For rehabilitation to be successful it must be a coordinated team effort involving patients and their families. The programme must be consistent with short-term achievable goals. Morale is very important. Co-operation between nurses, and above all, family, carers ensures that the patient can look to the future with confidence. It is this confidence that gives stroke people the will to strive for every higher levels of recovery. The aim is to maximise recovery and help the patient return to maximum independence. This can best be achieved when the patients and their families are involved with team of Doctor, Nurses, Physiotherapists, Occupational Therapist, Speech and Language Therapists, Psychologists and Social Workers.
DOCTOR: The doctor is an important member of the rehabilitation team and is often seen as the natural choice for team leader, both in terms of responsibility and expertise. The doctor is usually the first to contact the client, before meeting other team members. The doctor consults with and involves the rest of the team who work together to bring the client back to optimum health and independence. They explain diagnosis and prognosis to the client and relatives and often chair case conferences and other meetings. They are responsible for service development and audit and for fostering opportunities for staff education and the encouragement of research. (Davis and O’Connor, 1999, p61).
NURSES: Nurses constitute the biggest group within the health service and are a key aspect of the rehabilitation process (Chamberlain 1988). Chamberlain recommends that it is the role of the ward manager/sister to influence the morale and ethos of the team of nurses on the ward. Through their handling of the patient, physically, emotionally and socially, nurses can probably do more harm or good than any other profession (Benson and Ducanis 1995). The quotation emphasises the pivotal role of the nurse in the rehabilitation team particularly in terms of community and liaison between team members, patient and family and reflects the continuation involvement of the nurse in the patient’s management. On Adwoa’s admission to the Accident and emergency, a doctor saw her. After thorough examination, Adwoa was transferred to the ward where she was welcomed and seen by the nurse in charge. Admission started with information from one of her daughter and information was collected from her past history from her notes. The nurse in charge assessed Adwoa. Problems were identified so a plan of care was formulised; implement action was then carried out. Nurses may be involved in various different aspects of care following a stroke. If a person are being cared for in an organised stroke unit there may be a specialist stroke nurse who will help care for you in the immediate period following stroke and work with other members of the team to devise a rehabilitation programme. The nurse plays a vital role in the monitoring the patient in the acute phase following a stroke. This include monitoring blood pressure, as this may vary widely in the acute post stroke period, blood glucose and state of hydration (IWPS 2000).
PHYSIOTRHERAPIST: Chartered physiotherapist has a great deal to offer some people who have had a stroke. Their overall aim is to help people regain functional independence in everyday tasks such as walking and eating through practising controlled movement. Because every patient is affected differently so as it is important the physiotherapist have individual assessment. A physiotherapist may use many different methods to help patients. These may include practising movements, or part of a movement to encourage both sides of the body to work together. Following Adwoa’s condition it was natural for her to try to use the unaffected side to allow her to move independently. Compensation for the lack of movement on one side by overuse of the unaffected side is discouraged, and the emphasis is on using both sides of the body to encourage recovery of balance and movement. If a person is admitted to hospital following a stroke, physiotherapist begins as soon as possible. The first contact with a physiotherapist may involve correct and varied positioning of the patient in bed. A physiotherapist will try to ensure that muscles and joints remain flexible and pain free. Early treatment may include guided movements of the limbs, and practising sitting or standing with one or more therapists.
OCUUPATIONAL THERAPIST: O.T. can help improve your ability to carry out daily tasks and everyday skills such as bathing, dressing, using the bus, going to the pub and where applicable getting back to work and can help you adapt to any major changes imposed by your stroke. A home-visit assessment is carried out by the occupational therapist. The occupational therapist will visit the patient to assess the physical suitability of the home and facilities according to the amount of return of functional capabilities. Where mobility is reduced, particular areas for concern will include access to the house itself and use of the stairs. In severe cases, where the patient is wheelchair bound, adaptations to provide accessible facilities may be required. A work assessment will be done if the patient is employed, in which case liaison with the employers would help the occupational therapist identify the requirements of the job in order to stimulate them in the occupational therapist department. Occupational therapist assesses the patient domestic activities of daily living. It is important to identify the patient’s previous role in relation to domestic activities and running home. (Thompson and Morgan,1990, p28).
HOME MANAGEMENT: Including payment of bills, general finances, comprehension of money value, etc.
SHOPPING: Frequency of trips and amount of help available.
COOKING: Types of meals eaten and previous skills used.
GENERAL HOUSEWORK and LAUNDRY: Assessment of tasks previously undertaken at home and amount of help available.
