Independent Learning PackageAcute2005

6. Considerations when prescribing exercise to Diabetics : - Don’t exercise straight after a meal - Don’t exercise when insulin levels are high or BSL are low - Don’t exercise an infected limb - maintain intake / diet while exercising eg. gym - exercise can be used with obese patients to decrease glucose and therefore BSL’s (weight reducing diet also) - care of skin if PVD - be aware of cardiac limitations Please consider the Patient Case History below and answer the questions which follow. A 50 year old male is admitted to a Vascular surgical ward Day 1 post ABFG. PMHx : NIDDM PVD Retinopathy IHD PSHx : ( R ) Femoral TEA 6/96 ( R ) Fem- pop Bypass 1/97 Post-op orders : - RIB for 3/7 - intra-operative ST depression - ?? elevated CK -MB’s - NBM for 5 days - qid BSL’s 1. Why might this patient be placed on an insulin sliding scale? 2. What mechanisms might cause his BSL’s to increase? 3. What mechanisms might cause his BSL’s to decrease? 4. What considerations must be made before you treat this patient? ANSWERS : 1. Sliding Scale of Insulin - A sliding scale of insulin provides for regular checks and easy correction of changes in BSL’s outside normal range. The amount of insulin given via an IV infusion is varied according to the BSL’s which are taken either hourly or 2nd hourly. Why? • Events such as surgery, fever, infection and trauma ⇒ Limbic System type response (fight / flight) ⇒ glycogen dumped ⇒ altered BSL’s • NBM for 5 days ⇒ not maintain BSL’s by oral intake of food or hypoglycaemics + IV fluids with glucose ⇒ disturb BSL’s • Altered level of exercise impact on BSL. Not mobilise for 3 days as ? intra- op MI (ST depression and checking CKMB – creatinine kinase M and B bands specific for cardiac damage) 194 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

2. Mechanisms which cause BSL to increase : - body’s physiological response - insufficient Insulin or hypoglycaemic agents. 3. Mechanisms which cause BSL to decrease : - increased metabolic rate - too much Insulin or hypoglycaemic agents 4. Considerations prior to treatment : - check BSL ie. when it was last taken and its value, ensure it is within the normal range - look for a trend in BSL to assess stability - check when and how much Insulin was provided to the patient - it is best to treat this patient approximately 40 -60 minutes after Insulin is given - check the status of the vital signs, particularly the BP in this situation - consider what treatment is most appropriate to their condition from both a post-op perspective and their diabetic status - check the vascular observation sheet on the bed chart of this patient - diligent infection control practices are mandatory for these patients - remember that opportunistic infections can be fatal in this group.. - ensure safe handling due to increased risk of skin tears and lacerations ie. no jewellery to be worn etc. - ensure adequate pressure area care for patient ie. sheep skins etc. - Unstable IHD will limit exercise capability and contraindicate the use of isometric exercise - consider the impact of visual problems and what modifications need to be made. 195 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

RENAL FAILURE Please complete the following questions and ensure that you have a thorough understanding of the implications of renal failure in your clinical management 1. What are the causes of Acute Renal Failure (ARF)? 2. What signs and symptoms indicate the development of ARF? 3. What are the causes of Chronic Renal Failure (CRF)? 4. What is the relationship of LVF to CRF? 5. What are the signs and symptoms of CRF? 6. What conservative treatment would medical staff prescribe for CRF? 7. What are the implications of the effects of CRF with respect to exercise and treatment for the patient? 8. What are the indications for dialysis with a CRF patient? 9. What are the specific indications for dialysis in the ARF patient?” 10. What is CAPD? Describe the technique and implications for the patient? What possible Physiotherapy involvement may there be for patients receiving CAPD? 11. What is Haemodialysis? Describe the technique, and discuss the implications for your treatment in the ICU setting. 12. What other systems of dialytic treatment are there? Describe briefly how they work. ANSWERS : 1. Causes of Acute Renal Failure : - multiple injuries - medical - drug therapy - urological - obstruction or glomerulopathy - obstetric - pre-eclamptic toxaemia/ eclampsia, haemolytic-uraemic syndrome - post-operative Can occur in any age group : - Young / obstetric - often due to trauma - Elderly - often precipitated by cancer, surgery – such as AAA Repair or urological surgery. - Patients often debilitated prior to ARF. 196 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

