PR- 2 Final

All of the following can contribute to fall risk in the elderly EXCEPT: Medication management: side-effects or overmedication Strong bones and joints Cognitive deficits Difficulties with ambulation or balance, mobility

Strong bones and joints

Diabetes mellitus (DM): Prevalence 34.2 million children and adults in the US (10.5% of the population) have diabetes Of those individuals, about 7.3 million have not yet been diagnosed What is Diabetes?

Diabetes mellitus (DM): a group of metabolic conditions characterized by a malfunction in the body's ability to either make or use insulin Insulin is a hormone produced by the pancreas which regulates glucose metabolism Without insulin, organs and tissues do not receive glucose causing the body to break down its own lipids to produced energy The condition of DM will result in glucose building up in tissues and being excreted in urine (Atchison & Dirette 2011) One of the things they test for is glucose in the urine

Ot intervention for renal dysfunction: examples

Impaired activity tolerance: energy conservation education Neuropathy: patient education to teach safety and compensation for sensory loss Cognitive dysfunction: do cognitive retraining, problem solving, safety Self-care: adaptive techniques, recommendations for adaptive equipment Impaired mobility: if independence in mobility is affected, assisting the patient in safe transfers and use of assistive devices

Classic Signs & symptoms of diabetes

Polydipsia (increased thirst) Polyuria (increased urination) Increased hunger Blurred vision & dizziness Weakness Fatigue Difficulty healing Ketouria (leads to diabetic ketoacidosis or DKA) Sexual dysfunction A lot of times people don't understand these symptoms could mean they have diabetes

Occupational therapy intervention for diabetes

Psychological intervention: ¡ Give emotional support and encourage/improve self care habits ADL and IADL retraining ¡ Adaptive equipment/techniques to facilitate full participation in ADL if possible ¡ IADL which supports compliance of self-management Cognitive Retraining ¡ Problem solving as changes occur in medical status ¡ Gain understanding regarding how to properly manage disease and avoid complications

Acute renal failure (ARF)

Renal function decreases quickly, over hours or days, lab marker is increased serum creatinine ARF may affect other body systems: CNS - headache, confusion, seizures; cardiac - hypertension, heart failure; can be fatal ARF is affects 15-20 percent of patient in intensive care units, with high mortality rates (Ludlow 2013) A lot of times people who have become very sick Can kill you because renal failure can cause damage to other systems - 15-20% of people have this in the ICU

Etiology of type I versus type II diabetes

Type 1 ¡ Cause is not well understood; autoimmune response that destroys beta cells in the pancreas ¡ Strong genetic predisposition with environmental factors ¡ Insulin Dependent Diabetes Mellitus, abbreviated as IDDM Type 2 ¡ Strong genetic predisposition ¡ Related to aging, physical inactivity, stress, obesity, ethnicity ¡ Can be IDDM or Non-Insulin Dependent (NIDDM)

Medical/surgical management: daily monitoring Self-monitoring of blood glucose levels are crucial for all types of diabetes

Type 1 patients should monitor glucose levels 3-4 times per day (usually IDDM) or with continuous glucose monitoring (CGM) Type 2 patient should monitor glucose levels before each meal (if IDDM may be done more frequently) Medication adjustment may be done depending on level

Five types of diabetes

Type 1: Complete lack of insulin (found in children or the acutely ill), 5-10% of all cases Type 2: Some insulin is produced but not enough, adult onset, 90-95% of all cases Gestational diabetes: occurs during pregnancy, then resolves Diabetes from other causes (cystic fibrosis, chronic pancreatitis) Pre-diabetes: people have impaired glucose tolerance, 25% eventually develop Type 2

Evidence-Based Intervention for falls • Research is mixed in reporting the most effective interventions • PT, home modification and Vitamin D • Incorporating exercise strategies to improve balance during ADL

"Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists

Types of PVD(Smith-Gabai & Holm, 2017) * Peripheral Venous Disorders: lack of blood supply (usually lower extremities) as a result of stenosis or occlusion within the veins. Symptoms include: * Painless ulcers of the ankle or leg

* Aching pain that decreases with elevation * Brown discoloration of the skin * Warm extremity, especially if thrombosis is present * Severe itching * Venous insufficiency/venous stasis or ulcers can also occur

What causes Polytrauma? * Examples:

* Blast injuries (combat): exposure to a deployed explosive device or a rocket-propelled grenade; can result in traumatic brain injury, spinal cord injury, amputations, wounds, and psychological stressors (PTSD) * Motor vehicle accident: bone fractures, head injury, damage to internal organs, infection * Diving accident: cervical spine compression with vertebral fracture & paralysis, cerebral anoxia Could get one of these things or all MVA for civilian population When it affects multiple body systems= polytrauma

OT Treatment of Polytrauma * OT evaluation must be tailored to the patient; relevant assessments are used and usually when patient is stable

* Family may be consulted to complete patient's occupational history prior to injury * OT plan of care will be determined based on clinical decision making and triage of needs * OT goals must reflect occupational performance of functional outcomes

Discharge from Acute Care * Rehab consult team must recommend discharge destination; patient must be medically stable for further rehabilitation * Discharge settings:

* Inpatient rehabilitation * Sub-acute rehabilitation * Home with Home Health * Outpatient * Home with no services

Early Intervention: OT * Trauma patient may spend extended periods in an ICU setting

* Interventions in the ICU can help ensure that patient are prepared for a higher level of activity when they are medically stable * Early intervention is needed to prevent complications and allow patients to reach their full potential Have to get patients moving

Vascular Conditions * Medical dysfunction referring to blood vessel circulation in the body

* It is necessary to be familiar with several conditions as occupational therapists often encounter patients with them in their medical histories * Same risk factors as cardiac

OT Treatment of Polytrauma * OT practice must incorporate psychological as well as physical interventions in the case of polytrauma, e.g., stress management techniques, cognitive behavioral therapy

* OT, along with the rehabilitation consult team, has one common purpose: facilitate patient success ** May be using a lot of tools in our tool box, psychological treatment skills in addition to physical rehab

Philosophy of Early Intervention * Begin appropriate rehabilitation as soon as possible * This does the following:

* Optimizes functional outcomes * Provides thorough patient/family education * Allows opportunity for ongoing collaboration * Prevents medical complications * Allows early discharge planning and preparation Early intervention is the approach we want to take with patients who have polytrauma As soon as we get in there we will optimize functional outcomes, educate family and patient

Pulmonary Embolism (PE) & DVT(Smith-Gabai & Holm, 2017) * PE is a life threatening complication of DVT * Symptoms include: shortness of breath (SOB), chest pain, rapid heart rate, low blood pressure, and loss of consciousness/fainting * Patients need emergency medical attention if exhibiting these symptoms

* Prevention (prophylaxis) for PE and DVT includes anticoagulants (blood thinners) & use of TED hose after surgery

What is Polytrauma?

