Lecture 1 - Schizophrenia,

Schizophrenia are frequently diagnosed in _____ (M/F) and in ___ areas. There is ____ difference related to race, social status, and culture. In ____ it occurs betwee 15-25, and in ____ it occurs between 25-35.

It is associated with psychosis, altered ____, perception, and ____ testing which is the inability to determine what is real/fake.

DX includes 2 or more of the following: delusions, ____, disorgagnized _____, gross diorganization/catatonia, ____ impairment and negative symptoms. These are continuous for at least ___ months.

80% of the risk is due to _____. Other risk factors include any issues that involve brain ____ such as during pregnancy .

males; urban; no; men; women; cognition; reality; hallucinations; speech; functional; 6; genetics; development

Common comorbities of schizophrenia include:

1. The use of ____ as a way of self-TXT for symptoms. IT increases the risk for ____, suicide, relapse, dec adherence. It can be a form of ____ for cognitive impairment/anxiety. Common ones include ______, alcohol, and marijuana.

2. Anxiety, depression, suicide. Suicide is most common within 3 years and especially upon discharge after the ___ episode of schizophrenia.

3. A physical illness due to poor ____, limited access to healthcare, povety, etc. Some meds like antipsychotics can lead to CV illnesses due to _____ prolongation. They can also cause _____ syndrome.

4. Meds have anticholinergic effects which can lead to dry mouth leading to _______. This can also be due to obsessive compulsive disorders. Taking in too much water leads to ____ which can lead to confusion, delirium, hallucinations, and sudden psychosis.

substances; violence; coping; nicotine; first; nutrition; QT; metabolic; polydispia; hyponatremia;

The phases of schizophrenia include:

1. The _____ phase which is the onset and includes mild symptoms. Patients may state that “something does not feel ____ or is strange.” They can have poor _____ and school/job performance.

2. The acute phase is when the sickness is at its ____. The patient will experience hallucinations, _____, anhedonia, disorganized behavior, etc.

3. During the _____ phase, the symptoms begin to diminish. The patient will move toward their ____ level of functioning. This is done in an ____ mental health center or partial hospitalization.

4. During the ____ phase, the condition has stabilized. The positive symptoms are diminished/absent but the negative/cognitive symptoms may _____ and a new baseline is established.

Patients are likely to need a med adjustment and many are likely to ____.

prodromal; right; concentration; worst; delusions; stabilization; baseline; outpatient; maintenance; continue; relapse

During the prodomal phase of schizophrenia, we want to ___ early to reduce risk factors and enhance social and ____ skills. We want to reduce risk of development.

Positive symptoms include:

1. Alterations in ____ testing and delusions. Alterations in speech and ____ thinking which is the inability to think abstractly.

2. Alterations in speech include associative looseness which in its most extreme form is called a word ____ which is a jumble of words meaningless to a listenter

   1. ____ association is choosing words based on sounds

   2. ____ are words that only have meaning for the patient

   3. ______ is pathological reptition of another’s words

   4. Circumstantial, tangential, cogntivie _____ which shows as delayed responses or difficulty finished responses, etc.

   5. Pressured speech, flight of ideas, and ____ speech which is using words based on what they symbol.

3. Disorders of thought include thought blocking, _____, and deletion. Paranoia and ____ thinking.

4. Alterations in perception which includes:

   1. ____ which is when you think you are not a person

   2. ____ which is when you think the environment is not real

   3. Hallucinations. The most dangerou types are auditory specifically _____ hallucinations, so make sure to assess what they are hearing. If the voicees are telling them to do something dangeour, do not leave them ____

   4. _____ which are misinterpretations of a real experience

5. Alterations in behavior include

   1. ____ which is pronounced inc/dec in rate/amount of movement

   2. Motor retardation/agitation

   3. ____ behaviors which are repetitive behaviors that do not have logical purpose.

   4. A ____ flexibility in which you can pose them and they will stay exactly how you put them

   5. Echopraxia, the tendency to resists requests/wishes of others called _____, impaired impulse control , gesturing/posturing, boundary imparirment

intervene; coping; reality; concrete; salad; clang; neologisms; echolalia; retardation; symbolic; insertion; magical; depersonalization; derealization; command; alone; illusions; catatonia; stereotypical; waxy; negativism

Nevgative symptoms of schizophrenia consists of the ____ of essential human qualities. Examples include:

1. Anhedonia

2. A reduced motivation or goal directed behavior called _____.

3. A dec in desire for social interaction or discomfort during it called _____.

4. A reduced/constricted affect called affective ____. Other types of affect include ____ which is no emotion at all, ____ which is incongruent w actual emotional state/situation, and ____ which is odd/strange/illogical.

