Geriatric rehabilitation and resilience from a cultural perspective.

Geriatric Nursing 35 (2014) 451e454

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Feature Article

Geriatric Rehabilitation and Resilience from a cultural perspective Darlene Yee-Melichar, EdD a, *, Andrea Renwanz Boyle, PhD b, Linda J. Wanek, PhD c, Sarah B. Pawlowsky, MSPT, DPT c a b c

Gerontology Program, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132, USA School of Nursing, Dominican University of California, San Rafael, CA, USA Physical Therapy Program, San Francisco State University, San Francisco, CA, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Received 31 July 2014 Accepted 4 August 2014 Available online 10 September 2014

Resiliency is a key aspect to aging successfully. Promoting healthy lifestyles, strong social bonds, enhancements to one’s environment, accessibility to quality care and rehabilitation are critical in a positive aging experience. Issues of personal, social, medical, and rehabilitative care are addressed in the context of resiliency from a cultural perspective. Various research studies explore resiliency through the progression of aging within changing environments, medical needs, and social conditions. Findings suggest that a strong connection to culture, accessibility to medical attention, and comprehensive assessment of a patient’s background can effectively improve the rehabilitation for an aging individual. This article addresses aspects of caregiving that are essential in raising cultural sensitivity and resiliency, discussing three case studies (i.e. fall risk; stroke; congestive heart failure) in the geriatric patient. Resiliency in culture and rehabilitation has a connection needed to advance the quality of care and quality of life for an aging patient population. Ó 2014 Elsevier Inc. All rights reserved.

Keywords: Geriatric rehabilitation Resilience Cultural perspective Healthcare interventions Caregiving Case studies

Resilience from a cultural perspective The scientific community has begun to recognize resilience as a central component for success in later life. Although there is no universal definition for resilience, it is a key factor of aging well. Resilience as part of the aging process has received inadequate attention with more research needed on the multidimensional and cultural perspectives of resilience in older people. Resilience, associated with the ability to cope with stresses, is defined as a capacity to flourish in spite of adversity1 as well as the maintenance or improvement in health following challenges.2 Comprised of multiple factors such as sociological, psychological, biological, and social elements including social support,2(p166) resilience is characterized by personality traits and personal attributes including high self-esteem, determination, humor, curiosity, creativity, optimism, and a sense of purpose.3 Resilience in elders has also been connected with responses to difficult events that have been learned over time.3 Van Breda has defined “resilience as the strengths that people and systems demonstrate that enable them to rise above adversity” and described ways to build resilience.4 According to Neill, “cultural

* Corresponding author. Tel.: þ1 415 338 3558; fax: þ1 415 338 3556. E-mail address: [email protected] (D. Yee-Melichar). 0197-4572/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2014.08.010

resilience refers to a culture’s capacity to maintain and develop cultural identify and critical cultural knowledge and practices.”5 Bowen defined “community resilience as the ability of a community to establish, maintain, or regain an expected or satisfactory level of community capacity in the face of adversity and positive challenge.”6 Europe and the United States contain such diverse populations that an understanding of cultural and other differences is crucial. Grundy7 examined older Europeans and proposed a variety of interventions to increase resiliency and minimize vulnerability. The interventions included the promotion of healthy lifestyles, strong social relationships, environmental improvements (i.e., reducing the risk of falls, street crime, influenza immunization), and access to quality acute care and rehabilitation. In a recent study3 involving data from over 1000 women living in the United States related to the Women’s Health Initiative, researchers aimed to understand how resilience might change over the lifespan. Results indicated that resilience appeared to relate to other healthy aging determinants and the way one ages (within a cultural and/or other context) may change the way that resilience is expressed.8 Bauman, Adams, and Waldo examined resilience in the oldestold in a series of three separate studies conducted in Europe identifying common strategies used to overcome hard times.9 Baltes and Baltes10 noted common traits in resilient older women included flexibility, tolerance, independence, determination, and

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pragmatism as did LaFerriere and Hamel-Bissell11 in their ethnographic study of six elderly women aged 87e93 who lived in northeastern Vermont for an average of 70 years. Talsma studied elders in the Netherlands finding three dimensions of resilience: physical functioning, psychological functioning, and well-being.12 The concept of resilience was identified as an important variable in the above studies despite the presence of cultural variability. Findings suggest that a strong connection to culture, easy accessibility to medical attention, and in-depth assessment of a patient’s background can effectively improve the conditions of living and resilience for an aging individual. Researchers have also identified a number of cultural issues relevant for elders that are associated with an increased need for resilience. These include: 1) material factors such as food and shelter; 2) health factors, 3) social linkages, 4) cultural values e especially those of independence, and 5) cultural change (i.e., having to adapt to new cultures or changes in culture).13 Growing older is not a uniformly “good” or “bad” practice; rather consideration of the aging process should be looked at from a cultural perspective, life experience, and local circumstance.5 Specifically, this consideration should include resilience and the cultural impact on resilience and the individual’s reaction to later life, the overall picture of their individual experience. Prior research examining the impact of culture on resilience Gunnestad examined resilience in a cross-cultural perspective with a study about: 1) protective factors, 2) different ways of creating resilience, 3) resilience and vulnerability from culture, and 4) minority and majority cultures and biculturalism.14 Although this discussion is not specific to older people, it examines cultural, familial, and social issues which both aid and hinder the development of resilience in children. The author outlined protective factors and processes which help to create resilience as: 1) Network factors (external support), 2) Abilities and Skills (internal support), and 3) Meaning, Values, and Faith (existential support).14 According to this study,14(p2-3) “Network factors” include external support from family, friends, neighbors, teachers, etc. “Abilities” include internal support such as physical and mental strength, temperament and emotional stability, intellect and appearance. “Skills” include communication skills, social and emotional skills. “Meaning, Values, and Faith” include existential support such as perception of values and attitudes. The author stated that culture is contained in all three protective factors which are interrelated.14 Culture, an integral part of meaning, value, and faith, affects the way we form external support and determines what skills are appreciated. Gunnestad14(p3) also described the need to create resilience which occurs when protective factors initiate certain processes within the individual. The author examined resilience and vulnerability in different cultures: Latino, North American Indian First Nation, and South African youth. The author illustrates how the culture over a long period of time has developed behavior that generates resilience.14 Rutter further identified different ways of creating resilience.15 These included: 1) building a positive self-image; 2) reducing the effect of risk factors; and 3) breaking a negative cycle and opening up new opportunities. Those immigrants and their succeeding generations who master the rules and norms of their new culture without abandoning their own language, values and social support seem more resilient than those who just keep their own culture and cannot acclimate to their new culture or those who become highly acculturated. It can be seen that if you take the culture from a people, you take their identity and strength e the resilience factors e which makes them vulnerable.