* Used to describe multiple, extreme, often totally incapacitating set of traumatic injuries suffered by a patient * The term polytrauma is used by the US military and others to describe significant injury to multiple body parts and organ systems

OT Treatment of Lymphedema: Manual Lymphatic Drainage Process • General process involves clearing proximal areas of the body first (make room for fluid to move proximally), then clearing more distal areas allowing for proximal movement and entry into lymphatic system Precautions:

**** Precautions: Manual lymphatic drainage is NOT used if there is active cancer, active infection, kidney failure or congestive heart failure

****#1 cause of death after a joint replacement is???

****#1 cause of death after a joint replacement is a PE!!--Pulmonary Embolism (PE) Its our role to convince patients to wear TED hose after surgery

Stages of HIV Infection

1. Acute infection 2. Clinical latency 3. AIDS

Renal Dysfunction People can lose up to 75% of kidney function before being correctly diagnosed as having renal dysfunction Renal dysfunction often develops in patients with diabetes

**Renal dysfunction is highly related to diabetes

INR- International Normalized Ratio

- How long your blood takes to clot 2-3 for people on Warfin or other blood thinners. Less than .9 blood clots too quickly >5 blood is too thin Cardiac Troponin- specific enzyme released with muscle injury or infarction in the blood - used to dx a heart attack. Should be trending down.

Fall risk - Most common risk factors: previous falls, balance impairments, decreased muscle strength, vision impairment, >4 meds or psychoactive meds, gait impairment

- Other risk factors: depression, dizziness or orthostatic hypotension, limitations of ADLs, disabilities, >80 years old, female, low BMI, urinary incontinence, cognitive impairment, arthritis, diabetes, pain, environment set up, sensation changes, chronic health conditions, sleep disturbances - Fear of falling in 50-60% of older adults 4-8

Palliative vs. Hospice- what is the difference? Both end of life care

- Palliative - varies more from location to location - Hospice care- the care that has the clearest guidelines- have to have a doctor saying the person has 6 months or less to live - get care through a Medicare program - people can do Hospice at home or through a facility - Hospice does not cover the cost of a facility - medical people can come in to a home - No more chemo to cure the cancer in Hospice- basically you let this person pass away - Their chance of survival is so small that its more passionate to go through the Hospice route - You are not continuing measures to prolong life- usually DNR orders

Myocardial infarction is a heart attack - doesn't get oxygen for a time so part of heart muscle dies - The way the heart muscle fires is electricity - Fires different at different chambers - Circuits are off and don't fire as they should in a heart attack STEMI names these in terms of the rhythm you see in the testing EKG

- STEMI involves complete blockage of an artery Non-STEMI is incomplete blockage of an artery - MI is often the beginning of other things

TYPE 2 diabetes can be insulin dependent or non-insulin dependent

- Some people with type 2 diabetes (NIDDM)- people that are not taking insulin- can be managed by diets and pills sometimes - ***Depends on the control of the glucose levels- unmanaged high levels may cause people to go on insulin

Fatigue Assessment: Piper Fatigue Scalehttp://geriatrictoolkit.missouri.edu/fatigue/PiperFatigueScale.pdf • OT should assess the effect of fatigue on ADL/IADL; use standardized measure, e.g., PFS; example question: 3. To what degree is the fatigue you are feeling now interfering with your ability to complete your work or school activities? None A Great Deal 1 2 3 4 5 6 7 8 9 10 There are reasons to assess fatigue as well- want to keep track of this

- There are specific questions that assess ADL/IADL - Fair to consider this if fatigue is a big issue

Poll Question What does COPD stand for and what are a symptom? 1. Chronic Obstructive Pulmonary Disease; dyspnea 2.Chronic Obtrusive Pulmonary Disease; angina 3. Chronic Obstructive Pleural Disease; tachycardia 4. Chronic Obstructive Pulmonary Disorder; chronic cough

1. Chronic Obstructive Pulmonary Disease; dyspnea

Poll Question Which do you feel is most appropriate for an activity during your OT session for a cardiac patient with sternal precautions? 1. Graded ADLs, rest breaks, no lifting over 10# 2. Exercises (Theraband) using the Valsalva maneuver 3. Pushing side to side into the bed for trunk stability 4. Reaching for items in closet/cabinets

1. Graded ADLs, rest breaks, no lifting over 10#

Poll Question Your working with your patient at the EOB and know from chart review he has CAD and acute Endocarditis. Throughout your session, you as a therapist are checking for cardiac signs and symptoms. Which are considered symptoms of cardiac dysfunction? 1.Angina, syncope, shortness or breath 2. Dizziness, nausea, dehydration 3. Hand tremor, orthostatic hypotension 4. Rapid heart rate, fatigue, sputum production

1.Angina, syncope, shortness or breath

Poll Question What is heart failure? 1. Complete blockage of an artery causing the tissue of the heart to die 2. The heart is not pumping effectively resulting in fluid backup into lungs/body. 3. A drop in BP when changing positions 4. Irregular and often rapid heart rate with blood flow not meeting body's metabolic needs

2. The heart is not pumping effectively resulting in fluid backup into lungs/body.

How long do patients have to rest after cardiac catherization? 1 hr 2 hr 3 hr 4 hr This order for 3 hours of rest would appear in the chart- so always check this to see if there are any restrictions to treatment

3 hr

Medical treatments for renal dysfunction: dialysis Three types ¡ Hemodialysis (HD): complete blood cleansing, a session every other day, requires fistula placement, takes 4-5 hours (go to a facility) ¡ Peritoneal dialysis (PD): blood cleansing using peritoneum as filter, 4 sessions each day (4-6 hrs of dwell time total), can do at home (patient or family), special tube is placed in the lower abdomen (high risk for infection) ¡ Continuous renal replacement therapy (CRRT): used in the ICU for patients in ARF (critical condition), mechanism similar to HD ¡ FYI after dialysis patient tend to be very fatigued and will likely refuse OT!