5. Apathy

6. A reduction in speech called ____.

Apathy and avoliton leads to deficits in basic activities like grooming, ____, and ADLs.

Cognitive symptoms include:

1. Concerete thinking which impairs the ability to recognixe social ____ like sarcasm.

2. Impaired memory which primarily affects ____ term memory and ability to learn. Use repetition, verbal, and ___- reminders to help them remember

3. Impaired info processing which manifests as _____ responses, difficulty understanding others, and the inability to screen out stimuli in the perophery which can lead to ____ so try to reduce the stimulation.

4. Impared ____ function which interefers with the ability to problem solve, set priorities, plan, etc.

Affective symptoms include ____ which can be a signal for impending relapse. Many will try to quiet their hallucinations/paranoia, etc which inc risk for substance abuse and ____ risk. These symptoms furhter impair function

absence; avolition; asociality; blunting; flat; inappropriate; bizarre; alogia; hygiene; cues; short; visual; delayed; overstimulation; executive; depression; suicide

Assess a patient with schizophrenia for the inability to realize they are ill called ______ which is caused by the illness itself. It may result in ____or cessation of TXT. It is often combined with ____ which makes accepting help impossible.

Perform a ___ assessment for fear, anxiety, frustration, and expectations

Assess for any medical problems as many can ____ or induce psychosis. Assess for drug/alcohol use disorders and perform a MSE which is based from _____ and interactions w the patient NOT the chart.

Include a _____ assessment like reality ttesting. Also assess for hallucinations, delusions, ____ risk, ability to ensure personal ____/health, prescribed meds, the symptom’s impact on ____, and family knowledge. .

agnosognosia; resistance; paranoia; self; mimic; observations; cognitive; suicide; safety; functioning

Outcomes for the phases of schizophrenia include:

1. Phase 1 is that the patient remains _____ and free from injury. You also want to medically ____ the patient and prevent complications of hyponatremia.

2. Phase II called stabilization is giving ____ to help the pt understand the illness/TXT and ______ with or control the symptoms. We are targeting the ____ and cognitive symptoms

3. Phase III called maintenance includes achieving health, getting them as ____ as possibel, prevent relapse, and satisfactory QOL.

Planning for the stages include:

1. Phase 1, safety/symptom stabilization

2. Phase 2 and 3 include recognizing the early signs of ___. Provide family edu.

Interventions for the phases include:

1. For the acute phase, using telling them they are ___ at the hospital, use ___ setting and supervisoin in the milieu, monitor ____ intake especially for patients taking lithium, monitor for suicide risk, etc. Some patients may demonstrate _____ due to hallucinations, delusions, impaired judgement, etc, so the priority intervention is to ___ the patients and others.

2. For the stabilization and maintenance phase, this include med admin and maintaining ___ to the regimen, building ____ with trusted HCP, using community based services,etc.

safe; stabilize; education; coping; negative; independent; relapse; safe; limit; fluid; aggression; protect; adherence; relationships

For patients with schizophrenia experiencing hallucinations, you want to ask what they are experiencing. If suicidal/homicidal themes are present, you want to implement ______ measures like closely monitring the patient and _____ the patient and potential victim. Use _____ like calling the patient by name nad speak loudly/simply.

For delusions, accept the patient’s experience but do not ___- it to them and help them to feel safe. Focus more on the ____ the beliefs are causing rather than the belief itself. It is _____ useful to prove the delusion is incorrect. You can ___ misinterpretations of environment to help the pt have a more reality based perspective

For associative looseness or ____ thinking, don’t let them think you understand when you do not. Place the difficulty of understanding on ___ and not the patient. Reinforce clear communication and reduce _____ as this symptoms is made worse by anxiety and overstimulation. You can ____ or paraphrase the patient’s communications at the end to leave room for correction.