To assess Adwoa’s safety within her home environment prior to possible discharge from the ward, the occupational therapist visited Adwoa’s home with Adwoa being present. Prior to admission to hospital Adwoa was not receiving any services and was independent in personal domestic activities of daily living apart from shopping which her daughter and neighbours completed for her. She was living in an environment that has not been adapted to enhance her safely although two Weldon toilet frames were in place. Rugs and mats impeded Adwoa’s safe mobility; there was lack of rail on both sides of the stairs and an outside lavatory. Suggestions were made to maximise Adwoa’s safe mobilisation around her home. Adwoa demonstrated difficult preparing hot drinks during home visit. A community alarm was also recommended as a result of Adwoa living alone combined with her history of falls. Her bed was transferred from her upstairs bedroom and sitting room was turned to bedroom. The occupational therapist recommended for a perching stool and meals on wheels for Adwoa due to her difficulty preparing a cup of tea.
SPEECH AND LANGUAGE THERAPIST (SALT): Speech and language therapist offer assessment, treatment and advice and counselling of people of all ages with communication disorder and related eating and swallowing problems. Speech and language therapist is aimed at maximising communication and reducing linquistic or motor speech difficulties resulting from stroke.
PSYCHOLOGIST
- Understands the special reactions of the patient, family and friends.
- Counsel the patients, family and team members, creating the optimal therapeutic environment- may need to explain the reasons for slow progress and the lack of motivation or difficult behaviour of the patient and suggest ways to manage these problems
- Counsel on chemical dependency.
- Participate in education programmes that include sexually and vocational goals.
- Quantitative and qualitative neuropsychological evaluation.
- Setting of goals and the establishment of the rehabilitation potential.
SOCIAL WORKER:
- Provide information on environmental barriers at home and at work.
- Provide the team with the patient’s vocational and social status and the family’s interaction with each other and the community.
- Provide and analysis of the financial status, the insurances available, and the impact that the stroke may have on the financial future of the family.
- Counsel on psychological needs, including sexuality.
Social workers are very helpful to the team’s group process. Prior to Adwoa’s discharged, at the case conference, based from the occupational therapist and physiotherapist assessment, the social worker recommended home carers for Adwoa- one in the morning, afternoon and at night. Meals on wheels were also recommended for her.
The initial shock felt by the whole family of the stroke victim is very real and alarming. The family may feel helpless, convinced that their loved one is going is going to die and may not appreciate all that is going around them (Fisher, 1961; Borden, 1962). The therapist and staff involved in the rehabilitation process can assist in the very early stages by giving clear explanations of procedures, positioning and treatment techniques. In the event of a stroke affecting a member of a family, the family’s needs, fears and anxieties of the situation should be well addressed as well as the needs of the patient. Understanding the illness and associated problems is usually the first hurdle to help family members overcome by providing information at a suitable level and by answering questions appropriately. There is the need for encouragement for the family when there is any change of personality of the patient. The previous role of the patient should be identify from the family so that it will give some indication as to the level of recovery expected by the patient’s family and thief hopes for the patient’s complete return to normal functioning. Partners, relatives or closely connected friends involved in the set-up may find it useful to be in contact with a support group or social worker early on for support and advice outside the main hospital environment (Mykyta et al., 1976). Documentation is sparse on the effects on the family as most literature concentrates on the stroke victim rather than others affected indirectly (Drummond, 1988; Thames and McNeil, 1987).
The nurse works closely with the social workers in getting the patient ready to leave the hospital. The first stage of discharge plan the following should be considered at the earliest possible stage in the patient’s recovery
- Identification of potential problems e.g. living alone.
- Projection of expected outcomes, shared between the different disciplines clearly documented and shared with the patient and significant others.
- Multidisciplinary care plan with stated long term and short term goals combining medical nursing and rehabilitation care plan with discharge aim.
As soon as there is a firm estimate of functional outcome and normally not less than one week prior to discharge the second state of discharge planning can be entered.
STAGE 2
- Revised or reaffirmed projection of expected outcomes, shared with the patient, carer and all staff.
- Home assessment where required, by appropriate team members led by occupational therapist. Confirm provision of adaptive equipment essential for patient safety.
- Alternatives to immediate discharge home considered- the use of pre-discharge accommodation, short- home stay or placement scheme and nursing home or other.
- Identification of potential discharge date.
- Self- medication ability confirmed and appropriate training and education given to the patient and or carers.
- Assignment of responsibility for co-ordination of discharge arrangements including transport, to a key individual.
- Social work involvement for community, finance and employment needs.