3 types of dialysis Hemodialysis- people go to a facility and over 4 to 5 hours pump it out of the body and pump it back in- what most people do - three days a week Peritoneal dialysis - for people who can do this at home- also everyday CRPT- hooked up to a machine and their blood is purified continuously If you are going to try and see someone after dialysis they are exhausted and probably won't want to do treatment

Poll Question All of the following are examples of energy conservation techniques you can educate your patient on or implement into your sessions, except? 1. Slowing activity pace 2. Implementing rest breaks 3. Creating a to-do list 4. Sitting for activities instead of standing

3. Creating a to-do list

Poll Question Which BP reading would correspond to stage 1 of High Blood Pressure? 1. 120/80 2. 160/100 3. 180/105 4. 140/90

4. 140/90

Lymphedema: Need for Patient Education Patient Education

: Often this is not consistently given to women after surgery that life-long attention to development of lymphedema is needed, and that precautions must be strictly followed and edema should be reported immediately A life-long condition

Your patient recently had an upper extremity amputation (transhumeral). She states that her residual limb feels strange, that the sensation she feels is sometimes like pins and needles; her skin is intact. At other times she has feeling of cramping and burning in her arm. You touch her residual limb very lightly and she jumps (she takes great effort to make sure it does not touch anything). It is clear she needs some desensitization. You decide having her start off touching her residual limb with: A rough towel Sandpaper Marbles A cotton ball

A cotton ball

Chronic Obstructive Pulmonary Disease (COPD)** Gradually progressive disorder involving lung deterioration and decreased expiratory airflow Includes emphysema, Alpha 1 Antitrypsin Deficiency, and chronic bronchitis Often associated with long history of tobacco use or work exposure to dust/smoke/chemicals Symptoms include chronic cough, sputum production, dyspnea on exertion or with anxiety and progressive deconditioning Treatments include medications, oxygen therapy, flu vaccine, exercise

A group of diseases including emphysema, chronic bronchitis The bronchioles start to collapse and walls of alveoli start to fail

Acute renal failure (ARF): symptomshttp://www.nlm.nih.gov/medlineplus/ency/article/000501.htm Bloody stools Breath odor and metallic taste in mouth Bruising easily Changes in mental status or mood Decreased appetite Decreased sensation, especially in the hands or feet Fatigue Flank pain (between the ribs and hips) Hand tremor High blood pressure Metallic taste in mouth Nausea or vomiting, may last for days Nosebleeds Persistent hiccups Prolonged bleeding Seizures Shortness of breath Slow, sluggish movements Swelling due to the body keeping in fluid Swelling, usually in the ankles, feet, and legs Urination changes

A lot of symptoms If you see enough of these symptoms together, you have to get the person medical attention b/c renal failure is possible

Pulmonary Rehabilitation & OT OT Assessment: Must be done to find deficit areas Goal: To stabilize or reverse the disease process and return the patient to their prior level of function (PLOF), reverse deconditioning Psychosocial Considerations: Depression and anxiety are common in this population; may need help with coping skills OT can educate patients on techniques to ease breathing difficulties and calm the body & mind

A lot of times trying to have them gain strength

OT Treatment of People with HIV/AIDS • Poor endurance: Patient education in energy conservation and work simplification is important • Pain: Patients benefit from strengthening and increased joint movement as they often have joint pain and stiffness • ADL Retraining: Adaptive equipment and positioning can be used to improve ADL independence, but these may be rejected as part of the "sick role" • IADL Retraining: OT can help patients transition to productive activities if worker role is compromised

ADL/IADL retraining

OT Assessment of Patients with Cancer • What areas would you assess?

Activity tolerance Pain Cognition MMT Levels of assist for ADL Sensory deficits Scars checking vitals Sleep, nutrition Psychosocial aspects- big for people with cancer balance

Medical Management** of Cardiac Conditions: General Improving diet, losing weight, and increasing exercise/activity usually helps all cardiac conditions (must adhere to precautions) Medications can be given to lower BP, decrease edema, prevent blood clots, correct irregular heartbeat, manage angina, relax blood vessels, improve blood and oxygen supply, lower cholesterol Anticoagulant therapy (Warfarin, Heparin) may be given if patient is at risk for blood clots, need frequent blood draws to test for level Diuretics may be given for conditions causing increased edema Surgery may be done for CAD and heart valve dysfunction, other problems (e.g. ablation to destroy tissue causing arrhythmias)

An increase of activity will helps all cardiac conditions usually A-fib may also have blood thinner and anticoagulants Diuretics help you get rid of lots of fluids so avoid edema in the legs- often get frustrated when they take diuretics- have to get up and go to bathroom all the time Surgery can be done for coronary artery disease and hear Ablation- Destroy part of tissues to stop arrhythmias

Types of PVD: Treatment(Smith-Gabai & Holm, 2017) * Antiplatelet drugs * Anticoagulants (thrombolytic therapy) * Angioplasty & stent placement * Surgical bypass * Prophylactic -- use of by compression stockings or sequential compression devices (SCDs), lifestyle modification

Anticoagulants (thrombolytic therapy) - Why would we want to thin the blood? - PREVENT clots- especially in legs b/c legs are farthest from the heart Plaques could be blocking blood flow Thin blood could flow easier Surgical bypass can be used in LE - especially the knee- popliteal bypass b/c could have blocked blood vessels here sequential compression devices (SCDs) - they are these wraps that go around your legs- use them in inpatient- they inflate and deflate - help with circulation of people who are bed bound - And those who had a recent surgery - Encouraging exercise

Signs of blood glucose being too low (hypoglycemia) Low blood sugar (if level is below 70 mg/dL): if conscious, immediately give carbohydrates ¡ Headache ¡ Hunger ¡ Nervousness ¡ Rapid heart rate* ¡ Shaking* ¡ Sweating* ¡ Weakness ¡ Unconsciousness and even coma* - call 911

Are more lethargic than hyperglycemia Having a patient test their blood levels before sessions can help Continuous glucose monitoring (CGM)- being able to know what their glucose level is right away and be able to check with their smartphone is huge

Medical Management** of Cardiac Conditions Arrhythmias/Atrial fibrillation: Treated with surgical insertion of pacemaker, pacemaker/implantable cardioverter defibrillator (ICD), or ablation Heart Valve disease/dysfunction may be treated with surgery to replace or repair valves Endocarditis: treated with antibiotics or surgery Cardiomyopathy: treat signs and symptoms Orthostatic hypotension is treated appropriately depending on its cause and the patient's medical history; compression stockings, medication and increased salt and fluid intake may be recommended, as is moving slowly when changing body position

Arrhythmias/A-fib- Pacemaker and or defibrillator Heart valve disease- Can repair/replace valves

A person is diagnosed with COPD. The OT instructs the patient on breathing exercises to use to control respiration rate during activities. The therapist tells the person to inhale as if smelling roses. How should the therapist tell the person to exhale? As if blowing forcibly to relight a dying campfire As if making a lit candle flicker, then extinguish As if quickly blowing out 40 lit candles on a birthday cake As if blowing up a balloon, in quick, short, multiple and forceful breaths

As if making a lit candle flicker, then extinguish

Vascular Conditions(Smith-Gabai & Holm, 2017) * Hypertension (Htn): high blood pressure can result from atherosclerosis, genetic factors, poor diet, obesity, and lack of exercise; sometimes called the "silent killer" * Hypotension: Low blood pressure occurs when blood pressure is much lower than normal; this means the heart, brain, and other parts of the body do not get enough blood; normal blood pressure is usually between 90/60 mmHg and 130/80 mmHg