Participating in ____ can help to enhance self-esteem and can dec withdrawal, and modify unacceptable behaviors.

safety; separating; redirection; question; fear; never; clarify; disorganized; yourself; stimulation; summarize; activities

Psychobiological interventions for schizophrenia include:

1. First-gen antipsychotic medications which primarily target the ___ symptoms. They produce ____ affects like urinary retention, dry mouth, dilated pupils, etc. These are less ______ than 2nd gen. They do have an increase risk of ______, tardive, weight gain, sexual dysfunction,etc.

2. Second gen address both positive and ____ symptoms and have ____ side effects overall. The ffrist line fr 2nd gen is clozapine but worry about ______ so obtain a CBC or neutrophil count. It takes 2-6 weeks for these to work and ____ or use of single antispychotic is recommended. They do tend to cause ___ syndrome.

3. Aripiprazole, brexpiprazole, and cariprazine are known as dopamine system ____ as they are partial agonists. They can improve positive/negative symptoms but also imrpvoe _____ function.

4. Injectable antipsychotics can be short-acting which is used for agitation and ____ like assaultive behavior. It is given IM. Long-acting can increase _____ as it avoids conflict with meds.

positive; anticholinergic; expensive; EPS: negative; less; agranulocytosis; monotherapy; metabolic; stabilizers; cognitive; emergencies; adherence

An ____ disorder in children includes issues with emotional attachment. These usually occur due to an inadequate -___ environment which allows no bonding to occur. There are two types:

1. A ____ attachment disorder consists of inhibited or emotionally withdrawn behavior. They rarely seek or respond to ___ from caregiver when in distress.

2. A disinhibited social enagement disorder is if they have no normal ____ to strangers and are unfazed in response to _____.

Risk factors include frequently changing ____, shifts in primary carefivers, impaired parenting, and prolonged ____ from parents. These lead to a lack of ___, friendships, partnerships. These children tend to be more _____ and develop healthy relationships with support. Complete a comprehensive _____ and physical eval.

The TXT should involve the ____ and the primary foal is strengthem the ____ b/w caregiver and child and provide stable living environment.

attachment; nurturing; reactive; comfort; fear; separation; homes; separation; trust; resilient; psych; family; relationship

PTSD In children will manifest as reduction in play, social ____, and negative emotions. They may blame ____, have diminished interest in activities, become irritable, aggressive, and have ____ disturbances.

It affects _____ compared to the other gender. Common comorbidities include learning and _____ problems, impulse control, nightmares, etc.

The repeated stress leads to frequent activation of the ___ axis which reduces the immune system and can influence adult functioning if the brain is still ____.

Trauma dysregulates neural neural pathways that control _____ regulation and arousal. Trauma can trigger the PNS which leads to a ____ state leading to dissociation. The ____theory suggests that many like to stay in the doral vagal response in which the patient feels numb/withdrawn.

Environmental factors that lead to development of PTSD include ____ on adults/symstems and anything that adds/supports stress.

withdrawal; themselves; sleep; girls; attention; HPA; developing; emotional; hypoaroused; polyvagal; dependence

WHen assessing a patient with PTSD, do a ____ assessment. Common outcomes include improved ___ to trauma, improved development/attachment.

Interventions for stages include::

1. Stage 1: provide ___ and stabilization

2. Stage 2: Reduce ____ and regulate emotion through symptoms reduction. Help the child stay in the window of _____ which is a balance between SNS and PNS.

3. Stage 3: catch up on developmental and ____ skills and devlop a ____ system.

Other interventions include establishing ____, use developmentally appropriate language, teach _____ techniques like guided imagery and deep preating, and duse art and ___ to promote expression of feelings. You can also involvue caretakes in 1:1 UNLESS that are the ___ of the truma. You can provide education about the ____ process and assist caretakers in resolving personal distress and coordinate with ____ work for protections.

Meds are used for targeting specific ____ or comorbidities.

The first line TXT for traumatized children is the _____ which helps them process the mmeories by thinking abt htem while also focusing on the stimulation.

developmental; response; safety; arousal; tolerance; social; value; trust; relaxation; play; cause; grief; social; symptoms; EMDR

Evaluations for child with PTSD include:

1. The child’s ____ has been maintained

2. Anxierty has been reduced and stress is handled ____

3. Emotions/bhevaiors are ____ for the situation

4. The child achives normal developmental ___ for his/her chronological age.

5. The child is able to seek out adults for ____ and help when needed.

safety; adaptively; appropriate; milestones; nurturance

Adults with PTSD may re-experience their traum through ___ recollections like flashbacks, dreams and vivid ____ input.

