Preventing and Managing Common Complications in Wo

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Information about Preventing and Managing Common Complications in Wo

Published on August 9, 2007

Author: Pumbaa



Preventing and Managing Common Complications in Women with Disabilities:  Preventing and Managing Common Complications in Women with Disabilities Amie B. Jackson, M.D. Chair and Professor, Dept of Physical Medicine and Rehabilitation University of Alabama at Birmingham Karion G Waites, RN, MSN, FS-CNP, CRRN Nurse Practitioner Department of Physical Medicine and Rehabilitation University of Alabama at Birmingham Slide2:  Preventing and Managing Common Complications in Women with Disabilities::  Preventing and Managing Common Complications in Women with Disabilities: Obesity Skin Problems Osteoporosis Bladder/bowel Problems Slide4:  Obesity Definitions:  Obesity Definitions Overweight 1) Bodyweight greater than desirable level for a given age, sex, and skeletal frame.(NIH). 2) Greater than 15% for adult men and 23 % for adult women of body fat relative to body weight (i.e. percentage body fat). (Lohman TG, 1992) Obesity 1) Bodyweight exceeding 20% of the desirable level for a given age, sex, and skeletal frame (NIH) 2) Greater than 25 % for men and 32 % for women of body fat relative to body weight (i.e. Percentage body fat). (Lohman TG, 1992) Obesity Magnitude of Problem :  Obesity Magnitude of Problem Obesity and being overweight are common secondary conditions in women with disabilities. Obesity Contributing Factors:  Obesity Contributing Factors Sedentary Life Styles Changes in Body Composition as a consequence of immobility and paralysis Actual fat-free (i.e. residual lipid-free chemicals and tissues including water, muscle, bone, connective tissue and internal organs=water, protein and minerals) body composition in the disabled adult is unknown Obesity Contributing Factors:  Obesity Contributing Factors There are few studies on the variability and extent of body composition differences as a result of specific disabilities therefore no standards exist to accurately assess each individual with a disability Obesity Contributing Factors:  Obesity Contributing Factors Medical interventions (such as prednisone) may affect body composition Socioeconomic factors may lead to poor dietary habits Women with disabilities face barriers to physical activity and healthy diets—i.e. transportation, accessible fitness centers, lack of knowledge about capabilities for exercise, lack of knowledge or skills needed to engage in physical activity, fatigue and pain. Many health care providers are inaccessible to obtaining weight measurements for women in wheel chairs. Obesity Contributing Factors:  Obesity Contributing Factors Some women are unable to prepare healthy food or do not have sufficient attendant care There are inadequate weight management guidelines for women with disabilities. Appropriate guidelines must take into account other conditions such as neurogenic bowel and bladder, skin problems, fatigue, degree of neurological impairment. Many disabilities result in lower daily energy expenditure ObesityLong-Term Consequences:  Obesity Long-Term Consequences Premature Cardiovascular Disease Diabetes Increase obesity-related disability such as osteoarthritis, pain, respiratory compromise Increase need for expensive equipment or mobility aids (change in wheelchairs, orthoses, walkers, etc.) Increases injury or turnover of caregivers Impairs ability to maintain proper hygiene Predisposes to LE edema Predisposes to Sleep Apnea Syndrome Poor self-esteem, depression ObesityPrevention/Management:  Obesity Prevention/Management Dietician referral with attention to bowel programs. INVOLVE CAREGIVERS. Education Disability specific exercise program Arm Exercises FES-Assisted Exercise Involvement in recreational therapy Surgery?? OBESITY: Nutritional Education:  OBESITY: Nutritional Education Food Guide Pyramid 4 servings of milk or cheese 3 servings of meat 4-5 serving of fruit andamp; vegetables 6 servings of bread andamp; cereals products Guidelines for Weight Reduction:  Guidelines for Weight Reduction 3 meals a day Minimize saturated fats Limit/avoid sweets Limit Avoid snacking Broil or bake INCREASE PHYSICAL ACTIVITY and WATER INTAKE Skin Problems:  Skin Problems =Decubitus Ulcers =Pressure Sores Skin Problems:  Skin Problems Classification of Decubitus Ulcers Grade 1 – Skin area with erythema or induration overlying a bony prominence (i.e., an incipient sore). Grade 2 – A superficial ulceration that extends into the dermis. An ulcer that extends into the subcutaneous tissue but not into the muscle Grade 3 – Deep ulceration that extends through muscular tissue down Grade 4 – An