PERSPECTIVES

Meeting the Needs of the MedicallyComplicated Rehabilitation Patient:A Unit--Based Case StudyGrace Campbell, BSN RN

Duringthepast5 years,therehas beena shift toward admittingmore medicallyinvolved inpatients to acuterehabilitationprograms. Although these patients arestill considered "medically stable," fre-'quentlytheyhaveunresolved medicalis­sues that affect the course of their reha­bilitation program. These patients mayhave difficulty participating in a tradi­tional rehabilitation program, yet theirfunctional needs are too complex to bemetadequately in a subacute setting. Tra­ditionaltreatmentmodelsmay be too in­flexible to allowtheinterdisciplinary careplanto be individualized according to thepatient's needs.The rehabilitation nurse,acting as the liaison between the patientandthe restof therehabilitation team,canfacilitate the development of nontradi­tionaltreatmentmodels. Usingbothmed­icalinsightand rehabilitation experience,nurses can lead the way in developingnewparadigms of inpatient rehabilitation.The following story illustratesone facil­ity's experience.

"Mrs. W." was a 68-year-old patientwho came to inpatient rehabilitation af­ter an extended acute care episode dur­ing which she suffered numerous med­ical complications.Initiallyhospitalizedfor treatmentof osteomyelitis with intra­venous antibiotics, she had developedacuterenalfailure, respiratory failure withsubsequent tracheostomy, and Van­comycin-resistant enterococcus (VRE)infection, and was transferredto the in­tensive care unit (lCU). After nearly 2months of bed confinement, she was se­verely debilitated. She arrivedat the re­habilitationunit just 5 days after leavingthe ICU. Many of the rehabilitationstaff

wonderedwhetheror not shecouldwith­stand the rigorous demands of the pro­gram.

When I first met Mrs. W.in her roomupon admission to the rehabilitation unit,she said nothing and looked at me withfear. Herhusbandanddaughterwereanx­ious and askedmanyquestionsaboutthecare she would receive at our facility.They expressedconcernabout our abili­ty to care for such a "sick" patient, andwerealsoconcemed aboutMrs.W.'sabil­ity to tolerate an aggressivetherapypro­gram. I beganby discussingin depth thenursingcareMrs.W.wouldreceive. ThenI shared information about the rehabili­tationprogramat ourfacilityand its pos­itive outcomes, including examples ofcare that previouscomplex patients hadreceived in the past. The family seemedreassured. I also promised that the nurs­es would coordinateMrs W.'s care withthe otherclinicians of the treatmentteamto ensure that shereceivedprogrammingto meet her needs.

Mrs.W.'s fearescalatedafterher fam­ily left for the night. She was afraidto at­tempt speaking,so she gesturedthat shewanted to be suctioned frequently. Thenurses assessed herpatiently eachtimeshedemanded tobesuctioned anddeterminedthatsuchfrequent suctioning wasnotnec­essary. Theytaughthercoughtechniquesand explained the advantages of mini­mizing invasive proceduressuch as sue­tioning.They encouragedher to attemptclearingher own secretions, and surpris­ingly,she didso withcueing. Sheseemedpleased that she had learned somethingearly in her rehabilitation that she coulddo herselfto improvehow she felt.

Anotherimportantmilestone occurredfor Mrs. W. when the nurses facilitatedher progress away from dependency onthenasogastric (NG)tube andmovedhertowardmoreregulareating.MrsW.'sNGtube was a large-bore, rigid plastic sumptube that had been insertedat the ICU. Itbothered herthroat, causeda choking feel­ing, and decreasedher appetite.Mrs. W.also was distressedby the appearanceofthe tube and refused to look at herself inthemirror. Shepleadedwiththenursestodo somethingabout it. At the same time,herfamily wasconcerned thatshehadde­pendedon this particularNG tube for solong that the transitionto anothertype oftube would be difficult or dangerous.Again, it seemed to the family that welackedappreciation for how sickMrs.W.was.The nurses,physician,and dietitianassured the family that Mrs. W.'s nutri­tionalneedscouldindeedbe managedbymeansotherthan a nasogastrictube.Theteam, in consultation with Mrs. W. andherfamily, decided toremove theNG tubeas a trial. Thenursesexplained to Mrs.W.theimportance ofmaintaining her oralin­take to facilitate healing, and consultedthedietitian forfoodsthatwereeasilyeat­en and nutrient-densein small portions.Mrs.W.knewhowimportant it wasto eat,butshebecaineanxious at mealtimes. Thenursing staff sat with Mrs. W. at meal­times and talked with her about family,and about one of her hobbies, traveling.They also enlistedcliniciansfrom recre­ation therapyand psychology, as well asunit volunteers, to visit with her duringmeals. Creating a more social situationduringher meal allowedher to relax andenjoy the experience. Her calorie count

6 Rehabilitation Nursing> Volume 26, Number 1 • JanlFeb 2001

indicated that she was consuming suffi­cient food to avoid another feeding tube.She was so pleased by her improved ap­pearance without the NG tube that she re­quested the nursing staff to help her ap­ply makeup.