Katzko et al examined and compared a sample of elderly Spanish participants (n ¼ 83) and elderly Dutch participants (n ¼ 74) to gain an idea of the cross-cultural content of self-concept,16 a critically important aspect of resilience. Data suggest that the participants look to continue meaningful lives after family and career goals are met. Overall, the results of the study16 indicated that in both cultures, the elderly participants maintain a “still-healthy” image of themselves and often look for opportunities with which to fill their day-to-day existence with meaningful activities. Model programs in geriatric rehab and resilience from a cultural perspective Lewis summarizes the role of Alaskan elders in the cultural resilience of Native communities.17 Lewis commented on cultural resilience, examining the obstacles that specific societies face in establishing and maintaining their various traditions and social norms.17 He explored resilience and cultural resilience within the elderly community and defined the typical roles of elders (i.e. grandfather as a mentor). “Cultural Identity” is an important topic since elders rely upon it to maintain status within their community.17 Regarding the maintenance of a community’s resiliency, Lewis highlights the peoples of Native Alaska to show how a culture preserves its identity. While Alaskan Natives make a positive effort to speak and teach their native language and folklore to their children, they also face the challenges of their out-migrating youth and their reliance on imported goods. Tensions between personal and communal resilience address the elders’ desire to maintain independence and identity within their culture. Lewis concludes6 that the issue of resilience sparks innovative efforts within specific cultures to sustain its identity. In his article,18 Moody describes how different cultures view geriatric care by featuring a Chinese family opting out of traditional medical care and choosing herbal treatments to remedy their aging relative’s pain caused by cancer.18 The family attributed this decision to their cultural values, while their doctor and health care team was left shocked and in disagreement. Moody also describes a study by the Fan Foz and Samuels Foundation which surveyed elders of different ethnicities about their views on aging.18 Common ideas between cultures included: shared belief of fatalism, reluctance to communicate with health care professionals, and the belief that health care professionals did not want their opinion in relationship to care. The study18 predicted they would find differences among cultures, finding instead a number of significant cultural similarities. Consedine, Magai & Conway19 considered resilience among individuals from six ethnic groups: African Americans, Jamaicans, Trinidadians, Bajians, US-born Whites, and Immigrant Europeans, predominantly Russians and Ukrainians from the former Soviet Union. The mean age of sample participants was 73.8 years. For the purposes of the study,19 resiliency was defined as functionality relative to health impairment. It was concluded that “later life is associated with both gains and losses; aging brings with it a variety of challenges in coping with losses in physical, social, and economic realm.”19(p124-125) This research data19 suggested that resilient members of African descent (African Americans, Jamaicans, Trinidadians, and Bajians) were more likely to manifest patterns of adaptation characterized by religious beliefs, while resilient US-born Europeans and immigrant Europeans were more likely to benefit as a result of a nonreligious social connectedness. Social networks, religion, emotions, and emotion regulation were identified as among the key proximal components underlying ethnic difference in later life adaptation and in resilience.


The impact of resilience on health care interventions Health care providers note that the concept of resilience is important for work with elders in a variety of care settings. Health care providers are in a unique position to enhance resilience in geriatric patients, as they are often spending the most time with patients. This aligns with the resilience literature which identifies the promotion, enhancement, and strengthening of resilience through the implementation of supportive services and professional interventions.20 Grundy7 has proposed specific interventions that would increase resiliency e promotion of healthy lifestyles and coping skills, strong family and social relationships, environmental improvements to reduce fall risk e and these interventions all fall within the purview of nurses and PTs. But while a health care practitioner can prescribe these interventions to a patient, prescription alone does not necessarily cause a patient to incorporate these interventions into his/her daily routine to enhance resiliency. Health care practitioners understand firsthand how challenging it can be to convince any patient to incorporate healthy lifestyle changes, regardless of age. If a health care practitioner can make a lifestyle change meaningful to a patient and easy to incorporate into his/her life, there may be a better chance of this change happening. Adding to the complexity of encouraging healthy habits and coping skills in geriatric patients is cultural diversity. Many characteristics can be used to describe culture including: national origins or residency, customs and traditions, language, age, generation, gender, religious beliefs, political beliefs, sexual orientation, perceptions of family and community, perceptions of wellness, health and disability, physical ability and limitations, socioeconomic status, education level, geographic location, and family/household composition.21 Using these characteristics, culture becomes more of a framework that guides human thoughts and behaviors.22 For many clinicians, cultural care refers to the many aspects of culture that both influence and enable individuals or groups to cope with illnesses or death and also to improve the human condition.23 Leininger’s theory of cultural care diversity promotes understanding of universally held and commonly understood elements of care among humans as well as the caring contexts and interactions of such care activities.24 Culture must therefore be a primary consideration when working with patients in a variety of care settings. Integration of cultural awareness into health care interactions is underscored by a number of epidemiological studies predicting dramatic increases in the number of ethnic elders in the United States. Many of these elders will suffer from chronic illnesses.25 These demographic shifts create new challenges for clinicians who must provide culturally appropriate care and health services to individuals and families with diverse beliefs, values, life experiences, and languages.26(p62-67) At the same time, clinicians also must strive to include health equity, disparity elimination, and improvement of health for all United States citizens as identified in the United States Department of Health and Human Services Goals of Healthy People 2020.27 Using a model of patient-centered care is one way that health care providers can identify how a patient’s culture interacts with his/her health. “Patient-centered care refers to the focus of the practitioner on the condition from the patient’s perspective and seeing the patient as a whole person, independent of the condition.”28 The World Health Organization had developed a new model of patient function, the International Classification of Functioning, Disability, and Health WHO-ICF29 that places the patient at the center of care. The WHO-ICF, used to describe functional states associated with health conditions, is intended for use in multiple sectors, assessment of needs and in the matching of specific interventions to both specific health states and to rehabilitation in

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general.29 The model underscored in the WHO-ICF is integrative, viewing health conditions in context with environmental and personal factors. Within this approach, disability is then viewed as complementary to functioning, encompassing impairments, activity limitations, and participation restrictions.30 Examples of case studies are available in Appendix A below. These cases demonstrate how to utilize cultural sensitivity and build resilience in the geriatric patient. Summary Resiliency is a key aspect of aging successfully. Promoting healthy lifestyles, strong social bonds, enhancements to one’s environment, and accessibility to quality care and rehabilitation are critical in a positive aging experience.31 As aging is not a binary practice of “good” and “bad,” its process must be studied from aspects of culture, life history, and individual circumstance to realize someone’s reaction to their later years. One’s ability to maintain principles and preserve their identity whilst shifting into a new community and lifestyle directly influences their quality of life as they grow older. Having a foundation of social connections e close family and friends e as a network can help an individual in maintaining resiliency against negative effects of aging. This network can support physical and mental strength, emotional stability, and social status. As communication can deepen these familial bonds, one’s skills in developing and maintaining social and emotional connections are important. It is also important for an aging person to have meaning, values, and faith as well, which fall under the existential aspect of support. This focus on conserving culture can help create a new positive self-image and outward perspective on life, which creates resilience on the psychological and social plane. One’s environment is crucial in maintaining resiliency and aging positively. A geographic setting that is both accessible to clinical centers and conducive to social growth can have great benefits to a person’s aging. A home setting and environmental layout that is not thoughtful to the individual occupying the space can hinder the well-being of an individual. Their susceptibility to outward communication (i.e., emergency calls, visiting friends and family, etc.) and their accessibility throughout their living quarters is vital to safety and security. Their community is also an aspect of environment, where a positive civic impression can foster a positive aging experience and deepen their connection to their social network. Treatment on a clinical plane is also very important to the physical, mental, and environmental standards of maintaining resiliency. Professional assessment of psychological health and potential risk of illness can help in sustaining positive aging. Clinicians, such as nurses and physical therapists, must assess many aspects of an individual’s physical health, living space, psychological state, and medical history to assist in improving their quality of life. Due to their accessibility and time dedication to geriatric patients, nurses and physical therapists have a unique opportunity to enhance resiliency. Nurses and physical therapists must have a great understanding of cultural relevance, demographic factors, and social trust. Rehabilitation for falls, psychological intervention, and clinical reasoning beneficial to a patient’s lifestyle is all essential to their physical and mental health. Clinicians may find it complex to aptly tend to cultural needs as they apply to medical illnesses. A patient-centered model of care is crucial for the well-being of each patient; this practice focuses on the patient as a person independent of their condition. Putting a person’s health conditions in context with their personal and environmental factors makes for a holistic and personalized care experience, which has immense potential benefits per individual.

