale is reassessed, the progress should show with the ratings of the patient improving. The nurse explained that the facility also uses this scale for repayment from the hospital. Expressing that the scale should increase and not decrease with patient treatment. The increase in the scale numbers show the patients progress in each ADL that is graded upon assessment. It is the facilities responsibility to make sure that the assessments are done correctly and timely. The ratings of the patients in these categories show what the team needs to focus on in patients care and rehab for the best outcomes of the patients.

The care of the patient in the rehab setting allows for the patient to develope to their individual bests of each physical aspects. It is however not a place that a patient can stay forever. Discharge planning always starts upon admission. Patients discharge planning can present challenges when they do not have the ability to care for themselves. There are several places a patient may be admitted to for a long-term care versus going home to care for themselves. For the higher functioning patient who needs minimal help at home they may be discharged to home with a home health service. Other patients who suffer more deficits may need a more total care facility. Long term care facilities are also known as SNF (skilled nursing facilities) are meant for this long-term care when families or home is not safe or accessible for this patient. There are support groups in the community and online that can help a family member through these hard times. It is difficult when you are caring for your family to place them in a long-term care facility, but sometimes it’s the safest for both the family and the patient. The transfer from inpatient rehab to an outpatient setting no matter where it may be needs to be the safest for the patient.

This experience was very informational. The way that the team works together including the nurses works very well for the patient and the best outcomes. The patients are able to develop a good rapport with the staff and this shows in the therapy sessions. The whole circular motion of the therapy team and how they all work together is really a great system for the patients. The way that the therapy team works for the patients, and educated observers shows the effort and purpose in their care of the patient. One thing to take away from this experience was the way they all work together as a team. No one part of therapy is greater than other in the care teams, and by working together they show the best outcomes in the patients’ responses. As a nurse, the role that is played is very important to the patient. Being able to collaborate with everyone for the best outcome of the patient is another great take away from this observation.

Conclusion

The therapy teams and nursing staff are responsible for the best physical outcomes for the patient. The care provided will shape the outcome of the patient and future care. The care of the Occupational therapists focuses on the occupational skills of everyday living. The physical therapy team members are responsible for the physical strengths and mobility of patients. The speech therapists are there to help with acts such as swallowing and speaking. As a whole the team interacts and works together to help strengthen and support the best outcomes of patients needing rehabilitation. Working as a team is important in the outcomes and discharge planning of the patient and for the family.

References

1. Deela RN. (2019, January 29). [Personal interview by the author]. Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia: Wolters Kluwer.
2. Mok, W. Q., Jagadish, U. M., Yiap, P. L., Yu, L. H., Lim, S. M., & Ker, S. Y. (2017). An interprofessional collaboration between nurses and speech therapists to detect dysphagia early in an elderly hip fracture population. International Journal of Integrated Care (IJIC), 17. https://doi.org/10.5334/ijic.3753
3. Peterson, B. (2018, December). Children's Technology & Engineering. Children's Technology & Engineering, 23(2), 30-31. ezproxy.cctech.edu
4. Statement on Occupational Therapy [Fact sheet]. (2010, August 11). Retrieved from http://wfot.org