extensive ulcer with widespread extension to bone along bursae into joints or body cavities (e.g., rectum, intestine, vagina, bladder). Slide17:  Skin Problems:Treatment of Pressure Sores:  Skin Problems: Treatment of Pressure Sores Wound Care Closed system Cleaning Remove pressure points! Colostomy Skin Problems:  Skin Problems Treatment of Pressure Sores Enhance Wound Healing Nutrition is most important component of decub care. Energy requirements are increased if woman with disability has a pressure sore. Must correct hypoalbunemia, vitamin A and C and Zinc deficiencies. Consider NG tube if individual is in catabolic or malnourished state. PDGrF Electrotherapy Ultrasound Control Moisture—Calcium alginate, VAC wound management ↓ Caustic Agents Specialty Beds/Mattress Oxandrolone—oral anabolic steroid Hyperbaric Oxygen SKIN CARE: Patient Education:  SKIN CARE: Patient Education Inspection Pressure Relief Developing Skin Tolerance Hygiene Foot Care Nutrition and Hydration Slide21:  Classifications of Decubiti Ulcers: Education andamp;Treatment GRADE 1 Skin area with erythema Superficial sore Non blanchable WHAT TO DO Keep pressure off the sore! Maintain good hygiene. Well Balance diet. Evaluate etiology Protective dressing Slide22:  GRADE 2 Partial-thickness involving the epidermis and/or dermis Superficial ulceration WHAT TO DO Follow procedure for Grade 1 Consult health care provider further treatment, which may include the Cleanse the wound with saline solution/wound cleanser and dry Hydrocolloid dressing or saline dampened gauzes Check for signs of wound healing with each dressing change. Slide23:  Grade 3 Deep ulceration that extends through muscle Full-thickness WHAT TO DO Follow procedure for Grade 1 and 2 Always consult your health care provider. Wounds frequently need special cleaning or debriding agents. Dressing Slide24:  Grade 4 Full-thickness, necrosis, bone and muscle Infection (?) WHAT TO DO Follow procedure for Grade 1,2,and 3 Antibiotic Therapy (?) Prolonged bed rest Surgery (?) Slide25:  OsteoporosisMagnitude of Problem:  Osteoporosis Magnitude of Problem All individuals experience bone loss to varying degrees following neurological loss as a consequence to a mobility disability. The degree of bone loss is dependent over time on the level and degree of neurological loss. If complete paralysis 50-70% of bone loss is by 16 months but continues over the lifetime of the individual. Osteoporosis Magnitude of Problem:  Osteoporosis Magnitude of Problem Pathophysiology of bone loss is initially from increased osteoclastic over osteoblastic activity of trabecular bone. Immobility, Endocrine, and Neural Alterations play a role in bone loss but details about these processes are lacking. Females and Males have unique concerns: The woman with a mobility disability will have an exacerbation of osteoporosis at menopause OsteoporosisConsequences—Fractures:  Osteoporosis Consequences—Fractures Incidence: 2-6% greater in women than men (with disability) Increases with age and in post-menopausal women Management: Surgery vs Conservative OsteoporosisConsequences—Fractures:  Osteoporosis Consequences—Fractures Complications: Non-union (2-10%) or delayed healing, Osteomyelitis, Skin break down, New risk for DVT/PTE, Autonomic Dysreflexia, Increased spasticity Morbidity, Mortality, and Development of New Disability Osteoporosis Prevention and Treatment Strategies:  Osteoporosis Prevention and Treatment Strategies Hormones: Calcitonin, Parathyroid, Thyroid, Estrogen (?) Passive vs Active Wt Bearing Modalities: FES, Ultrasound, Pulsed electromagnetic fields Supplements: Fluoride, Vitamin D, Anabolic Steroids, Calcium, etc Behavior Modification Bisphosphonates: Etidronate, Pamidronate, Allendronate, Zoledronic acid Slide31:  BLADDER MANAGEMENT:  BLADDER MANAGEMENT NEURO-ANATOMY OF UROLOGICAL SYSTEM Parasympathetic control Sympathetic control Somatic Muscle contribution Urinary System:  Urinary System Urine is made in the Kidneys Urine is stored in the Bladder Predominantly Sympathetically Controlled Urination Predominantly Parasympathetically Controlled Bladder muscles contract Sphincter muscles relax Bladder is emptied through the Urethra Urethra Kidneys Ureters Bladder Sphincter Urinary System :  Urinary System The kidneys, ureters, and urethra may have involuntary responses and act normally without the brain telling them to act Kidneys Ureters Urethra Neurogenic Bladder:  Neurogenic Bladder The bladder and sphincter muscles are voluntary functions and need communication with the brain to work normally The brain cannot usually send or receive messages through the spinal cord after injury Bladder Sphincter Neurogenic Bladder:  Neurogenic Bladder Reflex (spastic) bladder automatically