THey may _____ any stimuli associated with the trauma and demonstrate perssistent increased ____ meaning they are hypervigilant of their surroundings. They may become more irritable na dhave difficulty ____ or concentrating. They can have alterations in ____ like anhedonia and chronic depression.

When assessing these patients, use a pTSD ____ tool and also assess for suicidal or __ ideation, their support symptoms, and insomnia.

Outcomes include managing ____, increase self-esteem and improve ability to cope.

Implementation includes using ____ techniques for reducing arousal, improving _____ by using support groups, and help them to develop ____ of the event so they can heal. Meds are for symptoms/comorbidities.

Advanced practice therapy includes the use of ____ .

Evaluation includes:

1. The patient recognizes symptoms as related to the ____

2. the patient is able to use newly learned strategies to manage anziety

3. The patient experiences no ____ or intrusive thoughts

4. The patient is able to sleep adequately w/o ____

5. The patient can assume usual ___ and maintain satisfying interpersonal relationships.

intrusive; sensory; avoid; arousal; sleeping; mood; screening; violent; anxiety; relaxation; socialization; meaning; EMDR; trauma; flashbacks; nightmares; roles

An ____ ___ disorder occurs immediately after a highly traumatic event. Symptoms will persist for ____ days and diagnosis is made within a month. After a month, the disorder will resolve, but if it persists, the patient is elgible for the diagnosis of ___.

The patients may have ___ difficulty sharing the symptoms due to the recent traum and more likely to experience _____ which makes them feel less secure.

The patient may experience alterations in concentration, anger, ____ amnesia in which they cannot remember events associated w traumatic event, headache, irritability, and victimization.

For interventions you want to establish therapeutic relationship , assist but allow the patient to ____ solve, connect the person to supports, collab/coordinate care, ensure/maintain ____, refer to a licensed mental health provider, and monitor response and ___ to TXT

The advanced practice therapy of ___ is recommended.

acute stress; 3; PTSD; more; derealization; dissociative; problem; safety; adherence; CBT

An adjustment disorder occurs due to a ____ event rather than a traumatic event.

These patients have debilitating cognitive, emotional, and ehavioral symptoms that affect normal _____. The responses to the stressful event can include a combo of depression, anxiety, and ___ disturbances.

The diagnosis occurs immediately or within ____ months. The standard is the use of ______ such as reality orientation, group TXT and family therapy.

stressful; functioning; conduct; 2; psychotherapy

A ____ disorder occurs when individuals respond to stress/trauma with severe interruption of conciousness. This is an unconcious ______ mechanism that causes them to break from ______. It protects the individual from overwhelming anxiety through emotional ____.

Cognitive factors include ___ cognition and when the diff parts of their personalities are not fully _____.

Environmental factors includes traumatic events

Cultural considerations include seeing how the symptoms are ___ in cerstain cultures.

this isicually occurs due to issues in the ____ system.

When assessing these patients, ask them about their ___ of events, injuries, epilepsy, trauma, etc. Assess their impact on family and patient as families may find it hard to accept ___ behavior. Assess for suicide and observe for ____ swings.

Phase 1 includes establishing ____, stabilization, and symptom reduction. Phase 2 includes confronting, ___ through and integrating traumatic memories. Ohase 3 includes ______ integration and rehab.

Some techniques include the ___ tecnhqie to bring the person back to reality. CBT includes talking but also includes creating behavioral ____ for the patient. Sensorimotor therapy focuses on connection b/w mind/body and how that truma is stored allows the release of _____.

dissociative; defense; reality; separation; lower; integrated; viewed; limbic; HX; erratic; mood; safety; working; identity; grounding; goals; tension

Types of dissociative disorders include:

1. The inability to recall important personal info abt a traumatic/stressful event called dissociative ____. A subtype is called dissociative ___ in which they unexpectedly travel and are unable to recall their identity. They sometimes will assume this new identity and live ___ lives.