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In reviewing a patient’s life on all planes, there are several aspects to assess: strength, gait, balance, culture, fall risk, and environment. In rehabilitation a patient, it’s important to provide intervention in which to support the improvement of their new lifestyle in caring for this disability or illness. A high degree of dedication and support can improve or establish a resiliency against aging and illness that each patient can profit from in many ways. In caring for aging individuals, resiliency can greatly impact the ability of patients to overcome physical, psychological, and social obstacles they will face in their older years. Their connection with culture and their personal identity, along with personalized rehabilitation for their condition and lifestyle transition can maintain a higher quality of life than patients who lack those attributes. Although these various factors may be complex, it’s central to their well-being and prosperity in aging.

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1. Hilden Z, Montgomery S, Blane D, et al. Examining resilience of quality of life in the face of health related and psychosocial adversity at older ages: what is “right” about the way we age? Gerontologist. 2009;50:36. 2. Ryff C. Psychology and aging. In: Hazzard WR, Blass JP, Ettinger WH, et al., eds. Principles of Geriatric Medicine and Gerontology. 4th ed. San Francisco: McGraw Hill; 1999. 3. Touhey TA, Jett K. Ebersole & Hess’ Toward Healthy Aging: Human Needs & Nursing Response. St Louis: MO: Elsevier; 2012. 4. Van Breda A. Resilience Theory: A Literature Review. Van Breda Organization. Accessed 13.09.13, http://www.vanbreda.org/adrian/resilience/resilience1.pdf; 2001. 5. Neill J. What is Resilience?. Wilderdom. Accessed 13.09.13, http://wilderdom. com/psychology/resilience/; Updated May 2006. 6. Bowen G, Mancini J. Community resilience: a social organization theory of action and change. In: Mancini J, Roberto K, eds. Pathways of Human Development: Exploration of Change. Maryland: Lexington Books; 2005:245e265. 7. Grundy E. Aging and vulnerable elderly people: European perspectives. Ageing Soc. 2006;26(1):105e134. http://dx.doi.org/10.107/s0144686X05004484. Cambridge University Press. 8. Vahia I. Resilience in Aging. UC San Diego School of Medicine. Healthwise. 2008;26(8). Accessed 13.09.13, sira.ucsd.edu. 9. Bauman S, Adams H, Waldo M. Resilience in the Oldest-old. Health Care Industry, http://findarticles.com/p/articles/mi_qa3934/is_200110/ai_n8959937; 2001. Accessed 19.03.13. 10. Baltes PB, Baltes MM. Psychological perspectives on successful aging: the model of selective optimization with compensation. In: Baltes PB, Baltes MM, eds. Successful Aging: Perspectives from the Behavioral Sciences. Cambridge: Cambridge University Press; 1990:1e34. 11. LaFerriere RH, Hamel-Bissell BP. Successful aging of oldest old women in the Northeast Kingdom of Vermont. Image J Nurs Sch. 1994;26:319e323. 12. Talsma AM. Evaluation of a Theoretical Model of Resilience and Select Predictors of Resilience in a Sample of Community Based Elderly [Doctoral

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Appendix A. Examples of case studies Geriatric Rehabilitation and Resilience from a Cultural Perspective by Darlene Yee-Melichar, EdD, Andrea Renwanz Boyle, PhD, Linda J. Wanek, PhD, & Sarah B. Pawlowsky, MSPT, DPT. The following three case studies demonstrate how to utilize cultural sensitivity and build resilience in the geriatric patient. Health care providers require patient care to be patient centered. Patient centered care requires nurses to provide patient services that are individualized and also requires practitioners to always be responsive to meeting individual needs, values, and preferences of individuals and families.1,2 Recognizing that nursing care is always patient centered, application of the WHO-ICF by nurses has been identified as a potential strategy to broaden the nursing focus. This classification has not been fully adapted within the nursing profession to date.3 Examples for the practice of patient-centered care include: (1) incorporating the patient’s goals into the intervention plan, (2) taking into account the patient’s prior and current functional activities, (3) asking about environmental and personal factors that may be either a barrier or facilitator to interventions, (4) checking in with the patient about their preferred learning style, and (5) simply enough, asking right away by what name the patient would like to be addressed. All of these factors are important to place the patient at the center of the plan of care and help the health care practitioner to begin to understand the culture of the patient. The following three case studies provide examples of how a health care provider might approach the same geriatric patient, taking into account the multifaceted aspects of the patient’s life and culture. Through different professional lenses, the health care providers strive to see the patient as a whole person, and using their cultural perspectives will allow them to connect with that individual geriatric patient, and in turn develop a plan of care that is responsive to that person’s needs. The development of a treatment plan that a patient can incorporate into his/her life is vital to improving a patient’s resilience. Case study 1: geriatric patient with fall risk The patient is an 83-year old Asian female. She lives at home with her 90 year-old husband who has multiple health problems, including recent recurrent hospitalizations. Both the patient and her husband want to remain living in their home. She has been referred for outpatient physical therapy and nursing evaluations with a diagnosis of “gait/falls.” The patient’s chief complaint is weakness in her left leg and balance difficulties. Her personal goal is to avoid falls. She prefers for her health care practitioners to address her by her first name. When asked about her preferred learning style, she requests to have all exercises written down with pictures. History of present illness The patient underwent a lumbar decompression and fusion surgery (L3-L5) for spinal stenosis three years ago, which improved her lower back pain. Some improvements in her left lower extremity strength were noted after surgery, but the left lower extremity muscles remained weaker than the right. The patient reports 3 falls within the last year. One fall occurred while walking to her car holding another person’s arm. She required help up, but did not suffer any injuries. A second fall occurred while holding the refrigerator door with one hand and food in the other hand. She slipped and fell backwards, hitting a table. After this incident, she saw her primary care physician, who referred her to physical therapy. Since obtaining the referral, she slipped on a wet floor at home. The patient has waited 3 months to pursue physical therapy due to dealing with her husband’s recent hospitalizations.

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Medications Metropolol, Trazadone, baby aspirin. Social The patient worked as a physician until retirement 13 years ago. She continues to do some volunteer intermittent teaching, but this has been deferred recently due to her husband’s health issues. She has three adult children, with her closest child being a daughter who lives 2 h away with her husband and child. This daughter has a demanding work schedule. The other two children and their five grandchildren live out of state. The patient contacts all of her family members regularly. Stairs She has 20 stairs into her home with a unilateral railing and an additional 10 stairs to reach the laundry room. Housework A housekeeper comes once each week and cleans the bathroom and kitchen. The patient independently does laundry, change bed sheets, and does other housework in between housekeeper visits. The patient independently prepares meals for herself and her husband. A gardener helps with outdoor areas. The patient enjoys gardening, but finds she is able to do less of it recently due to weakness and balance challenges. Transportation The patient and her husband no longer drive. The patient’s daughter assists with driving when able. When she is not available, they use a driving service for appointments and shopping trips. Assistive device history The patient has used a single point cane (SPC) since 6 months prior to lumbar surgery; the SPC is now used for all community ambulation. The patient performs household ambulation without an assistive device. Pain The patient reports her ADLs are not limited by pain. Prior level of function The patient was able to perform some light gardening 1.5 years ago with her SPC. Her gait tolerance 1.5 years ago was 4e5 blocks with the SPC. She was able to ambulate in her home without an SPC and felt steady. She left her home about 4 times each week for errands. She was independent with doing laundry, as well as picking up objects on the floor. Current level of function The patient has discontinued gardening due to not feeling steady on the grass any longer. Her gait tolerance has decreased to 1 block with an SPC. She leaves her home less often now, about 1 time per week, due to difficulty with the stairs. She still does the laundry, but reports she is less steady now carrying the laundry basket on the 10 stairs. She now finds it difficult to pick up objects on the floor due to balance. Objective exam (highlighting significant deficits only) Gait (without SPC) Wide base of support, requires contact guard assist for loss of balance when changing directions. Trunk slightly flexed with decreased left foot clearance in swing phase with limited ankle dorsiflexion and hip flexion. Hip drop is noted bilaterally. With SPC, a patient is able to change directions independently.