Atherosclerosis- Plaque narrows blood vessel making BP higher "silent killer" b/c if don't get blood pressure checked regularly could lead to stroke heart attack, etc. Hypotension is not as common BP does go up with exercise but hopefully stays in 130/80 and 90/60 - Concern if people get higher than 160 over 110 during exercise - If person has normally high blood pressure - there will be a normal slight spike with activity but shouldn't be a lot - Some patients on their orders says to avoid exercise - b/c concern sometimes hypertension is difficult to control

Vascular Conditions: PVD(Smith-Gabai & Holm, 2017) * Peripheral vascular disease (PVD) is hardening, narrowing and/or occlusion by atherosclerotic plaques of arteries or veins outside of the heart and brain * Modifiable risk factors for PVD: diabetes, smoking, stress, hypertension and hypercholesterolemia * Non-modifiable risk factors: age, gender, and family history * Other risk factors: obesity, heart attack, &stroke

Basically blockage or narrowing outside of CNS and heart hypercholesterolemia- when cholesterol is too high These conditions likely make PVD worse - sometimes are modifiable

***A lot of time people fall b/c they don't have the correct equipment!!

Bowel bladder schedules can help put them on a regular schedule which will help reduce hurrying to toilet Kitchen safety eval - do they recognize sharp objects and hazards? Standing activity tolerance- assessing their balance in many ways- this is the time to challenge them in a SAFE environment Sometimes will do fall simulations

CABG Changes the Path of Circulation

CABG- if blockage is too big and bad? Just like a traffic jam- you're going to route around it Take a vessel from somewhere else like leg vein and stick it on the heart to bypass the heart

Cardiac Conditions** Types of Disease Angina: chest pain, usually associated with CAD Congenital defects: many and varied, may not be known until adulthood Cardiac Tamponade: pericardial effusion, buildup of fluid puts pressure on heart and reduces cardiac output Coronary Artery Disease (CAD) is caused by years of smoking and/or high blood pressure, making wall of arteries irregular; this encourages plaque formation (fatty deposits), then platelets collect on wall; result is more atherosclerosis

CAD= coronary artery disease Picture of CAD- years of smoking and/or high blood pressure- encourages plaque formation - fatty deposits- from fatty foods we eat like pastries Causes more arthrosclerosis- narrowing of artery opening - Like a hose, when you have a small hose vs. a large hose- water pressure - Smaller hose with smaller diameter will have higher pressure increasing blood pressure - The more narrowing of arteries, the more increased blood pressure - This is where diet and cardiac conditions are related

Early Intervention: OT * Positioning/Splinting * Casting * Range of Motion * ROM exercises * Continuous Passive Motion (CPM) * Mobilization: tilt tables, wheelchair fittings * Swallow (specialized are for OT, often done by SLP)

CPM machine to keep part moving after surgery Tilt table is a platform that brings a patient up - doing HW laying down is really hard- people fall asleep when they are lying on their backs There are arousal systems that make us feel sleepy when lying down So you actually strap the patient on the table and get them in a higher state of consciousness

Diagnosis of Cancer (Smith-Gabai 2011) • Screening • Mammogram • Computed Tomography (CT) • Prostate exam • Colonoscopy • Biopsy • Pap Test & HPV testing • Blood Test

CT scan is sort of like an MRI

Cardiac Conditions** Heart Failure: the heart cannot pump effectively, causing fluid to back up into the lungs or the body Can be congestive, right sided or left sided Heart can become enlarged and thickened Edema is noted especially in the lower extremities Ejection fraction is reduced Treatment is medication, low-sodium diet, fluid restriction, and slow increase in activity OT can help with graded self-care program

Can be different types of heart failure - Congestive - heart becomes thicker -b/c what happens to a muscle when you overwork it? - Muscle will become bigger and thicker - You can also see there is edema in lower extremities- especially the legs- WHY? - You get swelling in the legs because poor circulation in the legs b/c of gravity and the feet and legs are the farthest from the heart - So requires a lot more power for the heart - So often see their legs and feet become huge - Right sided congestive heart failure - can cause delusions - why is this? - A lack of oxygen to the brain - May be confusion and cognitive problems in people with significant heart failure - Ejection fraction is reduced - Sodium causes us to retain moisture and fluid, fluid restriction so doesn't get stuck in legs and the feet

Pulse oximeter

Can use this on finger to test that

Cancer arises from a loss of normal growth control In normal tissues, the rates of new cell growth and old cell death are kept in balance. In cancer, this balance is disrupted. This disruption can result from uncontrolled cell growth or loss of a cell's ability to undergo cell suicide by a process called"apoptosis." Apoptosis, or "cell suicide," is the mechanism by which old or damaged cells normally self-destruct.

Cancer is a mutation of cells as they grow Normally new cells crowd out old ones When cancer cells divide, they have MUTATED and continue to mutate as they grow - An uncontrolled growth of cells- start to crowd into other spaces - Not the same composition as the old cells

Different kinds of cancer

Carcinomas, the most common types of cancer, arise from the cells that cover external and internal body surfaces. Lung, breast, and colon are the most frequent cancers of this type in the United States. Sarcomas are cancers arising from cells found in the supporting tissues of the body such as bone, cartilage, fat, connective tissue, and muscle. Lymphomas are cancers that arise in the lymph nodes and tissues of the body's immune system. Leukemias are cancers of the immature blood cells that grow in the bone marrow and tend to accumulate in large numbers in the bloodstream.

Cardiac Rehab & OT: Borg Rate of Perceived Exertion** To monitor a patient's perception of their physical activity we can use the Borg scale This is an educational tool for patients to monitor activity level

Cardiac rehab and OT - Borg rate of perceived exertion - Different levels- - A way we can have people think about how they are doing with a certain activity - If you are gasping for air after going up and down the stairs, you may say that it's a RED activity, a level 18 on the graphic- you can't talk, just gasping for air - BORG scale can be used to educate patient in those activities - May be too much strain on you *** BORG scale has to do with tolerance, not picking a specific activity like in MET levels

End-stage renal disease (ESRD) Symptoms of ESRD include:

Changes in mental status ¡ Impaired sensation of hands and feet ¡ Decreased urine output ¡ Nausea ¡ Vomiting ¡ Headache ¡ Easy bruising or bleeding ¡ Fatigue ¡ Can cause the need for transplantation and/or dialysis to sustain life

Colostomy with bag

Catches all of the stool moving through - Will be more liquified b/c not going through small intestine

**Warning Signs of Respiratory Distress** Shortness of breath (dyspnea): severe form will prevent patients from uttering a short phrase without gasping for air Extreme fatigue Nonproductive cough Confusion & impaired judgment Cyanosis

Confusion and impaired judgment Cyanosis- bluish lips

* Vascular Conditions: Varicose Veins

The walls of the veins are kind of sticking out- poor circulation causes outpouching b/c blood is getting distended in extremity

