The large number of surgical procedures, the chronic nature of some diseases, and prolonged convalescence place ever-increasing demands on nurses in the provision of nursing care. This also applies to the field of rehabilitation, and since the workload of physiotherapists is high, the nurse can enter the picture. "One of the competencies of the nurse is to ensure the mobilization of the person and nursing rehabilitation and to participate in the prevention of disorders from immobility" (Decree of the Ministry of Health of the Slovak Republic No. 95/2018, Section 1u Coll.).

In the Czech Republic, rehabilitation nursing mainly includes "positioning, sitting up, basic passive breathing and conditioning exercises, training in mobility, transfer, self-care with the aim of increasing the patient's self-sufficiency, and exercises related to the rehabilitation of communication disorders, swallowing and elimination disorders, methods of basal stimulation with regard to the prevention and correction of body function disorders including the prevention of further disorders from immobility" (Decree No. 55/2011, Section 4, para. j Coll.).

Rehabilitation nursing involves active nursing care of the sick, where the nurse uses all available means within her competencies to prevent the occurrence of secondary changes and complications and helps shorten the patient's return to independent life. She implements preventive measures and thereby prevents deterioration of the health condition. We can speak of a specific form of nursing care in conjunction with routine nursing activities.

A fundamental feature is close cooperation with a physiotherapist or occupational therapist and an effective division of labor. To achieve the most optimal results, the work of the nurse and physiotherapist is consecutive and mutually complementary. "The physiotherapist works purposefully to improve the patient's mobility, self-care, and functional abilities. The nurse maintains these achieved abilities within rehabilitation nursing until the overall improvement of the patient's condition" (Dosbaba et al., 2021, p. 12).

The main therapeutic means by which a nurse can help a patient achieve greater independence are active procedures: breathing exercises, vascular gymnastics, training in self-care activities, mobilization, verticalization and positioning, passive movements as a passive component (Knapová, 2019).

The nurse provides basic nursing rehabilitation care, which is then followed by the physiotherapist with their specialized professional care. This type of nursing is applied especially in long-term care of the sick, in home nursing care agencies and hospices. Rehabilitation nursing requires an active type of nurse willing to cooperate with the entire team, but especially with the patient, with the aim of improving their condition. Appropriately chosen communication and patience increase the chances of gaining the patient's cooperation. The nurse's advantage is that she is available 24 hours a day within one department and can fully dedicate herself to the patient during this time.

Let us gradually examine the individual means through which a nurse can help the patient.

Positioning is a set of positions with preventive, therapeutic, and relieving significance. The patient assumes the position themselves or the nurse changes it, regularly and systematically. The patient must be placed in bed in such a way as to prevent complications arising from prolonged immobility (prevention of immobilization syndrome, bedsores, joint stiffness, shortening of muscles and tendons, muscle atrophy, etc.). Positioning alleviates pain, allows relieving certain parts of the body from pressure and friction, and prevents secondary skin changes (Grajcarová, Kosťová, 2017). Each change of position is recorded in the positioning plan. The recommended time for changing position is two hours during the day and three hours at night, or as the patient's condition allows.

Passive movements are performed by the nurse during manipulation of an immobile patient during positioning and especially during hygiene. Passive movements can also be performed by a device, e.g., a motorized splint. This type of movement has a preventive character because it prevents muscle atrophy and degenerative changes of joint capsules (Knapová, 2019).

Active nursing competencies include mobilization and verticalization of the patient, or how to get them out of bed as soon as possible but effectively and safely. Initially, we sit the immobile patient up for a while several times during the day according to the patient's condition. It is necessary to realize that if the patient has been lying down for a long time, pressure decompensation and fainting may occur. For a bedridden patient, sitting up is an intense experience, and appropriate communication must be chosen; if decompensation occurs, the patient should be laid back in bed and we should wait until the condition stabilizes (Mattová, 2021). Once the sitting-up phase is mastered, we slowly stand the patient on their feet, practice transfers from bed to wheelchair and back. After gaining strength and courage in standing, the first steps can be taken. All of this can and may be performed by a nurse who assists the physiotherapist using aids such as a walking frame, walker, axillary crutches, wheelchair.

Training in self-care activities or activities of daily living such as hygiene, dressing, undressing, eating, simple toileting in bed, helps the patient gain independence from the nursing staff. The nurse contributes mainly through appropriate communication, a patient approach, and the choice of suitable aids.