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Stairs (using unilateral railing and SPC) Step-to pattern, leading with right lower extremity on ascent. Descends with step-to pattern, leading with right lower extremity. Strength Weakness noted in L > R hip flexors, gluteus medius, quadriceps, anterior tibialis, and posterior tibialis, with strength on left measuring 4/5 and strength on right measuring 4 to 4þ/5. Sensation Diminished sensation to light touch in left lower extremity e L3, L4, and L5 dermatomes. Balance tests MINI BESTest of Dynamic Balance (Balance EvaluationeSystems Test): Score ¼ 21 (out of 32 possible points). Items on test that presented most difficulty were eyes closed balance on foam, gait with pivot turns, lateral compensatory stepping and the timed up-and-go with dual task. Gait speed 0.6 m/s. Clinical reasoning from a PT and nursing perspective The treatment approach to this patient at risk for falls was designed to address the following: (1) cultural factors; (2) fall risk assessment; and (3) fall prevention interventions. Cultural factors Treatment considerations for this patient include an awareness of her cultural values and background. It is important to note that the term Asian or Asian American actually refers to many diverse sub-groups residing in the United States from regions including the Far East, Southeast Asia, and the Indian subcontinent incorporating China and India.4 While assumptions about values from individuals in such a broad category are not helpful, it can be noted that for many Asian Americans, the concept of family assumes great importance. Roles of women in Asian American families have traditionally respected the dominant roles of elders and men in society. As these perceptions change, women who assume nontraditional roles may experience more stress and difficulty.4 Both the nurse and the physical therapist need to include cultural awareness into the care plan, specifically recognizing the importance of family in this patient’s care. The nurse will assess the family including the daughter in terms of frequency and duration of visits and ability to assist with shopping, participation in social events, and housecleaning. Regular visits from grandchildren could also serve to decrease possible social isolation that the patient and her husband may experience because they spend much of their time in the home setting. While the patient worked for years as a physician and continues to complete volunteer work when possible, the nurse should assess for possible stress from changing roles for both the patient and her husband. The physical therapist will encourage any family members that can attend the PT session to participate, both to learn the exercises to help with patient instruction and to motivate the patient to regularly perform her home exercises. For example, if the patient’s daughter and granddaughter come to a PT visit, the granddaughter can perform the exercises with the patient while the PT instructs the daughter in how to appropriately guard the patient for safety. If the patient’s husband currently does physical therapy exercises himself at home, the PT can review these exercises to determine which ones would be beneficial for the patient and her husband to perform together. If the patient is willing to use technology, computer conferencing

methods may allow grandchildren in other states to perform exercises with the patient as well. In addition to family networks, other social networks for the patient and her husband will be assessed by the nurse. This may include the number of friends, participation in church activities, professional organizations, clubs, or other professional connections from the volunteer work completed by the physician. The physical therapist may incorporate this type of information into the therapy goals, such as writing goals aimed at improving participation in these networks, if they are important to the patient. Fall risk assessment Falls are the leading cause of morbidity and mortality in individuals aged 65 and older.5 It is estimated that one-half of all fallrelated deaths occur within home settings.5 Both the PT and nurse should perform a comprehensive assessment of fall risk factors. For elders, common fall risk factors include the following: (1) impaired mobility with changes in mobility, gait, and lower extremities; (2) movement difficulties; (3) weakness; (4) diminished peripheral sensation; (5) slow walking speeds; and (6) use of medications.5e7 The physical therapist used the MINI BESTest to assess and quantify this patient’s fall risk. This 14-item balance scale includes aspects of dynamic balance control such as the ability to react to postural perturbations, stand on a compliant or inclined surface, and ambulate while performing a cognitive task.8 It has high interrater and test-retest reliability, and is able to differentiate between fallers and non-fallers with a neurological disorder.9 A score of 4 points on the MINI BESTest is the most accepted value for minimal important change8; thus this 4-point improvement will be incorporated into the therapy goals. Improving the patient’s dynamic balance is an important aspect of addressing the patient’s personal goal, which is part of her culture, and her resilience, to allow her to avoid a fall the next time her balance is challenged. In addition to dynamic balance, the patient’s gait speed is concerning from both a fall risk and a resilience perspective. Studies have examined the relationship between gait speed and mortality and resilience, with a positive correlation between resilience and gait speed.10 Survival increases across the full range of gait speeds, and gait speeds slower than 0.6 m/s may be used clinically to identify older adults at risk of early mortality.10 Gait speeds faster than 1.0 m/s suggest better life expectancy, with 1.2 m/s suggesting exceptional life expectancy.10 Physical therapy interventions will aim to improve the patient’s gait speed to at least 1.0 m/s to enhance resilience and life expectancy. This patient’s use of her assistive device is related to her dynamic balance and gait speed. She refuses to use an SPC in her home, even though she is willing to use the device for community ambulation. Given the patient’s current fall risk, use of an assistive device in the home is a necessary safety measure. Many older adults reject use of adaptive equipment for reasons such as the device being too cumbersome, too time consuming, too much trouble, or the client perceived no need for the device.11 This patient feels the SPC in the home is too much trouble and limits her when performing activities such as cooking and housework. In using a patient-centered treatment approach, the therapist and nurse begin the intervention from the patient’s viewpoint, acknowledging that carrying a cane when making meals can be challenging. However, using the cane may have helped to prevent the recent falls in the kitchen. The physical therapist could suggest other types of assistive devices that may be easier to use in the kitchen, such as a quad cane or a walker with a tray, to see if these devices would increase usage. Approaching this discussion from the viewpoint of the patient may allow for better incorporation of the suggestions into the patient’s daily life, which must occur if the intervention is