Complications (more severe when blood glucose out of control) Macrovascular ¡ Hypertension (affects 70%) ¡ Cardiovascular Disease (75% of deaths) ¡ Cerebrovascular Disease & Peripheral Artery Disease (2-4 times higher risk) Microvascular ¡ Diabetic Retinopathy (leading cause of blindness) ¡ Diabetic Nephropathy (leading cause of end-stage renal disease) Neurologic ¡ Peripheral neuropathy: most common complication ¡ Diabetic autonomic neuropathy (DAN) Other ¡ Diabetic foot (ulcers) ¡ Periodontal disease

Controlling blood sugar is NUMBER ONE!!!! - But even very disciplined people can struggle with this - Macrovascular- high BP, CV disease, brain things like stroke - Microvascular- retinopathy- diabetes is the leading cause of blindness- nephropathy- bad circulation in kidneys - Neurologic- numbness in hands and feet is very common, diabetic autonomic neuropathy- the ANS is not functioning well - Other- foot ulcers, disease of the gums- periodontal (require a lot of circulation)

On the subacute unit you are treating a patient who recently had an elective knee replacement due to severe osteoarthritis. After doing some functional transfers the patient complains that she has pain in her right shoulder. You ask her to do some AROM at her shoulder and you can feel grinding in the joint as she moves. This clinical sign (which is a specific clinical indicator of arthritis) is called: Nodules Crepitus Gelling Poor arthro-mechanics

Crepitus

DVT Etiology(Smith-Gabai & Holm, 2017) * Damage to blood vessels following surgery * Cancer * Blood clotting dysfunction * Hormone therapy * Pregnancy * Varicose veins * Cardiac history * Obesity * Inflammatory bowel disease * Inactivity or long periods of sitting

Deep vein thrombosis= DVT Most often occurs in the legs, sometimes the arms Damage to blood vessels following surgery*** is probably the most common one!! Lots of pregnant women with DVT

Diagnosis of diabetes: Blood glucose (BG) level Normal 8-hour fasting blood glucose level is <100 mg/dL Range is 100-125 mg/dL for impaired fasting glucose (pre-diabetes) Diabetes is diagnosed if fasting blood glucose level is >=126 mg/dL or random (non-fasting blood glucose level is 200 mg/dL with DM symptoms Hemoglobin A1c (average concentration of glucose in blood over 6-wk to 3-mo) levels =>6.5% diabetes is also diagnosed (5.7% for pre-diabetes)

Diagnose diabetes via blood glucose level Normal should be less than 100 Test out hemoglobin and get percentage of glucose in blood based on hemoglobin - a longer measure - get a snapshot of fasting and what's been going on the past three months - Could capture this in an A1c, gives you more of an idea - If more than 6.5% diabetes is diagnosed - Adjust diet and do more exercise can help this be managed for those with pre-diabetes

Tests: Electrocardiogram (EKG) Record heart rate and rhythm Telemetry in the hospital or outpatient Holter Monitor (photo)

Don't always do these Sometimes on an outpatient basis- they go with a monitor for 24 hours- and you would log this - What were you doing at this time a day for count for why your heart rate went up

Invasion and metastasis

Don't just stay in one space- sometimes metastasize and spread throughout the body - Many times cancer cells are transported by the blood - Sometimes they do get spread through the lymphatic system

Cardiac Disorders Cardiac disorders are super common- one of most common diagnoses you will see Cardiac Risk Factors

Heredity Male gender Age Hypertension Cigarette smoking Cholesterol levels Inactive lifestyle Contributing factors: diabetes, stress, obesity Even if its just less cigarettes a day or less vaping - It not only damages your lungs, but also slows your circulation and slows healing - Cholesterol - Contributing factors- some are controllable some of them are not

Cardiac Conditions** Atrial fibrillation (A-fib): an irregular and often rapid heart rate (arrhythmia) that results in blood flow not meeting body's metabolic needs

During atrial fibrillation, the atria beat out of coordination with the ventricles; symptoms include heart palpitations, shortness of breath and weakness Treatment can be medication for cardioversion and/or ablation of cardiac tissue People with atrial fibrillation are five times more likely to have a stroke (CVA) than someone without A-fib A-fib-basically the heart chambers are not coordinated properly - will feel that their heart is fluttering or have shortness of breath - A bad thing to have b/c can lead to other issues - Can take medicine to regulate A-fib - Ablation is trying to regulate electrical sequence by burning out heart tissue - People with atrial fibrillation are five times more likely to have a stroke- WHY?? - If you don't have blood flow all the time, what happens when blood pools? It CLOTS - So what happens to those clots? - They become embolisms - They travel to bad places, brain causing a stroke, or the lungs and cause a pulmonary embolism - This is why A-fib is really important to treat- want a regular heartbeat b/c don't want this to happen

Tests: Cardiac Catheterization Angiogram

Dye injected into the heart via a leg vein and an x-ray is taken of the coronary arteries Three hours of bed rest following the procedure (patients need pressure to femoral vein to stop bleeding) Checks for blockages in the heart Insert dye that shows up on X-ray it shows you if there is circulation in the arteries itself

Pulmonary Rehabilitation & OT** Dyspnea control posture: patient can bend forward slightly at the waist while supporting upper body by leaning the forearms on table or thighs Pursed-lip breathing: increases use of the diaphragm; steps are (1) purse lips as if to whistle; (2) slowly exhale through pursed lips; (3) inhale deeply through the nose; (4) take twice as long to exhale as you do to inhale Progressive muscle relaxation in conjunction with breathing exercises can be effective in decreasing anxiety and controlling shortness of breath (SOB) Energy conservation/work simplification/lifestyle modification should be taught to patients so they can save their energy for valued activities (time management, sequencing, rest breaks, slowing activity pace, sitting for activities, etc.)

Dyspnea control posture if someone is short of breath can bend forward to catch their breath Pursing your lips and increase use of diaphragm- inhaling through the nose, exhaling through the pursed lips- smell the rose and blow out the candle - Purse the lips and exhale twice as long as you inhale - Proning means you go in and you turn patients over into prone- COVID likes to be in the rear of the lungs so its resting in there and fluid is accumulating - In prone, you allow the fluid and virus to get out of the lungs and move - If it stays in one area, can get pneumonia and have it get worse - Turning patients every 2 hours to make sure - But OT is being minimized with COVID patients b/c risk of transmission

Occupational Therapy Treatment for PVD * Encourage exercise (including an ambulation program), daily diabetic foot inspection, daily bathing, changing socks or stockings daily, selection of well-fitting shoes without open heels or toes, and regular podiatrist care if needed * Discourage use of restrictive clothing * Encourage patient to care for extremities with sensation impairments

Encouraging exercise b/c without it, blood flow will be limited, sped up with exercise A lot of elder patients don't feel like bathing everyday- cause them to be dirtier and if they get a cut they can get infections easier Restrictive clothing can limit blood flow If you have numbness, you are likely to have wounds you won't see or notice

Cardiac Risk Factors Heredity Male gender Age Hypertension Cigarette smoking Cholesterol levels Inactive lifestyle Contributing factors: diabetes, stress, obesity

Even if its just less cigarettes a day or less vaping - It not only damages your lungs, but also slows your circulation and slows healing - Cholesterol - Contributing factors- some are controllable some of them are not

Role of OT regarding falls • Screening • Assessment: Fall History, occurrence, location • Treatment: education & prevention • When should OT address falls?

