During my first rehabilitation following the onset of SCI, I was sharing a room with a patient who was suffering from pressure ulcers. Seeing her suffer, I promised myself then I would not allow that to happen to me. But just three months after I returned home, I had my first ulceration. And now I’m back here again two years later with my second.
Monica, January 2007
Figure 1: ICF Categorical Profile; 1, 2, 3: Relation to Cycle goals; SP: Relation to Service-Program goal; G: Relation to Global goal; * ICF Qualifier rates the extent of problems (0 = no problem to 4 = complete problem) in the components of body functions (b), body structures(s), activity and participation (d) and the extent of positive (+) or negative impact of environmental (e) and personal factors (pf).
Monica’s perspective was assessed by her health care team. Her own view of her condition focused heavily on activities and participation, and her issues with body functions and structures were limited.
For instance, she didn’t feel pain, could sense dull touch and felt her joints were very flexible. Her true level of activity, she felt, was quite limited by her dependence in toileting, caring for her skin, changing her body position and dressing (particularly as she feared disturbing her incision).
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.
Monica’s health care team consisted of her physician, nurse, a physical and an occupational therapist and a psychologist. The intervention targets were attended to by the corresponding team members (details can be seen in the Table 2 below).
The intervention targets associated with the personal factors and related to health behaviour would be addressed by the psychologist to implement specific therapeutic approaches. However all health professionals integrated these intervention targets in their treatment.
I’ll leave the rehabilitation center the day after tomorrow. The doctors wanted me to stay for one more week to make sure everything is OK. I have to say, I’m just tired of the hospital.
Monica, one day before discharge against medical advice
Monica was released one week early against medical advice and at her insistence. Hence, after five-weeks evaluation took place.
Health maintenance is a critical factor that essentially contributes to the quality of life of patients suffering from spinal cord injuries. While health care professionals can do much to influence an individual’s health maintenance through interventions such as routine clinical monitoring, the patient’s own health behaviour is equally important, if not more so.
Such health behaviour may be understood as having two essential components — risk behaviour and protective behaviour, each of which may be present or absent to varying degrees in each individual. Under ideal rehabilitative circumstances, the former would be minimized and the latter maximized. However, promoting health behaviour that contributes to health maintenance may face challenges in every patient and the final responsibility for engaging in these health behaviours ultimately lie with the patient him- or herself.