Grand Rounds
NURS 441-Clinical Management of Rehabilitation Clients
Purpose of Assignment
To provide the student an opportunity to integrate previous knowledge from the sciences to the
care of a client with a physical disability. Also, to provide the student with an opportunity to
demonstrate critical thinking and independent judgments in managing care of a client with a
physical disability
Student Approach to Assignment
The Clinical Management of Rehabilitation Client Grand Rounds Presentation offered me the
opportunity to present a patient to my future colleagues and open dialogue up for a round table
discussion atmosphere. The focus of the session was set by presenting past and pertinent health
history, what the client’s chief reason for needing rehabilitation was and the psychosocial history
that was relevant to her care. The notion of a working concept map was introduced in order to
allow for other members of the group to provide input as to possible nursing diagnosis and
rationale/ nursing interventions that were being utilized to support such diagnosis. Yet, another
aspect of this presentation was to describe a diagnosis that has been a management problem and
develop an alternative intervention.
Reason for Inclusion of this Assignment in the Portfolio
This essential portfolio presentation exemplifies some of the program's core behaviors that were
met during my clinical rehabilitation experience. The following curricular objectives were
highlighted:
 Critical Thinking
 Revises actions and goals based on evidence rather than conjecture
 Case in point: The patient utilized for this presentation has an wide-ranging past
history which includes bronchitis, hypokalemia, anemia, morbid obesity, possible
sleep apnea, fibromyalgia, chronic lymphedema, myasthenia gravis (diagnosed
within last two years), atrial fibrillation with rapid ventricular response
(diagnosed within the past year), obsessive compulsive disorder, chronic anxiety,
depression, hyperlipidemia and congestive heart failure (also diagnosed within the
past year). It should also be noted that she has an extensive history of falls.
General debility was the admitting diagnoses with an increased focus towards
lower extremity weakness and the inability to stand for periods greater than three
minutes or ambulate with or without assistive devices for short distances. Her
general debility is greatly related to the myasthenia gravis. The rehabilitation plan
of action was to include physical therapy sessions to assistance with activity
intolerance and occupational therapy sessions to assist with learning ways to
accomplish active daily living tasks independently. The short term goals initially
set for this client were to be able to stand with minimal contact assist for greater
than three minute and to ambulate a distance greater than twenty feet at a time.
During therapy sessions, one must continuously monitor SPO2% and heart rate
due to periods of atrial fibrillation. During one session the preset goal for the day
was to stand with minimal assistance for a period greater than two minutes.
Through the monitoring of her vital signs it was noted that her heart rate increased
to 255 beats per minutes and her SPO2% decreased to 85%. Actions and goals for
the day were then modified to include bed rest and advocating to the physician for
a change in her cardiac medications to allow for greater control of atrial
fibrillation.
 Nursing Practice
 Applies appropriate knowledge of major health problems to guide nursing practice
 Case in point: As previously stated above, this client had a rather extensive list of
medical diagnoses. Possessing the appropriate medical knowledge of how these
disease processes were inter-related afforded me a better understanding of how to
plan and manage her care. Recognizing that an increase in her heart rate and a
decrease in her SPO2 levels may be an indication that she was experiencing atrial
fibrillation and may need to have her cardiac medications re-dosed to meet her
needs.
 Demonstrates an awareness of complementary modalities and their usefulness in
promoting health
 Case in point: A complementary intervention that I was able to introduce and
educate this patient on was the usefulness of visual imagery. By teaching her to
focus her thoughts on an imagine that she enjoyed, while attempting to maintain
standing unassisted, she was able to progress toward her goal of standing for three
minute period of time.
 Teaching
 Evaluates the efficacy of health promotion and education modalities for use in a
variety of settings with diverse populations
 Case in point: Within the presentation I addressed several aspects of health
promotion. By utilizing the idea of a working concept map I was able to provide
the group, which consisted of several of my peers and a clinical advisor that had
earned her degree as a nurse practitioner, the opportunity to incorporate their
thoughts and rationales into the process. Things such as medications,
interventions, goals, studies completed and medical diagnosis were written on
different color post it notes. These post-it notes were then disturbed to the
audience. Members were encouraged to place the post it under the nursing
diagnosis where they thought it applied best and provide a rationale as to why
they placed it there. This proved to be very enlightening and educational to hear
the differences in opinions and yielded a score of 99/100 fr the overall
presentation grade.
 Research
 Applies research-based knowledge from nursing as the basis for culturally sensitive
practice
 Case in point: The client presented within this assignment fell within multiple
different cultures, the first of which was those of people who were morbidly
obese. She was very aware of society’s views and admitted that she felt
embarrassed and shameful in regards to the amount of weight that she had gained
since being diagnosed with myasthenia gravis. She openly confessed that once she
learned that a side-effect of prednisone was extreme weight gain, she used it as an
excuse to eat comfort foods. The morbid obesity was a contributing factor to a
great deal of her physical limitations. Another culture this client falls within
would be that of the member who feels powerless. This client expressed on
multiple occasions the difficulties that she faced with accepting help from others
and the frustrations related to not having the physical ability to care for herself.
She would often become tearful and apologetic for having to ask for assistance
with what she termed “the simplest of tasks”. This client had also been diagnosed
with obsessive compulsive disorder, chronic anxiety, depression and an extensive
history of falls. The nursing research article applied to this presentation was titled
“Nurses’ response time to call lights and fall occurrences”. Within the study it
discusses an exploratory study that was conducted to prove that nurses will
respond quicker to a patient that has a history of falls then to one who does not.
The fall that occurred while in the facility was reportedly due to the call bell being
out of reach – she relates that as she was reaching for it, she fell out of the bed and
it took an extended amount of time for any of the nurses to acknowledge the bell
after she rang it several times from the floor. This was the first incidence of a fall
within the facility even though she had a documented history of prior to being
admitted to rehabilitation. This incident contributed to the patient’s fears and
insecurities relating to feeling helpless as well as not wanting to attempt other
aspects of therapy due to complaints of increased back and knee pain. We as
nurses may not have control over intrinsic factors such as mental status or reduced
vision or unsteady gait, yet we do have some control over the extrinsic factors
such as physical environment or responding to a call bell in a timely manner.