Fall history - Was it a medical issue, an environmental issue? Once you know scenario that led to the fall- then can provide appropriate treatment When should OT address falls? ***ALWAYS- think about falls constantly - How am I immediately going to prevent falls and how will I prevent them in the future? - Think about this during screening, eval and discharge

Falls What constitutes a fall? Controlled falls vs. unwitnessed/uncontrolled fall

Fall- Any unintentional way of moving whether that is onto another object or the ground When the lower limbs touch the ground

You are working in an outpatient clinic and a patient arrives for an evaluation. She has a history of shoulder pain with no known mechanism of injury. You talk with her further and discover she has pain throughout her body (lower and upper extremities) as well as trouble sleeping & symptoms of irritable bowel syndrome. You suspect she could have the following condition: Osteoarthritis Fibromyalgia Rheumatoid arthritis None of the above

Fibromyalgia

Pursed Lip Breathing

Pursing your lips and increase use of diaphragm- inhaling through the nose, exhaling through the pursed lips- smell the rose and blow out the candle - Purse the lips and exhale twice as long as you inhale

Medical Treatment: Pre-Exposure Prophylaxis (PrEP)

For people at RISK for HIV/AIDS - Gay or bisexual population may want to take this on a regular basis b/c at risk - PREP is meant to prevent HIV b/c likely to be exposed to population who has it

Gastroenterology: What is GERD? GERD is Gastric Esophageal Reflux Disease: a condition in which the lower esophageal sphincter inefficiently closes, then stomach contraction propels acid/acidic bolus back into the esophagus; person reports heartburn and/or chest pain

GERD- almost everybody has GERD in their chart- has to do with our yucky diet- have a lot of stomach acid and sphincters are insufficiently closing If they are managing it fine there's not much to do Just be aware of this Treatment for this is a healthy diet- less fat and less spicy food

Renal Pathophysiology Glomerular filtration rate is reduced Sudden retention of exogenous and endogenous metabolites ie, creatine, urea, potassium (hyperkalemia), administered drugs Urine output is low (below 400ml/day) Increased protein in the urine

Glomeruli are in the kidneys that filter the blood that comes in Filtration is reduced!!

Functional reach Test

Good indicator for fall risk - Simple test - Measure in inches how far they can reach - The less the reach, the greater the fall risk - The less they can reach, the less they can move out of their base of support

Pectoralis stretch for Patients Who are Post CABG (Post Precautions)

Good stretch to stretch out sternal scar

You are working with a patient who is status post (S/P) CABGX3 in the hospital. Today you are trying to help the patient get dressed and bathed at his bedside; previously your activities in therapy have just been sitting at the edge of the bed and doing BUE activities. While sponge bathing the patient starts complaining of feeling nauseous and starts saying he is very tired. You believe the following: He is lazy and just doesn't feel like doing therapy He didn't get a good amount of sleep last night He shouldn't be on OT caseload, he is just too weak He is not ready for this level of activity, it requires too many METS

He is not ready for this level of activity, it requires too many METS

Ot Patient & family education: 7 self care behaviors for diabetes management

Healthy eating Being active Monitoring Not only BG but also weight, BP, foot health, exercise Taking medications Problem solving Healthy coping Reducing risks Keeping up with medical appointments, smoking cession Education is super important for patients with diabetes - Best things we can do for these people - Obesity is not in the person's control - a lot of weight loss we are learning may be beyond a person's control to do

Medical Management** of Cardiac Conditions Heart Failure can be treated with Diuretics (mild); Ventricular Assist Device (VAD) if more serious; Or heart transplant for terminal patients (not for smokers or obese people; must take immuno-suppressants)

Heart failure - Diuretics - Heart transplant too- not always feasible need to get on a list- triage based on their need- and others aren't even eligible for this

Per the powerpoint posted on Canvas, the lower limb amputation level that would make prosthetic training the most difficult would be: Below knee amputation Hemipelvectomy Above knee amputation Hip disarticulation

Hemipelvectomy

What can OT do to prevent falls?

How to prevent this fall from happening? Home eval - Make sure don't have slippery surfaces - are they wearing shoes? - Patient education - Teaching them about proper body mechanics - Do not use wheeled walker on stairs - when leaving their room, refrain from leaving their walker near them and give them the call button - Especially if they are impulsive or confused

Signs of blood glucose being too high (hyperglycemia) Very thirsty or hungry Tired, fatigued or anxious Blurry eyesight* and shakiness* Fruity breath odor* Neuropathy Rapid breathing* Slow responses* Weight loss, increased urination Nausea and/or vomiting* Can lead to diabetic ketoacidosis, diabetic coma or mortality from other comorbidities (MI, CVA, sepsis) - call 911

Hyperglycemia can be very dangerous Things with asterisks are things you should be more concerned about and take action to keep person safe, call 911 or their doctor Asterisked items can lead to diabetic ketoacidosis Always put as a precaution for diabetes to look for these signs and take action

Restrictive Pulmonary Conditions Pneumonia: Inflammation of lung tissue caused by infection; symptoms are cough, malaise, dyspnea, tachypnea, fever, chills. Treated with antibiotics, oxygen therapy, ventilation; pneumonia (and other conditions) can lead to respiratory failure and a need for mechanical ventilation Atelectasis: partial or complete collapse of a lung, usually caused by lung compression or obstruction

Idiopathic pulmonary fibrosis: progressive lung disease of unknown etiology, poor prognosis and no cure Adult respiratory distress syndrome (ARDS): bilateral pulmonary infiltrates, lungs become fibrotic Pulmonary edema: buildup of fluid in extravascular spaces of lungs, which impairs gas exchange causing difficulty with breathing COVID-19: fever, cough, shortness of breath, chest pain, can lead to confusion and altered consciousness - even death

VP Shunt

If too much CSF, want to discharge it to peritoneum to decrease cranial pressure Person needs to be upright and are often on bedrest

Viral Load • Viral load is the level of HIV in your blood • Helps to monitor the progress of the HIV disease and determine when to start/stop treatments • Increased Viral Load = Decreased CD4 Count • Decreased CD4 count = suppressed immune system = more likely to get sick

If you are having an increased viral load, having a decreased CD4 count- more likely to get sick - The effect of the virus is to depress this amount

A-fib-basically the heart chambers are not coordinated properly - will feel that their heart is fluttering or have shortness of breath - A bad thing to have b/c can lead to other issues - Can take medicine to regulate A-fib - Ablation is trying to regulate electrical sequence by burning out heart tissue - People with atrial fibrillation are five times more likely to have a stroke- WHY??

