Partnering with the resident

Nursing Homes, April, 1999 by Karen L. Bonn

Do your residents know and understand the medications and treatments they receive? Has anyone ever explained, or even attempted to explain, these to them? We are missing a great opportunity in nursing facilities to have residents play an active role in their daily care, which will keep them more mentally and physically alert, more "compliant" with medical orders and perhaps even easier to get along with. It also happens to be the law.

This topic came up recently when we started asking residents with contractures whether anyone had ever explained their condition to them, including what a contracture is and how it forms. Not one resident - no matter how alert and oriented - responded that anyone had ever discussed this beyond the fact that he or she had suffered a stroke.

Since we now know that contractures are preventable and correctable, at least to some degree, and that many are totally correctable, we must also remember that this is a diagnosis that falls under the category of an injury, just as bed sores do. We must take the responsibility of keeping our residents as informed about contractures as about any other diagnosis.

Because Medicare Part B will now pay for only one orthosis per joint every five years, facility decision makers must make sure that any resident who has a contracture receives a high-quality orthosis that is appropriate to the case. For example, because gravity will continue to bend a lateral spinal curvature, a maintenance orthosis designed to maintain a fixed position will cause increasing pain and tissue irritation as time goes by, and will soon require replacement.

Using a brace that will gradually "tug" the torso back toward normal alignment, and is flexible rather than rigid, will allow the joint(s) to repeatedly flex and extend the back toward normal alignment over the course of 15 or 20 minutes. A brace such as this, worn three to four hours each day, will result in the so-called "long effect stretch." It might also result in a grateful resident who will work harder to improve his or her own condition.

You will want to communicate with residents in words that they will understand - but don't sell them short. We have probably all seen very educated, bright people enter a nursing home and immediately start to vegetate because, to staff, they were elderly "patients" rather than vital human beings who needed physical and mental stimulation to survive. As we know now, residents must see themselves as an integral part of their own treatment, if they are to reach their highest level of functioning and then maintain it.

As you are making rounds, take the time to ask people if their condition has been explained to them. Especially check with those who have recent cerebrovasualar accidents, hip replacements or broken bones. The preventive treatment and education provided for these people today will hopefully save them from becoming the patients of tomorrow.

Work with therapists to develop a good team approach, and decide together who will do the patient teaching and how it will be done. Make sure this is reflected in the overall plan of care and that all caregivers are following the same approaches. Residents who are informed, are treated with respect and dignity, and feel at least somewhat in control of their care will do much better and probably not be as demanding. It is usually the people who feel hopeless and uninformed who become frightened and start to decline mentally and physically.

A good, specific place to start is to invest in the training of your restorative nursing staff in the causes, prevention and treatment of contractures. Remember, restorative nursing assistants (RNAs) provide contracture management approximately 90% of the year for residents affected by them. RNAs will find that they can share that burden, and get much better results, if residents are informed.

Karen L. Bonn, RN, ROF, a former director of nursing, is founder and president of Restorative Medical, Inc., Brandenburg, Ky.