to enhance resiliency. Both the physical therapist and nurse can facilitate family participation by having family members encourage use of the assistive device in the home and helping to remind the patient when she forgets to use the device. From a nursing perspective, the patient’s medications can be a contributing factor to fall risk. The patient’s use of an antidepressant may help in decreasing the anxiety or fear associated with falls, but this medication also increases fall risks, especially with movement from sitting to standing positions or with fast or sudden movement or position changes. While the patient is a physician and may have an understanding of antidepressants in general, education about fall risks while she is taking this drug should be discussed. The antihypertensive medication may slow the heart rate to a level that increases the risk for falls. The use of baby aspirin should also be recognized as a potential risk for the patient if she does fall. The nurse will educate family members about the patient’s medications and the importance of immediate medical evaluation after a fall. In addition to these fall risk factors, the health care providers must take into account the psychological impact of falling and being more home-bound on the patient. Fear of falling or falls that do not result in injury can be problematic, resulting in further fear of falling, decreased physical activity, social withdrawal, diminished confidence, and increased numbers of future falls.12,13 The nurse should determine the patient’s level of concern or fear regarding falls both inside and outside the home. The patient’s family members should also be questioned about their concerns regarding falls. In addition to the fear of falling, the patient now leaves her home less frequently, which may have a psychological impact. While the patient has not expressed feelings of isolation or depression, these feelings could occur over time if the patient becomes more home-bound. Isolation has been associated with decreased resilience, with those with fewer depressive symptoms having higher resilience levels.14 Fall risk assessment of the environment Fall risk assessment should also include careful evaluation of the home environment, examining factors such as uneven stairs or stair treads, uneven floors, throw rugs, unstable furniture, wet areas on floors, and adequate lighting.15,16 This patient spends much of her time at home and the practitioner should collect careful assessment data including the number of rooms, ease of access into rooms, ease of access to the exterior of the home, and identification of potential problems resulting from the 20 stairs accessed by the single hand railing. The interior of the home would also be assessed including the location and amount of furniture, rugs, plants, decorative items and other items that might increase fall risks. Many types of flooring increase the risks for falls, especially the use of scatter rugs or unsecured flooring materials. Fall prevention interventions Once fall risks have been assessed, the nurse and physical therapist should focus on eliminating or modifying fall risk factors through a comprehensive fall prevention program designed to include activities such as exercise and strength training, balance and gait training, use of assistive devices, and patient education.17,18 The patient’s family will be included in these interventions, consistent with the cultural values of this patient. The physical therapist will be directly involved in the exercise instruction to improve strength and balance. This may include abdominal and lower extremity strengthening exercises in a variety of positions, beginning with supine and seated positions for safety, and then progressing to standing exercises. Sit-to-stand exercises

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will address lower extremity strengthening in a functional manner for transfers. Standing exercises may include tandem balance, tapping a foot on a stair, and catching a ball with assistance as needed. Specific areas of deficit from the MINI BESTest direct the PT to appropriate dynamic balance exercises, such as lateral movements, multidirectional lunges, and dual task balance exercises involving mental math. Exercise instruction by the PT will also focus on gait training, both to improve speed and quality. Use of timed games, auditory feedback to encourage consistent cadence, and the treadmill may increase gait speed. Stair training will include instruction in leading with the weaker left lower extremity when descending stairs as an initial safety measure. This will later be progressed to using the stairs as a method to work on strengthening via step-up exercises leading with the weaker left lower extremity and eventually to descending with the stronger right lower extremity. Environmental modifications serve as important fall reduction or elimination strategies. Changes to the home environment to ensure functional lighting, grab bar placement in bathrooms, removal of uneven stair treads or floors, replacement of uneven surfaces, education of home clutter, furniture placement to ensure safe movement in the home, and removal of furniture that is not sturdy will serve to promote safety and fall reductions. The nurse should work with the patient, her husband, daughter and grandchildren to develop a fall prevention checklist for both the home and garden. Both the physical therapist and the nurse can provide patient education and instruction in activity modification to minimize fall risk. As fall risks are modified or eliminated, fear of falls would be reduced and resilience would be increased. As the patient’s balance improves to a point where she is safe to begin a group exercise class, either the nurse or the physical therapist might suggest a community-based program to promote regular exercise. Tai Chi may be one such program that would benefit this patient. Tai Chi has been shown to be effective in reducing balance impairments in patients with mild to moderate Parkinson’s disease19 and has beneficial effects on a range of psychological well-being measures such as depression and anxiety.20 As the patient progresses toward discharge from formal physical therapy sessions, a community-based exercise group would allow her to continue her rehabilitation process. Resilience would be enhanced through recommendations for group or community-based exercise programs by using existing support networks or developing new ones. Case study 2: geriatric patient with stroke History of present illness The patient is a 70 year old right-handed male who lives with his long-term life partner of 20 years and their cat in a second floor apartment in a large city. He requests that health care personnel address him by his first name. He has been employed as a faculty member at a local community college for the past 25 years. His partner works as an accountant in a large accounting firm, frequently working 50e60 h per week. Eight days ago the patient experienced sudden onset of dizziness, balance loss, right-sided weakness, and expressive aphasia. After a four-day hospital stay for acute stroke, the patient was strongly advised to transfer to a rehabilitation unit. While the patient had health insurance coverage for inpatient rehabilitation facility care, he insisted on transfer directly to his home with rehabilitation services provided less frequently than in the inpatient setting. The patient was concerned he would be treated differently or discriminated against in the rehabilitation facility because he is not married to his life partner. He noted that these concerns are regularly voiced by many of his friends. The patient has now been discharged to his home with home health nursing care and home PT three times per week.

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A home health aide is assisting in the home, 4 h per day, 3 days per week. The patient’s chief complaint is right-sided hemiparesis. He denies any pain. His preferred learning style is a combination of discussion followed by written materials. Prior level of function Prior to his stroke, the patient was physically active, regularly engaging in mountain climbing, sailing, biking to work, and bike racing on weekends. He frequently participated in 100-mile bike races and had planned an extensive bike race in Europe which was canceled following his stroke. He shared shopping, cooking, and cleaning activities with his partner and often entertained their friends by cooking gourmet dinners and planning weekend trips to local wineries. His primary modes of transportation included cycling and driving. Home environment The patient lives in a 3-bedroom flat on the second floor of a small apartment building. There are 16 stairs with bilateral railings from the entry to the second floor. There is no elevator in the building. The bathroom has a tub and shower combination without grab bars, so the patient now relies on bathing at the bathroom sink. The patient does not have any adaptive equipment for the toilet. Transportation The patient has been home-bound due to the stairs, with the exception of a visit to his physician for follow-up examination. Friends have volunteered to drive the patient as needed. Social history The patient has a PhD in English literature. He enjoys teaching at the community college but has been thinking about retirement within the next five years. The patient has no siblings or extended family members; both parents are deceased. Both the patient and his partner are active members of the city’s gay community, spending time with neighbors and friends in a wide range of social activities. The patient’s partner took emergency family leave from his job following the patient’s stroke, returning to his work as an accountant on a part-time basis in the past week. The partner now assumes responsibility for the cooking, cleaning, and shopping, and assists the patient with eating, bathing, dressing, and other activities when the home health aide is not available in the evenings and on the weekends. Patient goals Return to his functional abilities prior to his stroke so that he can resume biking as well as social outings and hosting dinner parties with his friends. Review of systems Neuron-musculoskeletal The patient is currently experiencing right-sided weakness with the strength loss more pronounced in the right upper extremity compared to the lower extremity. Active range of motion in the right arm and leg is decreased; passive range of motion in the right extremities is within normal limits. Strength grossly measures 2/5 in the right upper extremity and 3/5 in the right lower extremity, with 4þ/5 strength in the left upper and lower extremities. The patient has some active movement in his right hand and wrist and can grasp large objects, although he lacks opposing thumb control on the right hand. He presents with minimal spasticity in the finger flexors, wrist flexors, and elbow flexors. His ability to hold a spoon, fork, toothbrush, comb, and pen is limited due to the lack of thumb

