The Rehabilitation Team
Rehabilitation is a creative, dynamic process that requires a team of professionals working together with the patient and the fam-ily. The team members represent a variety of disciplines, with each health professional making a unique contribution. Each health professional assesses the patient and identifies patient needs within the discipline’s domain. Rehabilitative goals are set. Each health professional assesses the patient, identifies patient needs within the discipline’s domain, and sets rehabilitative goals. Team members hold group sessions at frequent intervals to col-laborate, evaluate progress, and modify goals as needed to facili-tate rehabilitation and to promote independence, self-respect, and an acceptable quality of life for the patient.
The patient is the key member of the rehabilitation team. He or she is the focus of the team effort and the one who determines the final outcomes of the process. The patient participates in goal setting, in learning to function using remaining abilities, and in adjusting to living with disabilities.
The patient’s family is also incorporated into the team. The family is a dynamic system, so disability of one member affects the other family members. Only by incorporating the family into the rehabilitation process can the family system adapt to the change in one of its members. The family provides ongoing sup-port, participates in problem solving, and learns to provide nec-essary ongoing care (Nursing Research Profile 11-2).
The rehabilitation nurse develops a therapeutic and support-ive relationship with the patient and the family. The nurse always emphasizes the patient’s assets and strengths, positively reinforc-ing his or her efforts to improve self-concept and self-care abili-ties. During nurse–patient interactions, the nurse actively listens, encourages, and shares the patient’s successes.
Using the nursing process, the nurse develops a plan of care designed to facilitate rehabilitation, restore and maintain opti-mum health, and prevent complications. The nurse helps the pa-tient identify strengths and past successes and develop new goals. Coping with the disability, self-care, mobility, skin care, and bowel and bladder management are frequently areas for nursing intervention. The nurse assumes the roles of caregiver, teacher, counselor, patient advocate, and consultant. The nurse is often the case manager responsible for coordinating the total rehabilitative plan, collaborating with and coordinating the services pro-vided by all members of the health care team, including the home care nurse, who is responsible for directing the patient’s care after return to the home.
Other members of the rehabilitation team may include a physician, nurse practitioner, physiatrist, physical therapist, oc-cupational therapist, speech-language therapist, psychologist, psychiatric liaison nurse, social worker, vocational counselor, orthotist or prosthetist, rehabilitation engineer, and sex counselor or therapist.
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