Goals for this Rehab Cycle were determined by Monica’s health care team (see Table 1). The global goal was defined to be health maintenance and the prevention of pressure ulcers. Four weeks after the surgery, Monica was on the way with the healing of her surgical incision, and the standardized treatment scheme would allow more activity.

Thus, a new program goal was established: independence in daily living. Three cycle goals were defined to help achieve this. At the time, the skin healing was proceeding well and cycle goals could be decided for reaching the new program goal. Cycle Goal 1 continued to focus on the healing of the skin structure. Cycle Goal 2 focused on mobility and was based upon Monica’s physical limitations — without support, she was bedridden at the start of this Rehab Cycle. Lastly, Cycle Goal 3 was defined as looking after one’s health, which would include the prevention of future pressure ulcers and other secondary conditions. This goal was discussed in more detail in Box 1.

Four weeks after the surgery, Monica was on the way with the healing of her surgical incision...

Setting intervention targets

Intervention targets were established by the health care team for each of the three cycle goals. Intervention targets related to the healing of the skin involved the repair functions of the skin and the structure of the skin. Those selected to improve mobility were defined to be supportive functions of the arms, transferring and changing body positions considering the risk for impairment of the skin.

Addressing looking after one’s health was more complex and would naturally impact the other two cycle goals over time. It involved affecting specific behavioural intervention targets that sought to achieve this through improvements in body image and some of her personal factors including low acceptance of her disease, little self-responsibility, emotional instability and low levels of health behaviour.