Mrs. W.'s inability to speak audiblybecause of the tracheostomy was anoth­er source of frustration. Although the staffand her husband could understand hervery well, she was upset because shecould not speak to her grandchildren onthe phone. The nursing and speech ther­apy staffs worked with the physician onplugging and downsizing the tracheosto­my. The speech therapist incorporatedphone calls to her grandchildren into hertherapy sessions when her tracheostomywas plugged.

Despite Mrs. W.'s multiple medical is­sues and compromised stamina, she alsowas scheduled for physical and occupa­tional therapies.The therapy gymswere inanother wing of the hospital, and the nurs­es knew how difficult it would be for herto attend, so they staggered her therapysessions with frequent rest periodsthroughout the day. Even so, by the timeher nursing and self-care were complet­ed each day, she was too exhausted to at­tend therapy. This frustrated Mrs. W.Theteam met to discuss the situation andagreed that the only way to meet Mrs.W.'sneeds was to institute a therapy programfor her in the rehabilitation facility. Thiswas logistically difficult,because the ther­apists were based in the gym for all oftheir other patients; however, they agreedto juggle schedules so that they could bepresent on the unit to treat Mrs. W.

Adjusting to the inconvenience waswell worth the extra effort. The team wasable to respond to the patient's needs onan ever-changing basis and to providetreatment when she was able to tolerateit. Co-treatments between therapists andnurses were frequent because they oc­curred in the patient's room. The new

model created a problem-solving ap­proach among the disciplines as theyworked together to determine the bestmethods for facilitating functional im­provement. It also fostered a consistentapproach across disciplines. Follow-upwas consistent because the nursing staffwas able to discuss Mrs. W.'s progresswith visiting family members in theevening, in great detail. Because the nurs­ing staff was so involved in Mrs. W.'stherapies, they could effectively reinforcetreatment strategies with the family andassist the family in working with Mrs. W.on functional tasks.

After approximately I week of unit­based therapies, with many of her med­ical issues moving toward resolution,Mrs. W. was able to progress to a moretraditional gym-based therapy program.Within another 2 weeks, she was ambu­lating independently with a wheeledwalker, able to perform her own self­care, and was gaining weight. Her res­piratory status improved and she was de­cannulated with no further difficulties.She was discharged home soon after, ex­cited to begin planning a trip to visit hergrandchildren the following month.

Since caring for Mrs. W., we haveseen patients with multisystem problemswith greater frequency. Like Mrs. W.,these patients do not fit the mold of thetraditional rehabilitation patient. Be­cause of our success with Mrs. W., ourrehabilitation unit developed a formalunit-based therapy program that im­proved our ability to manage complexpatients. Nurses, therapists, and supportstaff worked side by side during muchof the day, capitalizing on opportunitiesfor collaboration and problem solving.Through flexibility and creativity amongthe clinical disciplines, the team couldrespond to ever-changing patient needsquickly and effectively. Families whowere reluctant to go to the therapy gym(preferring to wait in the room until the

patient returned from therapy) were ableto see their loved ones "in action" righton the nursing unit, increasing family par­ticipation in therapy.

Coordinating all disciplines becomesmore challenging and more important asthe complexity of the patient's needs in­creases. As illustrated in the experienceof Mrs. W., nurses are instrumental in as­sessing needs and advocating with theteam to ensure that those needs are met.Patients experience positive outcomes be­cause the plan of care is individualizedby all disciplines to meet specific needsand is directed and coordinated by nurs­es. The nurse provides a holistic, round­the-clock view while collaborating withall other disciplines to ensure that patientsreceive help to meet their goals. I amproud to have worked with my fellow re­habilitation nurses to increase the team'sresponsiveness to Mrs. W.'s needs and tohave supported Mrs. W. and her familythrough their rehabilitation stay success­fully.

Grace Campbell is the rehabilitation unitdirector at UPMC Rehabilitation Hospitalin Pittsburgh. Address correspondence toGrace Campbell, BSN RN, Unit Director,UPMC Rehabilitation Hospital, 1405 ShadyAvenue, Pittsburgh, PA 15217 or via e-mail,campbellgb@msx.upmc.edu.

AcknowledgmentThe author gratefully acknowledges

helpful commentary in preparing thismanuscript from Charlene Stanich, MNRN NHA ONC CRRN, director of reha­bilitation nursing, and James Eng, PT, di­rector of clinical services, at the UPMCRehabilitation Hospital.

Editor's noteThe author took first place in the 2000

Rehabilitation Nursing Writers' Contestfor this article. The MarchiApril issue ofthe journal will include an announcementof and guidelines for the 2001 contest.

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