2. Signs and Symptoms of ARF : - metabolic acidosis - fatigue - confusion - markedly positive fluid balance - marked peripheral oedema - total electrolyte disturbance - high creatinine and urea - lassitude - anorexia - oliguria Patients are often extremely unwell - can require prophylactic bed exercise and later will need exercise to increase muscle mass. 3. Causes of Chronic Renal Failure : - Hypertension and Renal Artery Stenosis - Glomerulonephritis - Analgesic nephropathy - various other nephropathies e.g. diabetic - polycstic kidneys 4. Relationship of LVF to CRF - LVF can arise from systemic hypertension (see Cardiac Conditions in this manual) - LVF can arise from CRF - Systemic hypertension can cause CRF - LVF can impact upon renal circulation and in the long term contribute to the development of CRF - CRF or ARF can worsen HT and LVF CRF HT LVF 197 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. Signs and symptoms of CRF? - fluid retention due to excessive retention of sodium - can give peripheral or pulmonary oedema (NB oedema can be related to both LVF and HT) - increased creatinine (N = .06 - .12) and urea (N = 3.0 - 7.5) - itch - bruising - Osteoporosis - due to hyperphosphatemia -> hypocalcaemia - Pericarditis - LVF - Peripheral Neuropathy - ↑ BP - ↓ urine output / oliguria (only occurs in terminal stages) - metabolic acidosis - ABG changes - decreased ability to excrete H+ ions - anaemia - due to decreased production of erythropoietic factors Also known as Uraemic Syndrome with : - toxicity due to retention of metabolities - drowsy, twitching, fitting, N/V/D, very itchy, cardiac failure (due to retained metabolities) - weakness, tiredness and SOB. 6. Conservative management for CRF - - Weight control - cease smoking - fluid restriction - diet control eg. salt restriction - exercise - treatment of underlying cause eg. infected kidneys, correction of fluid and electrolyte imbalance (e.g. anti-nausea or anti-diarrhoea medications ) - ?TPN - ?steroids. 7. Implications for exercise and treatment : - patient tires easily and may be confused - adapt handling especially verbal - osteoporosis / bruising - care with manual techniques, apply principles of exercise for Outpatients as well - exercise should be aerobic and of short duration to avoid increasing waste products. Coronary artery disease is strongly associated with CRF and has significant mortality. - in CRF exercise can increase renal function and decrease renal failure ( refer to normal physiology of exercise on the kidneys) - concomitant conditions will necessitate care with exercise prescription eg. LVF or ascites - patient might demonstrate altered breathing pattern. 198 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

8. Indications for dialysis in CRF : - Based on the severity of the presenting signs and symptoms eg. oliguria - Failure of conservative management strategies. 9. Indications for ARF : - severe electrolyte disorder - Creatinine > 0.6 - 0.7 - Urea 30 - 35 - severe hypokalaemia ( low potassium) - cardiac arrhythmia’s and muscle weakness 10. CAPD : - CAPD = Continuous Ambulatory Peritoneal Dialysis - Tenckhoff catheter inserted with laparoscopic control under LA - Aseptic technique. - 2 litres of fluid are run into the abdomen via the tenckhoff catheter - left in for 4 - 6 hrs while patient is active - 2 litres are then drained out. - takes 30minutes to drain in and out. - Uses peritoneal membrane as dialyzing surface Risks include : - peritonitis - blockage - leakage around the catheter or subcutaneously - herniation (less so with laparoscopic technique) - HT - limited to patients with manual dexterity who can perform an aseptic technique Physiotherapy involvement : - Postural advise - Rx of LBP - need exercise prescription such as abdominal and pelvic floor exercises - general aerobic strength and maintenance - ergonomic advise - perhaps deep breathing exercises as have a tendency to develop bibasal collapse. 199 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

11. Haemodialysis : - AV Shunt needed for access - used for both ARF and CRF - need systemic anti-coagulation - blood is directed outside the body through the dialysis machine - solutes that need to be eliminated pass across a membrane into a carrier fluid of carefully chosen composition - excess water is also removed in this way - between dialysis sessions body weight increases owing to the inability to excrete excess water ICU - bagging and PD generally contraindicated due to lability of BP related to blood volume changes while on dialysis. Need to wait 1 hour post dialysis to treat to ensure that BP has stabilised. 12. Other Dialytic systems : - Haemofiltration - takes less blood out of circulation than dialysis. • Note Kidney Transplantation represents a viable surgical option for some patients. 200 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