If you don't have blood flow all the time, what happens when blood pools? It CLOTS - So what happens to those clots? - They become embolisms - They travel to bad places, brain causing a stroke, or the lungs and cause a pulmonary embolism - This is why A-fib is really important to treat- want a regular heartbeat b/c don't want this to happen

At the hospital you have a patient (Mrs. Kaynine) who has COPD and is on 2 liters of oxygen by nasal canula per doctor's order; she is A&Ox3. You help her to transfer to the edge of the bed, where she sits and does dowel exercises as she did yesterday with you. Unfortunately, after two sets of 10 repetitions the patient becomes very short of breath and confused (she calls you "Fido," which is her dog's name), unlike yesterday when she had no difficulty with this exercise. When she lays down her dyspnea gets worse. The best course of action regarding the patient at this point is: Let the patient take a break from the exercise, then try it again in a few minutes Help the patient lay down, then come back later to check on her Call her "Fido" right back, then try a different, more challenging exercise Immediately talk to the patient's nurse regarding patient's increased shortness of breath and confusion since yesterday

Immediately talk to the patient's nurse regarding patient's increased shortness of breath and confusion since yesterday

At an outpatient clinic you are treating a patient with rheumatoid arthritis in a state of remission. You know you should probably avoid the following due to the likely weakness of joint tissues: Trigger point release Hot packs Joint mobilization Electrical stimulation

Joint mobilization

Type 2 diabetes

Insulin is what allows us to use the energy that we are consuming in food The pancreas makes insulin- insulin is the sugar that we can use in our bodies If there's not enough insulin to translate glucose into a usable form, it just hangs out in the body - Like having gas in the car but not in the tank -can't make the car go

Cardiac Conditions** Arrhythmia is a problem with the rate or rhythm of the heartbeat; during an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm Arrhythmia is often a result of other cardiac dysfunction (MI, valve disease) Normal HR 60-100 HR <60 bradycardia HR>100 Tachycardia Asystole= absence of cardiac activity

Irregular heart beat is an arrhythmia - Can be too fast, too slow, or irregular - Bradycardia is too slow a beat, tachycardia is too fast a beat - Absence of cardiac activity is asystole

Obstructive Sleep Apnea OSA: Stopping breathing for at least 10 seconds during sleep; treated with CPAP machine (compliance an issue here) OSA is largely undiagnosed in 80-90 % of cases OSA is associated with cerebrovascular disease (including stroke), cardiac arrhythmias, and myocardial infarction if untreated

It is undiagnosed in a lot of people - If they wake up a lot during the night and snore - It's a good thing for us to suggest to them they see someone to be tested for it b/c it's a risk factor for a lot of things b/c it's very hard on the heart - Can cause stroke or arrhythmia

Current stats for CA five-year survival (see Page 20)

It's really good to understand what the 5 year survival rates are for certain types of cancer This affects our treatment planning Be really careful that you don't reveal a terminal diagnosis - talk to the nurse to know what is going on Don't be afraid to say you don't know the answer to certain questions- be very careful b/c you don't want to give misinformation Make goals conservative and based on what they want to do

Early Intervention: OT * Patient and Family Education * Many patients are unaware of injuries * Trauma is sudden and unexpected - shock * Interaction with many professionals * With survival family focuses on outcome * OT can help clarify functional status and potential to facilitate planning for discharge * OT can instruct on gentle interventions done by family and precautions

Its helpful a lot of times to give the family something to do Also will want to know the future for the loved one- want to give hope but not over promise

Warning signs of renal dysfunction High blood pressure, low back/flank pain More frequent urination, particularly at night Difficult, painful or bloody urination Decreased urination Swelling at eyes, hands and feet Shortness of breath Nausea and vomiting Confusion & lethargy, sluggishness Neuropathy, seizures/rhabdomyolysis Decreased strength/ROM/coordination

Kidneys are the garbage collectors and if they are not picking up waste, its going to affect the rest of the body Kidney dysfunction affects COGNITION!!

Which one of the following is not a symptom of compartment syndrome? Swelling Pain Loss of involuntary control Sensory changes

Loss of involuntary control

Cancer: Etiology (Heredity can also be a factor)

Lots of different causes of cancer - Tobacco use - Obesity or overweight - Cancer-causing pathogens HPV virus does make it more likely that women have cervical cancer - Insufficient physical activity - Poor dietary habits - Exposure to UV light from the sun or tanning devices

Lymphedema • Process: When lymphatic system is damaged, it may be unable to transport fluid; therefore there is a buildup of protein that attracts fluid and results in a build-up of lymph fluid in the subcutaneous tissues. The excess fluid causes edema which also predisposes the patient to infection: https://www.mayoclinic.org/diseases-conditions/lymphedema/symptoms-causes/syc-20374682 • Incidence after Breast Cancer: varies, 43-94% at 5 years https://ascopubs.org/doi/abs/10.1200/jco.2010.28.15_suppl.e19520 • Incidence with general medical populations: Lymphedema is possible in men or women with damaged lymphatic systems, e.g., lymphedema associated with obesity

Lymphatic fluid has a lot of protein build up in it Axilla is where all those lymph nodes out Mastectomy breaks the system and fluid then just hangs out in the interstitial space Then person is more prone to infection b/c fluid is more stagnant Lymphedema and obesity can occur as well!! Fluid will start to leak out of their tissues - will see the legs having fluid leaking fluid Not just extra adipose tissue but extra fluids- vessels are so fragile

Lymphatic System

Lymphatic system is a WHOLE body system

Metabolic Equivalent for Task (MET)** Levels

MET levels- NBCOT loves to test about this A really important thing to understand how to grade activities according to MET levels - Like what would be the better activity considering the MET level they are at? - Lower for low energy activities - Higher for high energy activities - Light intensity- is sleeping, watching TV, walking on a level surface - Moderate intensity- - Vigorous intensity - includes SEXUAL activity, they can return to sex when they can do other vigorous activity - ex. If you can go up and down the stairs right away and not be short of breath- you can safely return to sexual activity Cardiac rehab usually starts in inpatient To evaluate MET levels- you look at a list- - Lists posted on canvas - There are lists of different activities and how much units of (Metabolic equivalent for task) MET they require - So may start out with person doing exercises in sitting - May progress to standing- at a higher MET level than sitting - Want a gradual increase in MET level - Even getting dressed can be a huge challenge for some people - Look up MET levels for ADLs specifically too - Ex. Folding laundry is a lot harder than brushing teeth at the sink *** BORG scale has to do with tolerance, not picking a specific activity like in MET levels