triggers the bladder to empty Non-reflex (flaccid) bladder the automatic reflex is weak or absent Mixed bladder Bladder Urological Complications:  Urological Complications Lower Urinary Tract Complications Cystitis Epididymitis Orchitis Penoscrotal abscess Penoscrotal fistula Bladder stones Urological Complications:  Urological Complications Upper Urinary Tract Complications Kidney stones Hydronephrosis Pyelocaliectasis Renal failure Pyelonephritis BLADDER MANAGEMENT:  BLADDER MANAGEMENT Three Approaches to Managing Your Bladder 1. Continuous drainage 2. Facilitate Bladder to Emptying 3. Prevent Bladder from Emptying BLADDER MANAGEMENT:  BLADDER MANAGEMENT Intermittent catheterization program Indwelling foley catheter External condom drainage Suprapubic Ilioconduit Other BLADDER MANAGEMENT:  BLADDER MANAGEMENT Many factors are important in deciding how someone manages her/his bladder : Desire and motivation Living environment and Lifestyle Employment and facilities available Attendant care Level of Injury BLADDER MANAGEMENT:  BLADDER MANAGEMENT UMN vs LMN Hand function Trunk balance Time since the Injury Bladder and urethra change over time Whether you are Male or Female No external collection device for females How well the kidneys and bladder stay healthy without complications Purpose of Good Bladder Management Method:  Purpose of Good Bladder Management Method Prevent Urologic Complications Prevent Renal Dysfunction/Failure Surveillance:  Surveillance Renal scan* IVP (intravenous pyelography) Ultrasound* KUB/X-rays Urodynamics* Cystoscopy Other *Urodynamics, renal scan and renal ultrasound have improved methods of assessing the patient with a neurogenic bladder and renal function. Slide45:  NURSING INTERVENTIONS: Methods for Bladder Emptying Crede’ Valsalva Anal sphincter stretch Catheterization Indwelling catheter Intermittent catheterization Slide46:  INTERMITTENT CATHETERIZATION PROTOCOL (ICP) Catheterized Q4-6H QID 0700, 1200, 1700, 2100 TID 0700,1700,2100 BID 0700, 2100 QD 0700 NOTE: Check at 0200 Fluid intake 2000-3000CC/day IN AND OUT CATHETERIZATION Maintaining Volumes 400 – 500CC Indwelling Catheter:  Indwelling Catheter Increased risk of UTI Fluid intake 3000cc/day Sterile technique Change every month Cleanse GU leg/bed bags daily 1:10 Clorox/water Open to dry Slide48:  BOWEL MANAGEMENT:  BOWEL MANAGEMENT In many neurologic disabilities the bowels do not work normally. Nerves can not control the coordinated way required to eliminate stool =Neurogenic bowel BOWEL MANAGEMENT:  BOWEL MANAGEMENT The most appropriate bowel management method and/or medication depends upon the level and degree of neurologic loss The internal workings of the bowel (=peristalsis) continues to work BOWEL MANAGEMENT:  BOWEL MANAGEMENT REFLEXIVE BOWELS Bowel activity occurs when reflexes are initiated Suppositories Digital stimulation Some Medications AREFLEXIVE BOWELS No active sphincter activity Manual removal Removal by suction BOWEL MANAGEMENT:  BOWEL MANAGEMENT Many medications taken for other neurologic conditions cause bowel side effects (either constipation or diarrhea) Antibiotics Bladder medications Blood Pressure Medications (andgt;,andlt;) Pain Medications NSAIDS BOWEL MANAGEMENT:  BOWEL MANAGEMENT What is the ideal agent to use? THERE IS NO IDEAL BOWEL AGENT!!! BOWEL MANAGEMENT:  BOWEL MANAGEMENT A GOOD BOWEL EVACUATION AGENT OR PROCEDURE MUST BE: Safe Effective Easy to Use Available Low cost BOWEL MANAGEMENT:  BOWEL MANAGEMENT Types of medications Laxatives Bulking agents Suppositories Enemas Promotility agents CAM agents BOWEL MANAGEMENT:  BOWEL MANAGEMENT PROMOTILITY AGENTS—MEDICATIONS OR MODALITIES THAT INCREASE THE MOTILITY INSIDE THE BOWELS Metoclopramide (Reglan)—only for short term use Cisapride—heart side effects Erythromycin Neostigmine—emergency use only (obstruction) Functional Electrical Stimulation Tegaserod BOWEL MANAGEMENT:  BOWEL MANAGEMENT PROMOTILITY AGENTS Tegaserod— FDA approved for IBS Stimulates bowel peristalsis by working on the nerves that control the bowels Not well studied in individuals with disability but promising Does not take long to act Concerning side effects BOWEL MANAGEMENT:  BOWEL MANAGEMENT COMPLEMENTARY-ALTERNATIVE MEDICINE Natural compounds found in nature The new hope for neurogenic bowel function BOWEL MANAGEMENT:  BOWEL MANAGEMENT COMPLEMENTARY-ALTERNATIVE MEDICINE SP CLEANSE Cryo-Yeast Cholacol II OKRA Pepsis E3 How Da Huang/Rhubarb Root Gastro fiber Dietary habits Slide60:  BOWEL MANAGEMENT: Patient Education Goals of Bowel Program S Schedule E Exercise L Liquids F Foods Slide61:  ITEMS NEEDED for BOWEL PROGRAM Digital Stimulation Medication Non-latex gloves Lubricant Chux Slide62: 

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