2. Feeling detached from your body, body parts, sensations, feelings, thoughts is called _____.

3. Believing that one’s surroundsings arent real is called _____.

4. The presence of 2 or more distinct personality states called dissociative ____ disorder. The main personality functions on a daily basis and _____ access/response to traumatic memories. The alternate personality is called the ____ and is fixated on the traumatic memory. They have their own pattern of perceiving, ____ to , and thinking abt self and environment. The patient usually does not ____ when the alter takes over and is usually unaware. A risk factor is ____ and ___ risk is extremely high.

amnesia; fugue; simple; depersonalization; derealization; identity; blocks; alter; relating; remember; abuse; suicide

The expression of stress through physical symptoms that are often manifestations of psychological and emotional distress is called _____.

A person w somatic symptom disorder has at least ____ distressing symptom AND has excessive thoughts, ____, and behaviors bt those symptoms. These usually occur without significant ____ findings and medical diagnosis. Their suffering is ____ though and it leads to a high level of functional imapriemnt.

Common comorbidities include anxiety and ____ disorders and ____ events often the precipitants. Help the patients to focus on developing self ____ to help reduce anxiety/stress. Help them to resist temptation to ___ on psychosocial issues and help them to maintain healthy relationships.

somaticization; one; anxiety; physical; real; depressive; stressful; compassion; concentrate

A preoccupation with having or acquiring serious illness for at least 6 months is claled ____ ____ disorder. They wil _____ any physical sensations and will attribute it to a serious illness. They have extreme anxiety, worry, and ____ abt possibly having an illness.

They may have excessive health related behaviors like visitng the dr ____. They may also do maladaptive ____ like avoiding going to the dr to avoid a diagnosis or confirmation of illness.

They will self-scan in which the actual symptoms may either be ___ or absent. The patient may be intrusive and hard to ____.

Exposure to the ____ that urges us to use health screens ot talk to Drs contribute to these fears.

Nursing care includes:

1. Allowing discussion of illness concerns but ___ that time to allow time for more favorable topics like edu.

2. Reassure patient that psychiatric care will ____ and not replace medical care

3. Encourage socialization as ______ is associated w development of this disorder bc it allows for self-focus.

TXT includes meds for symptoms: ____ can be used for anxiety while CBT and ECT can be used for ____.

illness anxiety; misinterpret; fears; frequently; avoidance; mild; dismiss; media; limit; supplement; loneliness; SSRIs; depression

A ___ disorder occurs when neurological symptoms occur in the absence of a neurologicl DX. It is the presence of deficits in voluntary motor or ___ functions. Common ones include ______, blindness, movement/gait disorders, parathesias, etc.

It is more common in ____ compared to the other gender and most common comorbidities include ____ and dissociative disorder.

Many will experience ____ ____ indifference in which they lack emotional concern abt a dramatic symptom.

Nursing care includes avoiding direct ______, encourage socialization, and explorign alternative/adaptive ___ mechanisms.

TXT includes hypnosis, DBT, ____ therapy for motor symptoms and BPOT.

conversion; sensory; paralysis; women; depression; la belle; confrontation; coping; physical

Many psychological factors may inc risk for medical disease, magnify them, or interfere with their _____.

Depression is a risk factor for CV diseases and ____. Stress also negatively affects medical conditions. You want to teach them positive affected responses, ____ which allows them to recover, and prevent loneliness.

TXT; cancer; resilience

Six key elementa for effective TXT fo SSD include:

1. Provide ___ of care

2. Avoid ___ procesudres

3. Provides freuqent, brief, but ___ visits.

4. Always confuct a _____ exam to rule out actual diagnoses

5. Avoid disparaging comments

6. Set reasonable therapeutic goals

Psychosocial interventions include the use of ____ strategies. Promote self-care and encourage ____ in completing activities. Use _____ training which teaches ppl how to express themselves without passive/aggressive.

Assign a ____ manager

continuity; unnecessary; regular; physical; coping; independence; assertiveness; case

Artificially, deliberately, and dramatically fabricate symptoms or self-inflict injuryis called a ____ disorder. The goal is assuming a sick role to gain ___ from it. Patients are often ___ for professionals to speak to their family/friends, and previous HCPs. They often demand ___ and interventions. New symptoms may pop up after ___ results and they often have ___ from exploratory surgeries, amputations, etc.

A facticious disorder by ____ means they are imposing it another person.This person is usually of a ___ population. The perpetrator is usually a parent/guardian with knowledge about ___. They aim to recive words like insurance ____, compensation, or attention. They will make the victim go to unecessary med visits and sometimes harmful medical ____.