control. He is unable to type or write. He can grip a urinal handle with his right hand but has trouble positioning it appropriately; he can hold the urinal with his left hand without difficulty. The patient can perform bed mobility and transfers from supine to sitting independently; he chooses to roll to his right side for supine-to-sit transfers. He requires minimal assistance for moving from a sitting to a standing position. He is able to ambulate 4 feet from his bed to a chair or wheelchair with minimal assistance and use of a single point cane on his left side. He has difficulty clearing his right foot in swing phase of gait, due to delayed activation of the right anterior tibialis. He currently uses his wheelchair for most mobility in the home, and he propels the wheelchair with the use of his left foot and left leg. When asked to complete the Timed Up and Go Test (TUG), the patient initially refuses, stating that he cannot ambulate the full 10 feet in each direction. With encouragement from the PT, he is able to complete the TUG with use of the cane and moderate assistance from the PT in 25 s. On the stairs, he requires use of the railing and moderate assistance from the PT for descending and ascending 5 stairs using a step-to gait pattern. He requires a 2-min standing rest break after 5 stairs. Psychological He is depressed, has difficulty sleeping at night, and is afraid he will fall with increased movement. While the patient has experienced some improvement in motor strength and movement in the right extremities following his stroke, he expresses anxiety about his hemiparesis and is concerned he will never fully recover. Clinical reasoning related to culture and resiliency: Culture, stigma and discrimination This patient’s culture is shaped in large measure by his sexual orientation. He identifies himself as a gay male with a long-term partner of 20 years. Both the American Physical Therapy Association and American Nursing Association promote the importance of treating all patients with respect, regardless of sexual orientation. The American Physical Therapy Association’s Guide to Professional Conduct states: “Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability.”21 The American Nurses Association Code of Ethics states in part that the nurse practices in all professional relationships with compassion and respect for the inherent worth, dignity, and uniqueness of all individuals, unrestricted by any considerations of economic or social status, personal attributes, or the nature of health problems.22 Stigma is identified as a significant issue faced by aging members of the gay and lesbian community who note years of dealing with societal fear, hatred, and homophobia.4 Many of these individuals either conceal sexual identity or as in this case, avoid health care service delivery that may be perceived to be damaging or potentially abusive. Stigma creates a climate of fear and mistrust for members of this cultural group that exacerbates problems and makes the provision of culturally sensitive services difficult or impossible.23 Discrimination or inequities in areas including health care and housing have been identified on a national level for members of the gay community who have been exposed to years of mistreatment in areas such as hospital visitation rights, Medicare and Social Security coverage, and health decision making.23 While same sex marriages have been legalized in many states, acceptance of marriages and acceptance of many gays and lesbians in long-term relationships continues to be problematic for many individuals. Many gays and lesbians face ongoing discrimination in care settings because their relationships are not formally recognized or legally protected.23


In this case, the patient has concerns of stigma and discrimination and refuses care in a rehabilitation facility. Gay individuals identify communication and interpersonal skills of health care providers affect their quality of care.24 Incorporation of the patient’s partner into care planning as appropriate is also strongly recommended. Allowing a friend or partner to be with the patient during the health care visit has been identified by gay patients as an important part of professional practice.25 The nurse and PT will need to communicate clearly with both the patient and his partner the importance of not withholding information due to concerns about possible discrimination, while providing a clinical atmosphere that is supportive and understanding. Resiliency Many of the resiliency issues discussed in the other cases also apply to the present case. The patient expresses feelings of depression, and those individuals with fewer depressive symptoms have higher resilience levels.14 The patient’s mobility level is also leaving him relatively home-bound, and given his previously active social life with friends, he may gradually begin to feel isolated. Isolation has been associated with decreased resilience.14 Clinical reasoning from a physical therapy perspective Important aspects of this patient’s culture are his personal goals of attending social outings with friends and resuming biking. The patient’s culture also encompasses his desire to have his partner actively involved in his rehabilitation. As discussed in the fall risk case, gait speed affects a patient’s resiliency, and thus the PT will work to improve gait speed with this patient. Physical therapy interventions to meet goals focused on culture and resiliency *Sit-to-stand transfers The PT will work with the patient on sit-to-stand transfers, with emphasis on equal weight bearing on the lower extremities, using the right upper extremity to stabilize the patient on the bed or chair, progressing from a higher sitting surface to a lower surface. This will be practiced on different surfaces and at various speeds. The patient’s partner will be instructed in how to appropriately guard the patient during this activity. The PT will educate the patient about how important independent sit-to-stand transfers are to allowing the patient to resume typical social activity outings with his friends. *Gait activities This will begin with pre-gait activities e balance training with active dorsiflexion to sway out from a wall at various speeds, with progression to staggered stance with anterior weight shift and active dorsiflexion to clear the right foot off floor in front of a mirror. Next will be an advancement to gait training with an SPC, with verbal cues and auditory pacing from a metronome or music for increased right ankle dorsiflexion to clear the right foot in swing phase of gait. An ace wrap and/or use of a device with functional electrical stimulation may be used to help facilitate dorsiflexion with the appropriate timing for gait. Daily gait tolerance goals, as well as the timed up and go test will be used for motivation to improve gait tolerance for social outings, as well as gait speed to enhance resilience. *Strengthening exercises The patient will be instructed in strengthening exercises for the lower extremities that the patient can perform independently in supine and sitting positions. Upper extremity strengthening exercises will be developed in conjunction with the occupational

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therapist strengthening of both the upper and lower extremities will be important to reach the patient’s goal of hosting dinner parties. *Balance exercises The patient’s partner will be instructed to appropriately guard the patient with all balance exercises. These exercises will be directly focused on functional activities, such as unilateral stance while lifting the right lower extremity to step over the tub, carrying objects from the refrigerator to the kitchen table, and reaching for objects out of the patient’s base of support when cooking. Because the patient enjoys cooking and hosting dinner parties, many of the balance exercises can be performed standing in the kitchen and can incorporate upper extremity strengthening and fine motor activities. *Adaptive equipment Following a careful assessment of the home environment, the nurse and PT will work with an occupational therapist to install adaptive equipment as needed such as a raised toilet seat, shower bench, and grab bars near the toilet and the shower. If dorsiflexion strength limitations continue to persist, the patient may benefit from consultation from an orthotist. *Because biking is an activity the patient wants to resume, getting the patient actively involved with biking immediately will address the patient’s personal goal and improve his endurance. A seated foot bike (a pedlar) will allow the patient to begin some biking at home immediately, until his strength and balance will allow him to later progress to using his regular bike on a bike trainer. *The patient will be provided with written instructions and pictures of all his exercises to meet the patient’s preferred learning style. The therapist will create a daily home exercise log that the patient can complete to document performance of these exercises, which will also reinforce fine motor skills of writing on the home program log. Clinical reasoning from a nursing perspective The nursing approach to this patient includes the following: (1) psychological assessment following stroke; (2) psychological interventions following stroke; and (3) summary of nursing interventions. Each of these areas will be discussed further. Psychological assessment following stroke Psychological problems are commonly encountered following stroke. While some of these problems are directly the result of cerebral damage, other problems occur as a result of stroke-related changes. Depression is one psychological problem seen frequently following stroke. Some researchers note that about thirty to fifty percent of all stroke survivors suffer depression. Depression is frequently characterized by sleep problems, lethargy, lowered self esteem, and withdrawal from society.26 Depression can reduce motivation for recovery following stroke, may worsen stroke outcomes, and may impact a patient’s overall resilience. While the PT has a treatment plan focused on improvement of motor deficits in this patient, the nurse will additionally need to collect assessment data from both the patient and his partner regarding potential psychological problems resulting from the stroke. The nurse can use one of many instruments available to measure depression. Instruments such as the Beck Depression Inventory27 can provide the nurse with a comprehensive assessment of the patient’s depression. Additionally, the nurse can talk with the patient’s partner as well as the home health aide, the PT, and other caregivers who may be in the home to collect assessment data regarding the extent and the severity of the patient’s potential

