Lecture 2-PPT PDF Rehabilitaiton Process

1. THE REHABILITATION PROCESS There are a number of basic tasks associated with the rehabilitation process: To work in partnership with the disabled person and their family To give accurate information and advice about the nature of the disability, natural history, prognosis, etc. To liste...

1. THE REHABILITATION PROCESS There are a number of basic tasks associated with the rehabilitation process: To work in partnership with the disabled person and their family To give accurate information and advice about the nature of the disability, natural history, prognosis, etc. To listen to the needs and perceptions of the disabled person and their family To work with other professional colleagues in an interdisciplinary fashion To liaise as necessary with key carers and advocates To assist with the establishment of realistic rehabilitation goals, which are both appropriate to that person’s disability and their family, social, and employment needs In this chapter we are going to discuss: Identifying the client Rehabilitation contract The rehabilitation process Documentation Discharge planning IDENTIFYING THE CLIENT REHABILITATION CONTRACT - Effective rehabilitation is always based on an implicit contract. - The agreement recognizes a shared aim, based on a shared understanding of the client’s aims and also of what can be achieved within a defined timescale. - Where the client’s (or professionals’) understanding is limited or where expectations are thought to be unrealistic, a signed agreement is helpful. THE REHABILITATION PROCESS 1. Data collection This step involves recognizing and defining patient problems and identifying the resources available for treatment. It includes the gathering of subjective and objective data. The assessment begins with patient referral and continues as an ongoing process throughout the course of rehabilitation. Subjective data: are information from the client’s point of view (symptoms) including feelings, perceptions and concerns obtained through interview. Objective data: are observable and measurable data (signs) obtained through observation, physical examination and laboratory & diagnostic testing. Data Sources Medical record Interview Screening Assessment procedure definitive 2. Data analysis and identification of problem The most critical step Disability must be interpreted in terms of a complex network (the person’s system). Data gathered from the initial assessment must be organized and analyzed. The therapist identifies and prioritize the patient impairment, activity limitations and participation restrictions and develops a problem list using the WHO framework, taking into account considering the person’s system.  Therapeutic decisions must be based on a thorough understanding of pathology, the problem identified, the needs of the patient, and the service available. Impairment and disability must be analyzed to identify causal relationships. The generation of asset list is also an important part at this stage Direct impairments Indirect impairments Activity limitations Participation restrictions R hemiparesis R shoulder subluxation Dep bed mobility: minA RUE  RLE Hypotonicity RUE Decreased ROM R shoulder Dep BADL: modA X 1 IADL: unable Spasticity RLE Dep locomotion: Decreased ability to perform modA x 1 social roles Synergy patterns: Stairs: unable Decreased home and RUE  RLE community mobility Gait deficits Increased fall risk Balance deficits: Kyphosis, forward head Standing  sitting Decreased endurance Mild dysarthria Decreased communication Mild cognitive deficits: Decreased problem-solving Decreased STM Decreased motor planning ability Co-morbidities Diabetic peripheral neuropathy Decreased sensation both Increase risk of skin lesions Increased fall risk feet Small ulcer L foot (5th toe) Contextual factors: physical, social, attitudinal One-level house entry with 2 steps, no handrails Highly motivated Personal factors: individual’s life and living situation Spouse is primary caregiver: has osteoporosis and decreased vision (bilateral cataracts). Has 2 involved sons living within 30-mile radius. Key: BADL: basic activities of daily living; DEP: dependent; IADL: instrumental activities of daily living; mina: minimum assistance; modA: moderate assistance; RLE: right lower extremity; RUE: right upper extremity; STM: short term memory. 3. Rehabilitation aim and goals There is difference between aim and goal Rehabilitation aim is the proposed overall outcome that the client and others believe should be achievable in the long run. Without one overarching aim, therapy may continue indefinitely with no specific outcome and there are likely to be radical differences in purposes and expectations between clients and professionals. For a mildly impaired person, the rehabilitation aim may be highly specific. The goals must be precise. There is no point in setting vague and subjective goals as neither the rehabilitation team nor the disabled person will be able to monitor where they are in the process.  A useful mnemonic to remember what the goals should be is SMART: Specific Measurable (at least in principle) Achievable (i.e., feasible both for the client and for the rehabilitation team, and timely) Relevant to rehabilitation aims Time limited: achievable within a defined period of time 1. individual 2. Behavior/activity Goal statement should include four essential elements 3. Condition 4. Time 4. Creating a rehabilitation plan/plan of care (POC) The plan of care (POC) outlines anticipated patient management. The therapist evaluates and integrates data obtained from the patient/client history, the systems review, and tests and measures within the context of other factors including: the patient’s overall health. Availability of social support system. Living environment Potential discharge destination  There are parameters that increase the complexity of the decision-making process. Improving quality of life (QOL) is important to patient/client Essential components of the POC include: 1) Anticipated goals and expected outcomes; 2) The predicted level of optimal improvement; 3) The specific interventions to be used including type, duration and frequency; and 4) Criteria for discharge. 