Consciously motivated fabricating illness for secondary gain like insurance, disability, obtaining meds, evading military service is called ____. The symptoms are hard to disprove and is more common in ____ compared to the other gender.

facticious; attention; reluctant; TXT; negative; scars; proxy; vulnerable; healthcare; money; procedures; malingering; men

When assessing patients suspected of factcious disorder or malingering, assess to see if their symptoms are ___ or unconcious. Avoid ____ if you think they are faking it.

Report anything to prevent the vulnerable population from undergoing ____ TXT.

Help the patient to have better ___ skills to handle stress and carefully monitor those who inflict damage on themselves.

Medical interventions are not helpful the gold standard is ____.

Perform a self-assessment as frustrations can lead to ____

concious; confrontation; unnecessary; coping; CBT; countertransference

A group of psychiatric disorders, most of which are primarily biological in origin, that can significantly affect functioning and one’s quality of life, especially if they go untreated is called a ___ ___ ____.

The ___ adults of 18-25 have the highest prevalence and it was highest amond adults reporting 2 or more ____.

This is a ______ condition with waxing and waning. Worsening of the symptoms is called _____.

These patients are more likely to be a victim of ____, live in poverty/homelessness, have a medical _____, and die ____.

Back then mental ilness was associated with danger, evil, and ___. Many patients were institutionalized in which human basic rights were often ____ and many had loss of ____ and were unable to make their decisions.

serious mental illness; young; races; lifelong; decompensation; crime; comorbidity; prematurely; shame; violated; autonomy

The shifting of a person or population from one kind of institution to another is called ______. These patients are moved without truly being ____ or stabilzied in the community which leads to episodes of relapse and readmittance. This is called the ___ go round experience. These patients will often be moved to jails, prisons, nursing homes, and even the _____.

The community health nurse is supposed to meet the client in ____ these institutions to provide support.

transinstitutionalization; treated; merry; streets; between

Barriers to care for those with SMI include:

1. TXT inadequacy meaning fragmented or poorly ___ serves, inadequare housing and escessive transinstittionalizations.

2. The inability to recognize one’s illness due to the illness itself is called _____.

3. Medication ___ effects make the patients not want to take them

4. Nonadherence which is influenced by medication ____, lack of trust in providers, and stigma

5. TXT will not eliminate symptoms completely/consistently which leads to the presence of ____ symptoms. These can lead to feelings of ___, helplessness, and hopelessness which can affect adherence.

6. Relapse, chronicity, loss

The top 3 barriers to finding a provider include:

1. Not accepting ___ patients

2. Not accepting ____ plans

3. Not close enough to work or ____

funded; agnosognosia; side; costs; residual; frustration; new; insurance; home

For patients with SMI, the ____ community TXT team (ACT) is a team based approach to deliver mental health care in the community setting to adults w severe mental illness.

It focuses on the ___ of the sick. The team seeks out and enafes with those who face ___- to traditional forms of care,

There is ____ coverage and includes crisis intervention which helps patients regain their ability to ____ when facing relapse/stress.

Impaired ____ and problem solving skills increases the risk of crisis in ppl with SMI. Crisis prevention seeks to help a person manage stressor in a less ____ setting and avoid more disruptive inpatient care.

assertive; sickest; barriers; continuous; cope; cognition; restrictive

AOT stands for assisted ____ TXT for patients with SMI. It is an outpatient commitment and is ____ mandated when a person with SMI leaves hospital/prison.

To qualify for this, the person must meet all of the following criteria:

1. Be unlikely to ___ in community without supervision

2. Have a HX of _____ that includes 2 hospitalization in the previous 36 months

3. Have acted/threatened _____ to self or others in 48 months immediately preceding filing of hte petition.

4. Be unlikely to _____ partiicpate in TXT

5. Be in need of TXT to prevent ____ or deterioration

6. Likely to to benefit from TXT

outpatient; court; survive; noncompliance; violence; voluntarily; relapse

The recovery model is ____ centered and is forward looking. It empowers the patient and focuses on the ____ of the patient. The ____ sets their own foals and the nurse collaborates w the patient. The goal is to improve the ____ of life rather than just symptom management.

The ____ model deals more with symptom management and being able to survive.

patient; strengths; patient; quality; rehabilitation