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depression. The nurse should also plan to talk with and assess the partner if necessary. Caregiver stress and burnout are problems that the partner may be experiencing during the patient’s rehabilitation. Both this patient and his partner should be assessed and treated if necessary together as a family. Psychological interventions The nurse should work with both the patient and his partner to deal with any identified psychological problems. Depression, if identified, should be evaluated by the physician or psychologist and antidepressants recommended to reduce or relieve symptoms including sleep disorders that the patient has experienced. Additional medications for anxiety and sleep can also be recommended by these clinicians. The nurse can work with the patient and his partner to discuss goal attainment post stroke. The patient wants to return to biking and his previously active lifestyle. The nurse can work with the patient to suggest interim strategies such as trips outside of the apartment on a limited basis to return the patient to limited activity. The nurse should also plan to discuss activities that begin to return the patient to his former active lifestyle including the re-introduction of social events with close friends in their community. While the patient may be unable to cook or plan dinners or drive to wine tasting events, he can meet with friends for simple meals or make arrangements with friends for short drives away from his apartment. These activities may help to reduce social isolation and thus improve depression and increase resilience. Case study 3: geriatric patient with congestive heart failure The patient is an 86 year old Caucasian male of Czech descent who lives alone in a small Midwest town in the United States. He is currently hospitalized for management of advanced stage congestive heart failure (CHF). While drug therapies and lifestyle modifications are used in the treatment of CHF, there is currently no cure for these problems and the prognosis for CHF remains poor. The patient is in a small regional hospital about 25 miles from his home. The medical plan is to discharge him to home in 1e2 days. Both physical therapy and nursing have been involved in his care in the hospital. Nursing will handle the discharge planning with input from physical therapy. The patient’s chief complaints are weakness in both legs, unsteadiness on his feet and limited endurance. His personal goals are to 1) return home; 2) drive his truck in order to perform Instrumental Activities of Daily Living (IADLS) and see his friends; and 3) go fishing. The patient prefers to be addressed by his first name. When asked about a preferred learning style, he requests to have all home interventions written down as he describes a hearing loss. History of present illness One month prior to hospital admission the patient started to develop increased edema in his legs, abdomen, and eyelids. He also reported increased fatigue and leg weakness with walking around the house. The patient reports at least one fall in the home over the past month which he describes happening when his legs became weak and gave out. The patient saw his primary care physician who referred him to his cardiologist who in turn admitted him to the hospital. The cardiologist performed an extensive workup and determined that the patient’s CHF had progressed to an advanced stage. Pain The patient reports that pain is not limiting his function. The leg weakness and buckling are the limiting factors in the patient’s ability to ambulate. He does complains of aching in his back and hip

which is almost constant and rates a 5/10 on a numeric pain rating scale where 0 is no pain and 10 is excruciating pain . Past medical history The patient has a history of two myocardial infarctions, first at age 52 and second at age 60. Following the second infarction the patient had a coronary artery bypass graft procedure utilizing 3 grafts. In his early seventies the patient developed cardiac arrhythmias and had a pacemaker implanted. In his late seventies he experienced an episode of ventricular tachycardia and his pacemaker was replaced with a dual pacemaker/defibrillator unit. The patient also has a history of orthopedic conditions. Thirty years ago the patient had several low back surgeries, the last one being a fusion of L4-L5-S1. The patient has osteoarthritis of the hips, knees, and spine. He has had bilateral total hip arthroplasty and a right total knee arthroplasty. The patient continues to report hip and low back pain which he takes medication for but tries not to let these conditions impact his function. Personal contextual factors The patient has a high school education and worked full-time as a manual laborer for the County Road Department and also farmed the family land at night and weekends. The patient retired from the County job 24 years ago but continued to participate actively in farming until about 10 years ago. His role in farming now is to crop share with a tenant farmer. Social activities for the patient include socializing with friends at the auto parts store and to go fishing as often as possible. The patient lost his wife of 63 years about one year ago. He has one adult daughter who lives 1400 miles away. The daughter regularly calls but is unable to come out to visit more than 2 times per year due to a heavy work schedule. She has been involved in the current health planning for her father via telephone. The patient lives on social security benefits, a modest pension from the state, and farm income. The patient feels this is adequate financial resources to cover his living expenses but he worries what might happen if medical bills accumulate that may not be covered by insurance. He is particularly worried that he might be forced to sell the farm which is homesteaded land and a central part of his family heritage. His primary insurance is Medicare but he also has a supplemental plan. Environmental contextual factors The patient lives in a small ranch style home with 3 stairs into the home and one railing. The patient needs to drive to get groceries, attend medical appointments, etc. but currently he cannot get in/out of his truck. The small town in which he lives has no public transportation system but he indicates he has some friends he can call to drive him. The town also has one assisted living facility, which is currently full, and two long term care facilities. Assistive device history Patient has used a single point cane (SPC) in the past. In the hospital PT used a front wheel walker for ambulation around his room. At home the patient “furniture surfs” using couches, chairs, walls for support as he walks through his very small house. Prior level of function Two months prior to this hospitalization the patient was able to perform all activities of daily living (ADLs) and IADLs independently with difficulty. The patient was driving and participating in all social activities. More recently, the patient has only been able to do minimal ambulation in his home: from bed to bathroom, to living room and kitchen. He is unable to go outside of his home as he cannot ascend or descend stairs. Family friends have been bringing him some groceries or meals and driving him to medical


appointments. He used a walker when out of the house and currently uses a walker in the hospital. Physical exam Joint range of motion (ROM) Upper and lower extremity joint ROM is adequate for his current functional level. Hip flexion is approximately 105 bilaterally. Knee flexion is 120 on the left and 110 on the right. Ankle dorsiflexion is 0e5 bilaterally. Muscle strength Gross muscle strength testing of the hip muscles reveals 4/5 bilaterally in all major groups (flexors, extensors, abductors, adductors). Quadriceps strength is 4/5 bilaterally. Hamstring strength is 3þ/5 bilaterally. Ankle dorsiflexors and plantarflexors are 4/5 bilaterally. Transfers Patient is able to side-to-side roll in bed independently. Patient requires minimal to moderate assist to sit at edge of bed. Sit to stand requires moderate to maximum assisting and varies from session to session. All transfers have improved over the 3 day course of stay in the hospital. Gait Patient ambulates 20 feet using the front wheel walker and moderate to minimal assist. Distance ambulated and level of assistance needed have consistently improved while in the hospital. Stairs The physical therapy plan is to work on stairs the final two days of the patient’s hospital stay. Current physical therapy treatment Emphasis to date has been bed and edge of bed strengthening exercises, transfers to bed side chair, and ambulation to the bathroom and into the hallway using a front wheel walker. Transfer level of assist is minimal to moderate; assistance with walking is now minimal to contact guarding. Clinical reasoning for discharge from a nursing and PT perspective This older adult has an advanced stage chronic condition that alone can limit his ability to participate fully in life. In addition he has musculoskeletal complaints, appears physically deconditioned and limited in mobility and function which adds further concerns of risk of fracture due to falls, social isolation, and depression. All of these stressors can reduce the resiliency of this patient.28 Wells, Avers, and Brooks14 examined the relationship of physical performance measures to resiliency in a sample of older Roman Catholic nuns. They found a positive relationship between gait speed and resilience in these women, thus supporting the importance of physical health in older adults. It is imperative that the Medical, Nursing and PT health practitioners design a plan of care for discharge that addresses these variables in context with the patient’s cultural perspective in order to maximize resiliency. Important cultural factors for this patent include: age; geographic location of small Midwest town with limited health care resources; lower middle class socioeconomic status; high school educational level; prior work involved manual labor and farming; lives alone; recently widowed. Socioeconomic status (level of income, education, occupation) The patient has a high school education and spent his working years in jobs of heavy manual labor, road/bridge construction and