5. Intervention Return to previous function Maintenance of function Return to wellness might Slowing progression of be considered functional loss Habilitation of function never achieved Striving for excellence in performance  The established plan of care determines the interventions and the method, or clinical road map, toward the achievement of the agreed-on outcome goals. The therapist, in collaboration with the client, can choose from restrictive and nonrestrictive treatment environments and interventions to best achieve identified goals. Involving the client in the goal setting and intervention planning process will lead to the best result These interactions require trust of the therapist as a guide and teacher. There are a conceptual triad used to attain goals and get the desired outcome: 1. The concept of human movement as a range of observable behaviors 2. The complexity of the CNS as a control center 3. The interactions between the client and therapist within closed and open learning environments (Figure 3). Each part of this triad has unique characteristics that have the ability to influence performance and progress in the clinical setting. Together they allow for the client to be viewed as a total human being, allowing the therapist to consider multiple constructs at once so that a client’s responses and movement patterns may all be considered and developed simultaneously. The concept of the Learning Environment There are four distinct components of the learning environment in operation: the internal and external environments of the client, and the internal and external environments of the clinician. All four represent interactive components of the learning environment. Figure 3. clinical learning environment 6. Monitoring progress/re-evaluation Standard documentation encourages a systematic approach to rehabilitation, provides a record of progress and facilitates all forms of audit. There should be an updatable list of problems, a serial record of impairments and disabilities, and a record of goals, actions, and outcomes. Effective rehabilitation requires all those involved to make a constant effort not to be constrained by prescribed routines. All members of the rehabilitation team, including doctors, should use the notes as a central information resource, and to record progress in a concise, standardized format. Figure 4: (a) a list of problems identified during rehabilitation of a young man with head injury, and (b) his goal record-sheet. 7. Follow-up and outcome A major weakness of many inpatient rehabilitation program is that professional input ends abruptly at the time of discharge. Since the rehabilitation plan is inevitably concerned with post-hospital life, its implementation often depends on factors beyond the immediate control of the hospital-based team.  During the rehabilitation process it is usually essential to identify a group of professionals who can comprise a community rehabilitation team, and to hold case conferences with these, the patient, and the family prior to discharge. At the time of discharge full clinical details must be communicated and follow-up arrangements established. DOCUMENTATION Why documentation? 1. Documentation provides baseline status, records pertinent information, measures progress and success, fulfills predictions, and declares the final outcomes. 2. It creates a record of the appointments the patient or client had. 3. It provides data for concurrent or retrospective audits as well as evidence for research. 4. It serves as a detailed bill for services rendered. 5. The medical record may also become evidence in legal proceedings, which can either defend or incriminate the clinician. 6. It provides a snapshot of a period of time that gives the reviewer a full and practical description of the status of patients and the impact care has made on their quality of life.  Data included in the medical record should be: meaningful, accurate, timely, and systematic. Written documentation is formally done at the time of admission and at discharge from the program and at periodic intervals during the course of rehabilitation. The format and timing of notes may vary according to institutional policy. The problem oriented system originally developed by Weed 1969, is one of the clinical decision making models which is adopted by many institutions. In this model, the rehabilitation process is divided into four phases: Phase 1: The formation of database. Phase 2: The identification of a specific problem list from the interpretation of database. Phase 3: The identification of a specific treatment plan for each of the problems described. Evaluative and progress notes are written for each problem (using a problem oriented medical record or POMR). Phase 4: The assessment of the effectiveness of each of the plans and subsequent changes in these plans as a result of patient progress.  When using POMR for documentation, the medical record is divided into four sections, representing each of the four phases. Progress reports are written in the SOAP format (subjective, objective, assessment, plan): The subjective findings: are what the patient or his/her family or caregiver tell you. The objective findings: are what you observe, test, or measure. The assessment includes professional judgments about the subjective and/or objective findings, and formulated into both long term and short term goals. The plan includes both general and specific aspects of treatment. Computer-assisted data management systems are the best way for data storage and retrieval, and it also helps in statistical manipulation. DISCHARGE PLANNING  Discharge planning begins as soon as the patient is admitted for rehabilitation. The discharge decision doesn’t depend only on fulfilling the preplanned outcome, the most important question to be answered during this stage is where the patient will live after discharge. There are two major types of housing available to persons with disabilities: 1) Community-based accommodation (private homes, retirement villages, and hotels or rooming houses) 2) Supported accommodation (any accommodation that provides personal care and medical services on a consistent, continual, or per need basis). The key to discharge planning is to consider the match between the patient’s skills and the demands of the environment, and then factor in the support systems available from a spouse, friends, or family to assist with tasks that the patient cannot manage.