Active movement is performed with the patient by the physiotherapist, but it should be mentioned since the nurse encourages the patient to repeat movements, motivates them to activity during the absence of the rehabilitation worker, and guides the patient toward activity.

Breathing exercises are mainly performed by the physiotherapist, so-called respiratory physiotherapy. The nurse takes care of airway hygiene and, upon the recommendation of the physiotherapist, assists the patient with coughing and static breathing exercises, assists the patient with inhalations, educates and motivates the patient to perform active breathing exercises, and positions the patient to ensure free and easy breathing (Ištoňová et al., 2009).

Prevention of thromboembolic disease through vascular gymnastics, i.e., non-pharmacologically, is achieved mainly through positioning, early ambulation, and improving venous return (elastic stockings and bandages of the lower extremities) with the active participation of the nurse and physiotherapist (Mrzenová, 2011).

Within our department, nurses operate motorized splints for patients after knee and hip joint replacements, administer cryotherapy, and since February of this year, administer gas injections and bioptron light therapy. We have a specialized nurse who works exclusively with amputated patients. After amputation, she teaches them how to care for the stump and shape it for the prosthesis, provides them with psychological support, and of course teaches them exercises they should repeat subsequently at home. She also arranges all subsequent care with them in our department. During the summer, she organizes a so-called FIT week focused only on amputated patients with the aim of rehabilitation and shared activities.

Rehabilitation Nursing as a Tool for Prevention of Pressure Ulcers

Bedsores are a problem that troubles many patients and nurses. It is damage to the integrity of the body cover resulting from the local action of pressure. Pressure on the skin of areas located beneath it can lead to necrosis and the formation of a pressure ulcer. In addition to the direct effect of pressure on the skin surface, a pressure ulcer can also arise as a result of friction against the bedding, when shear forces occur, causing the skin layers to shift against each other with subsequent compression of blood vessels.

Classification of pressure ulcers: 1st stage - pressure ulcer without skin damage, - mild swelling, redness, tenderness, - changes are reversible, - even such a pressure ulcer can very quickly change into the most severe type of damage, 2nd stage - pressure ulcer with partial skin damage, - the affected area is red, swollen to purple, circulation does not recover upon pressure testing, - a blister appears, the upper layer of skin is exposed, the wound is superficial, resembling an abrasion, 3rd stage - pressure ulcer with damage to all layers of skin, - in rapidly developing pressure ulcers, the pressure area is covered by a dry, black necrotic eschar, - this involves necrosis of all layers between the bone and the skin, - after removal of the necrotic tissue, an ulcer with wide margins develops, - it is advisable to perform a wound swab for bacteriological examination due to frequent wound infection, 4th stage - pressure ulcer with full-thickness skin loss with extensive tissue necrosis and damage to muscles, tendons, and bones, with undermining and pocket formation, - wound swab for bacteriological examination is necessary, - surgical treatment.

With 3rd and 4th stage pressure ulcers, there is a risk of septic complications.

Pressure ulcers can develop on virtually any part of the body. The greatest risk occurs when the pressure of the body and the counter-pressure of the mattress act over bony prominences with a thin subcutaneous fat layer. Predisposed locations include the sacral area, heels, ischial tuberosities, the area over the greater trochanters, and the lateral malleoli. 95 % of pressure ulcers occur precisely in these areas. They can also develop in the area of the temporal bones, ears, cheekbones, mandible, nose, shoulder, little finger and thumb, and other places on the human body with a thin fat layer.

The formation of pressure ulcers is influenced by six factors: moisture, hygiene, nutrition, body temperature, anemia, and mobility (Kozierová, 2004). Based on these data, high-risk patients can be identified and prevention can be emphasized, which is significantly less demanding than treating an already developed pressure ulcer.

As described above in the article, rehabilitation nursing is primarily a preventive tool. Immobile patients are mobilized by the nurse and physiotherapist with the help of support staff. Together they perform positioning to relieve predilection sites from pressure. Every patient admitted to our hospital has the Norton Scale assessed, which determines the risk of developing a pressure ulcer, with the danger of pressure ulcer development occurring at fewer than 25 points. Upon admission of a patient with an already developed pressure ulcer, a nursing record of the wound or pressure ulcer is also established, where the pressure ulcer is precisely recorded, its size, stage, and planned treatment. The patient is provided with an anti-decubitus mattress and all available anti-decubitus aids. The nurse, in cooperation with support staff, positions the patient according to the positioning schedule – every two hours during the day and every three hours at night.