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farming. Given his current concerns about finances for medical bills, the patient may likely be in the lower end of the middle class. The National Heart Failure Project of 2006 found an increased risk of readmission and 1 year mortality of low socioeconomic patients with heart failure. This data suggests that socioeconomic status may influence patient outcomes after hospitalization for heart failure.29 Although the patient currently uses the health care system for care of his condition, the discharge plan of care must keep in mind his current socioeconomic situation. Insurance coverage must therefore be considered when recommending services, adaptive equipment, or medications as the patient may not be able to pay out of pocket for higher priced medical procedures or services. Personal beliefs The patient was born in the United States but has immediate family who immigrated to the United States from Czechoslovakia. The family homesteaded land in the Midwest and this farm became their home and economic support. Farm work is difficult and comes with many kinds of health hazards including stress.30 According to White and Cessna, farming ranked in the top 10 of 130 high-stress occupations in North America. This stress comes from financial pressures, weather, grain markets, and government policy.30 Although the patient no longer actively performs the farm work, he is still invested in the business and relies on this for part of his income, therefore the stress associated with farming remains in his life. Personal environment The patient lives in a small town in the Midwest. Healthcare services include primary care physicians, a small hospital with some emergency services and physical therapy, one assisted living facility which is currently full, and two long term care facilities. The lack of more assisted living situations places the patient at a disadvantage. While he probably would do the best in assisted living, the facility is full. The patient has indicated he will not consider a long term care facility at this time. He prefers to be discharged to home. Given this, his discharge plan of care will need to consider inehome nursing and physical therapy services, adaptive equipment needed at home, possible ADL assistance from a home health aide, meals on wheels services, and transportation arrangements. Other personal factors The patient lives alone in a one story home with stairs to access the house. At the current time he is unable to walk stairs independently. The patient describes good social support but his daughter lives 1400 miles away and cannot be present to assist with home care. The patient has a network of friends in his community but many of them are also older adults and may be unable to assist him in and out of the home. This may place the patient in a situation where he can’t leave the house independently and he could become socially isolated. Social isolation has been identified as a contributor to depression symptoms.31 To fully address the patient’s condition and to put the patient at the center of care, the home health practitioners must address the patient’s goals along with those set by the practitioners. The patient has stated he wants to go home, drive his truck to see his friends and fish. While some of those goals may not be immediately attainable, encouraging friends to visit the patient at home and perhaps take him out for socialization with friends will be important first steps. In addition both Nursing and PT should provide interventions that will work towards increased mobility, strength, and endurance to move towards the patient’s goal of outside of home socialization and recreational/leisure activities.

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Physical therapy discharge plans Physical Therapy will work collaboratively with Nursing on the discharge plan. The problem areas addressed by PT will include: 1) Lower extremity weakness; 2) Transfer ability from bed to sit, sit to stand and stand to sit (including the toilet); 3) Gait and stairs mobility; and 4) Progression to out of house activities as safe and appropriate. A recommendation for home care PT will be made to address these goals. When the patient can safely and easily leave his home, PT services may continue on an outpatient basis at the local hospital based PT department. In all of the problem areas addressed, it will be important to educate the patient about how these interventions collectively work towards the patient’s goals of resuming social and recreational/leisure activities outside of the home. Strengthening exercises initiated in the hospital will be continued at home and progressed in resistance or repetitions as tolerated. By increasing repetitions for each exercise or increasing the daily frequency of exercise, muscle endurance can also be addressed. Muscle groups of focus will include the hip extensors, hip abductors and quadriceps. These muscles are important muscles that work eccentrically against gravity to prevent frontal plane hip instability, hip and knee buckling or giving way.31 If the hip and knee are not stable during gait, the patient is at risk for falling. The patient needs to be able to move freely in his home. Both PT and Nursing will do a home assessment to remove hazards and suggest adaptive equipment. It is likely that some sort of railing for his bed, grab bars for the bathroom, elevated toilet seat and elevated seating in other areas may be needed to minimize the physical exertion of the patient and decrease the forces that his muscles must control. Minimizing physical exertion will help reduce the fatigue and weakness feelings of the patient. The patient will need to use an assistive device at home instead of “furniture surfing.” This is important to reduce the risk of falling. While the patient will likely continue to use a front wheel walker for out of house activities, a quad cane may be more practical to use in the home. The PT will work with the patient in the home to use these assistive devices and also go up/down the stairs when appropriate. Nursing considerations for discharge planning From a Nursing perspective, discharge planning will be focused on the following: (1) fatigue caused by the congestive heart failure (CHF); (2) chronic pain caused by hip and lower back orthopedic problems; and (3) quality of life issues related to his chronic illnesses. Nursing assessment of the patient as well as the home environment would be focused on these issues and nursing interventions would then be proposed based on data gathered during the assessment. Fatigue and weakness are several of the major symptoms associated with CHF, especially in later stages of the disease process. The nurse will need to evaluate the energy the patient requires to complete ADLs for basic functioning in the home environment. Assessment of the home environment will also provide important information regarding treatment of fatigue and weakness. The patient has indicated that he couch surfs or uses strategically placed furniture for support as he navigates through his house and the nurse should take this into consideration during the home assessment. Both fatigue and weakness can increase the patient’s risk for falls so a comprehensive assessment for fall risks, as described earlier in the article, should also be completed by the nurse. Pain occurs as the result of multiple physiological and psychological causes and is unique to each individual. It is important to also consider each individual’s distinctive coping styles, culture, ethnicity, prior pain experiences, and emotional health. Researchers have noted that Caucasian patients are more focused on

strategies to control pain through a number of treatment options while patients from other ethnic groups tend to minimize or ignore pain experiences.32 This patient has chronic orthopedic problems in the hips and lower back that currently are the cause his ongoing and chronic pain. Chronic pain may also limit his abilities to perform ADLs and may complicate deficiencies from the CHF. The nurse will need to perform a detailed pain history and a comprehensive list of current medications and other strategies used to relieve pain. The nurse will need to collect assessment data on the home setting and surrounding environment following discharge from the hospital to identify factors that may either exacerbate or relieve the chronic pain. Quality of life is viewed as a sense of general well-being, of happiness, or joy in living that is not dependent on health status or the absence of chronic illness. For nurses, the goals connected to promoting quality of life include maximizing quality indicators of well-being with an emphasis on illness management rather than cure, delay of disability or deterioration, and enabling patients to move toward death with comfort, peace, and dignity.33 In the patient with CHF, it is important to note that the overall prognosis is poor in patients with CHF and is accompanied by compromised quality of life and limited therapeutic options.18 While assessing for quality of life indicators for individual patients, the nurse should also consider recommending palliative care services for patients with late stage CHF. Palliative care is an approach to service delivery designed to promote quality of life for both patients experiencing life threatening illnesses and their families. The palliative care approach integrates assessment and treatment of pain, as well as physical, mental, and spiritual problems. Palliative care and the inclusion of hospice services are considered by health care providers when curative treatments are no longer effective or available.33 Consideration of palliative care services may also serve to enhance resilience, especially in the setting of frail elders with CHF, through encouragement of connections with social support networks, links to community resources, and regular physical activity.33 In summary, this patient has been diagnosed with CHF and demonstrates many of the symptoms seen in the late stages of this disease process. In combination with his chronic pain, the CHF symptoms contribute to fatigue, weakness, and difficulty in performing many ADLs, IADLS, and can diminish the patient’s quality of life. Careful Nursing and PT assessment of the patient’s functional and emotional states and the home environment will allow progress to be made towards the patient’s goals, especially those connected to social activities at the local store and fishing with friends. In turn this may promote a better sense of well-being for the patient and overall improvement of quality of life.

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