AMPUTEES Please review your lecture notes on - Vascular Disorders and Amputee Management and answer the questions listed below relating to the Patient Case History. A 63 year old man is admitted to a Vascular Surgical Ward. PMHx : Severe PVD IDDM IHD MI x 1 - 7/9 O/E : • Confused • Poor compliance • Resting ® foot pain • Febrile • Gangrene of the ® foot • Fixed flexion deformity of the ® hip and knee Social Hx : • Lives alone in a first floor unit • no lift • 20 stairs to unit • Meals on Wheels (MOW) 3 x weekly • Home help (HH) x 1 fortnight He is listed for a BKA. 1. Describe an ideal pre-operative assessment, treatment and preparation for an amputee. 2. In what ways will you vary or limit your pre-op assessment given this patient’s history? 3. What implications do his associated conditions have in terms of his early rehabilitation? 4. Describe an ideal Day 1 treatment of a BK amputee. 5. When would you begin lying prone? 6. When would this patient begin mobilising? 7. When would the patient be taken to the gym? 8. Describe a gym exercise programme for this patient. 9. Outline the precautions in treatment and the danger signs to stop exercising. 10. When would you begin methods to shape and shrink the stump? 11. What are the methods for shaping or shrinking the stump? 201 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

12. How would you cope with re-educating gait if this patient is suffering from claudication in his remaining leg? ANSWERS : 1. Pre-operative assessment : - Check chert / patient history / investigations - Explain physiotherapists role ie. chest, circulation, rehabilitation - Describe post-op presentation ie wound drains, IV drip etc - Chest assessment - Institute chest physiotherapy pre-op if indicated - Commence strengthening exercises for upper limbs - especially lat dorsi and triceps - Commence strengthening exercises for the remaining leg - Assess ROM other joints - Commence exercises on the affected leg ; Quadriceps, hip extensors, abduction ex’s - Improve balance - Psychological support - where possible take patient to the gym pre-op to prepare for the surgery. 2. Limitations to your pre-operative assessment due to this patient’s history include : - Respiratory examination +/- treatment may be a priority - Confusion secondary to analgesics, pain or sepsis may limit compliance or memory - IHD limits position and demand - Focus on simple post-op DB exercises and (L) circulation exercises 3. Implications of associated conditions include : - IHD will limit exercise capability and positioning such as prone - Patient has already developed contractures from holding leg in flexion - Severe PVD means (L) leg will have significant changes - May have prolonged hospital stay trying conservative management options prior to BKA → debilitated. 4. Day 1 treatment : - Do as much as possible - Chest management - DB exercises, Triflo, Cough - Arm exercises - watch for angina - Leg exercises - for stump : active assisted knee extension, hip / knee flexion, abduction - for other leg : hip / knee flexion, dorsi / plantar flexion etc. - Pressure area care - check all areas for pressure - provide sheepskins etc. - Commence teaching bed mobility - Encourage good positioning of stump to prevent / reduce contractures. 202 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

5. Prone lying Usually the patient will begin prone lying ~ Day 3 depending on how the confusion settles and after the drains have been removed. For patients with cardiac conditions who cannot lye prone, try sidelying with some assisted active or passive hip extension, or quarter turn from prone, with the pillow on the opposite side to the amputated leg. Patients should never be left alone in prone on a hospital bed unsupervised. 6. Mobilisation Patients can begin mobilising on a rollator or hopper usually when the drains are out. Prior to this, they may be sat out of bed in a wheelchair with a stump board to gradually increase exercise tolerance. 7. Commence gym programme If the patient is stable and no longer confused a gym session can begin around Day 4. 8. Gym exercise programme : - Arm exercises (triceps and lat dorsi ) - Leg exercises (emphasising quads, abductors and hip extensors) : should be isotonic, continuous movements - Prone lying - Balance activities in parallel bars - Practice wheelchair mobility skills - Practice walking in the parallel bars ( air-bag, temporary prosthesis) - Practice gait / management of temporary prosthesis once supplied 9. Precautions and Danger signs : - Precautions - no isometrics, no heavily resisted exercise, supervise arm exercises at first, supervise prone lying at first. - Don’t exhaust patient - build up programme gradually / have adequate rests interspersed - Inform patient of danger signs to watch for - Danger signs - leg may go white i.e. ischaemic; sweating ; pallor; dizziness; angina; SOB. 203 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

10. Shaping and shrinking the stump Techniques are commenced usually when the wound is fully healed - 2 -3 weeks 11. Methods to shape and shrink the stump - Stump bandaging (different strengths of bandage) - Shrinker socks - Wearing of the temporary prosthesis / air bagging. 12. Re-educate gait if the patient is suffering claudication in the remaining leg, - Walk - until just before claudication starts, then stop, then walk again. - to the point where claudication starts seems to be the stimulus to build up collateral circulation. Do not walk through the pain as it is ischaemic in origin and may cause tissue damage. ** Protocols for early management of amputees vary from one centre to another. Be aware of the differences that may exist, and ensure you understand the rationale for variation in management. 204 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003