At the same time, she also cares for the patient's skin, keeping it dry and clean; for moisturizing and protecting the skin, she uses designated products. Visual inspection of predilection sites is performed with each turning of the patient. The patient is provided with necessary hygiene care in bed, and if possible within mobilization, we can assist them with showering.

The patient is supported in self-care activities; fluids and food are within reach, and we try to have them manage these activities independently. They are encouraged in basic hygiene care such as brushing teeth, washing their face, combing their hair. If within the patient's strength, they can also be seated in a chair.

For mobilization, our physiotherapists step in and, in cooperation with the nurse, try to teach the patient to get out of bed, stand by the bed, and take their first steps. We have walking frames, walkers, axillary and forearm crutches available. They also perform passive exercises with patients in bed. After gaining more confidence, the nurse accompanies the patient to the toilet, bathroom, or even the dining room. All these activities are performed by the nurse with an emphasis on pressure ulcer prevention. If a sign of a pressure ulcer does appear in a patient, the nurse takes photographic documentation, measures the extent of damage, proposes and applies an appropriate form of therapy. All actions are then recorded in the patient's documentation, along with subsequent further photographic documentation of the affected area to record the healing or worsening of the damage.

In our facility, a registry of pressure ulcers and chronic wounds is maintained. For illustration only, I present the number of hospitalized patients over the last 3 years compared to the number of pressure ulcers in our facility. Regarding the development of pressure ulcers, of all patients with pressure ulcers, only one originated in our facility. However, it should be mentioned that those hospitalized here have a high degree of independence.

Tab. No. 1. Comparison of the number of pressure ulcers to the number of hospitalized patients in the inpatient unit

In our facility, ŠNOP n. o., emphasis is placed on the professional preparedness of nurses; we are regularly retrained and always ready to stand by the patient. We are indispensable members of a multidisciplinary team at the center of which is the patient. However, it must be kept in mind that the nurse never replaces the work of the physiotherapist, but within the provision of nursing care, she can activate the patient and thereby lead them to greater self-sufficiency. At the same time, she can take care of the prevention of further complications such as contractures, pressure ulcers, thromboembolic disease, etc.

Recommendations for Practice

From practice in our facility, we have developed the following recommendations for practice:

  • Repeated retraining of all members of the nursing team in the issue of pressure ulcers has its purpose and should be performed once a year,
  • Communication within the nursing team should be an important part of patient care so that procedures are not repeated and everyone knows their tasks at the patient's bedside,
  • Enable nurses to further educate themselves regarding pressure ulcers and chronic wounds (certification preparation),
  • Do not neglect positioning and properly maintain positioning documentation with photographic documentation and regularly record treatments of pressure ulcers and wounds,
  • Implement assessment scales and checklists into patient documentation,
  • Statistically evaluate the numbers of pressure ulcers and wounds in the department and their improvement/worsening as an indicator of providing quality nursing care,
  • Regularly reassess the provided nursing care so that the patient's condition improves in the shortest possible time,
  • Familiarize yourself with the anti-decubitus aids assigned to the given department and use them,
  • Guide the immobile patient toward the greatest possible independence; even tasks that may seem trivial to us represent a certain degree of independence and progress for the patient if they can and want to do them,
  • Actively involve family members in patient care, educate them about preventing the development of pressure ulcers, positioning, passive movements,
  • Set aside sufficient time for the patient, do not rush away, do not attend to other duties, focus only on that particular patient at that moment,
  • Pay attention to the patient's nutrition and fluid intake,
  • During positioning, mobilization, and verticalization, involve multiple staff members and sensibly distribute effort,
  • Do not forget the psychological state of the bedridden patient, devote time to explaining and clarifying what we are going to do with them.

In conclusion, we add that the patient is not a burden, but a person who, in addition to having their basic needs met, also needs human company, attention, communication, empathy, and sometimes just a gentle touch on the hand.

Author: Bc. Magdaléna Popluhárová Specialized Hospital for Orthopedic Prosthetics, n.o., Bratislava

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