- Communication with the community services via the stroke liaison sister or other nominated member of the team should be aware of all identified needs and services and should ensure and document liaison with community nursing services, day centres, rehab services and voluntary support services.
When discharge date is confirmed stage 3 will be initiated.
- Patient, relatives, carers and all team members informed.
- Pharmacy advised re prescription needs at least twenty- four hours prior to discharge.
- Transport arrangements should be confirmed. If ambulance service is required this should be arranged according to local guidelines, ensuring time of pick-up, assistance, and direct route if required.
- Arrangements should be documented and carers informed.
- The designated co-ordinator to confirm the availability of community services and those they are appropriate.
- Discharge documentation should be completed.
- Contact numbers and services are issued. Patients have adequate information on who to contact if problems occur.
Rehabilitation aims, with short and long term rehabilitation objectives should be established and agreed by all parties including the patient and carers but Adwoa at times insists on mobilising with sticks or without aids rather than her frame, this increases her risk of falls due to her poor balance. Adwoa again was at risk of mobilising around her home due to steps at the front entrance, at the rear entrance at the doorways to both her kitchen and bathroom and due to the presence of mats and rugs but grab rails were suggested at the locations where steps are present and the removal of rugs but Adwoa rejected all these recommendations. For rehabilitation to be successful all information given to patients and carers should be documented to preclude passing conflicting information from different team members. Information should be presented both verbally and in written form to the patient and family or carers. Lastly but not the least stroke services should ensure an adequate level of nursing staff with appropriate specialist training.
From an older person’s point of view, rehabilitation should be a joined up service, helping them get back, as far as possible, to a normal life. From the provider’s point of view, rehabilitation can be viewed as succession of services, planned and provided by different agencies. Problems arise when these agencies do not work effectively together to provide a seamless service to the individual. For the agencies involved, the lack of joined- up services can create expensive duplication of effort and further cost implications, if the person’s condition deteriorates to the extent that they need to go back into hospital. Moreover, it can also damage the reputation of the agency and possibly expose it to the risk of litigation. Rehabilitation for older people might not seem to be a priority for trusts focused on waiting list targets. But the service has an important role to play in easing the pressure on beds, both by preventing admissions and facilitating timely discharge. It should also be a key priority in the development of intermediate care services, with continuity of care being promoted by intermediate care co-ordinators. The national service framework for older people in England requires agencies to adopt a Single Assessment Process (SAP) by ensuring that all those involved in providing care, at whatever location, have access to the patient single assessment (.).
From my experiences as a student nurse, I have known that rehabilitation following a stroke begins as the patient is medically stable and continues after discharge from hospital. Emerging new definitions of rehabilitation appear to identify more accurately the physical, social and psychological components of rehabilitation. However, definitions suggest that the process is always therapeutic. Restoration of independence in activities of daily living is one of the central aims of rehabilitation, and the combined services of all members of the healthcare team are required together with Adwoa and her family. Rehabilitation is a planned, goal-directed activity that requires assessment and re-assessment using standardised measures to monitor progress. The rehabilitation nurse has the most frequent and closest contact with the individual.
REFERENCES
Davis, S., O’Connor, S. (1999). Rehabilitation Nursing, Foundation for Practice.
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Edwards, A. (2002). A Rehabilitation framework for patient-focused care, Nursing Standard. Volume 16, (50) 28th August 2002, p.38-44.
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Gibbon, B. (2000). Rehabilitation following stroke, Nursing Standard. Volume16, (29) 3rd April 2002, p.47-50.
Laidler, P. (1994). Stroke rehabilitation: Structure and Strategy. London Chapman and Hall.
Langhorne, P., Dennis, M. (1998). Stroke Units: evidence based approach. London: BMJ Books.
Luker and Waters (1996). Cited In Edwards, A. (2000). A Rehabilitation framework for patient-focused care, Nursing Standard. Volume 16, (50) 28 August 2000.
Mulley, G. (1988). Practical Management of Stroke. London: Chapman and Hall.
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Nolan, M., Nolan, J. (1998). Cited In Edwards, A. (2002). A Rehabilitation framework for patient-focused care, Nursing Standard. Volume 16, (50) 28 August 2000.
Smith, M. (1999). Rehabilitation in Adult Nursing Practice London: Churchill Livingstone.
Snape, D., Burton, C. (2002). Stroke rehabilitation: an agenda for development. Nursing Standard. Volume17, (3) 2nd October2002, p.35-38.
. (National Guidelines for Stroke)
. (National Service Frameworks)
(What do speech and language therapists do?)