Medical Management** of Cardiac Conditions Myocardial Infarction (MI): Treated with cardioversion (electrical or chemical), aspirin, oxygen, nitroglycerin (to control chest pain); usually treated in the intensive care unit for 2-3 days; transferred to regular hospital bed when stable; may necessitate pacemaker insertion

MI - whenever you see this, it is cardiac arrest Cardioversion is shocking patients- Electrical or chemical

HIV & AIDS Testing Diagnosis (aids.gov) • Antibody Test (2 weeks) • Antigen Test (1-3 weeks) • PCR Test (Polymerase Chain Reaction Test) (2-3 weeks) • Infants at risk for HIV • Measure viral loads

Made by use of a variety of tests: rapid screening test, enzyme-linked immunosorbent assay, Western blot test; all detect the presence of HIV antibodies following the initial HIV infection but these tests are not immediately positive (takes up to 2 months) CD-4 Count is a lab test that can diagnose a person with AIDS; it is a count that measures immunosuppression. A normal CD4 cell count is more than 500 cells per cubic millimeter (mm3) of blood. If you have a CD4 count of fewer than 200/mm3, you will be diagnosed as having

OT intervention: ileostomy/ colostomy self-care Remember, when doing functional transfers avoid area of the ostomy or bag may detach and stool will spill out and/or stoma may be traumatized Changing the colostomy bag is part of ADL, so OT can instruct patient It is best to empty the bag when it is 1/3 to ½ full to avoid eruption of fecal matter on surrounding surfaces (remember to avoid breathing through your nose!)

May be working with people who have a colostomy bag b/c going to the bathroom is an ADL Be careful when it gets full that you need to empty it - Gas comes out here too in addition to stool so its very very stinky - Empty it when its 1/3 to ½ full - In transfers avoid bag and ostomy itself!! Place gait belt higher or lower than stoma- avoid it

OT Treatment of People with HIV/AIDS • Cognition: When patients experience cognitive compromise (e.g. AIDS Dementia Complex or ADC), a variety of strategies can help occupational performance: e.g., medication management, financial management, work management • Psychological: Helping develop coping strategies regarding the illness • Safety: If safety is compromised, changes can be made to the physical environment and/or performance patterns

May look at making sure they manage their finances, pay their bills May use some psychological tools- coping strategies If have sensory deficits and keep burning themselves on the stove

Cardiac Function: Ejection Fraction** Ejection fraction is a common measure of the health of the heart Ejection fraction refers to the percentage of blood that is pumped out of a filled ventricle with each heartbeat; no matter how forceful the contraction, it does not empty all of the blood out of a ventricle (normal is about 50%); less than 40% may mean patient is in heart failure Ejection fraction is usually measured only in the left ventricle Ejection fraction is tested via echocariogram Recovery depends on age and general health of patient

Measurement of the health of the heart Percentage of blood pumped out of ventricle with each heart beat Not normally 100%, normal is about 50% Ejection fraction measurements is talking about left ventricle most often!!

Fall risk --factors

Meds: side-effects or overmedication Hartley et al.- Clinical overview from APTA In a nursing home, previous falls and cognitive impairment may have a larger influence than if they are in a community setting Fischer et al. Cognition: More risky behaviors w/ declining cognition and increased fall rate, More difficulty utilizing problem-solving strategies and allocate attention Enderlin et al: Fear of falling: Barrier to performing physical activities, limits ADLs, decrease strength and tone, lose mobility, and decreases QOL, role in future falls Fear is often missed by healthcare professionals, don't share since fear they will lose independence, no injury w/ fall so it goes undocumented, med team fails to bring up the issue, patients, family, and health care professionals see falling as part of the aging process Landers et al: fear of falling, avoid activities due to fear of falls causing functional decline, restriction of social participation, increased risk of falling, institutionalization

Pulmonary conditions- melodica

Melodica- musical instrument only able to play with breath

OT Treatment of People with HIV/AIDS: Efficacy

Motivational interviewing (incorporates patient education) has been shown to increase safer sex behaviors with HIV-positive drug users - Motivational interviewing is almost like making these people realize this is what they need to do to increase their health and well-being

Vascular Conditions & OT Treatment

Need to know these to make sure patients are safe and educate patients as far as what they can preventively handle these conditions and not make them worse - So a lot of safety and patient education - Not that our treatment will stop or directly arrest these conditions - Also need to educate patients on preventing things from getting worse

**Warning Signs of Cardiac Dysfunction during OT Treatment** Angina Nausea/emesis Cerebral signs Orthopnea (dyspnea in supine) Syncope Shortness of breath (dyspnea) Poor activity tolerance (fatigue) Diaphoresis Orthostatic (>20 mm drop in systolic BP supine to sit)

Need to know this for NBCOT!!!! Angina is chest pain Nauseous- throwing up Dizzy/confused (cerebral sign) Orthopnea- shortness of breath Syncope - losing consciousness Shortness of breath Poor activity tolerance - fatigue orthostatic- drop in blood pressure in different position STOP activity when you see these*****

Lymphedema Precautions for Affected Extremity http://www.lymphnet.org/pdfDocs/nlnriskreduction.pdf • Have regular medical check-ups • Report changes in extremity • Keep normal body weight • Exercise • Wear compression garments • Treat cellulitis/infection immediately • Care for skin and use proper hygiene • Avoid trauma to affected extremity (falls, burns, skin punctures) • Avoid constriction • Avoid extreme heat and cold • Avoid surgery if possible or have a plan for lymphedema • Avoid stasis (lack of movement) • Treat varicose veins • Avoid air travel if possible (controversial)

Need to monitor any changes in that extremity Often doctors have patients keep antibiotics with them if they start seeing signs of an infection Blood draws should not be drawn on the lymphedema side

OT Treatment of People with HIV/AIDS • Neurological: • Some antiretroviral therapies cause nerve damage that is irreversible, even when viral loads are controlled • OT can help with accommodation to deficits: safety education and compensatory techniques, sensory reeducation if helpful

Nerve damage is not reversible even when viral loads are good - Need to have compensatory strategies for these

Chronic renal disease (CRD) progresses to chronic renal failure (CRF) CRD affects 1 in 9 adults (most are unaware) CRD can progress to CRF requiring dialysis Etiology of CRD can be severe or prolonged hypertension, diabetes mellitus, glomerulopathies, obstructive uropathy, heredity CRD has 5 Stages and the 5th is CRF (less than 10-15% kidney function CRF=ESRD which is End Stage Renal Disease; diabetes is most common cause

Not critical like ARF CRD can progress to CRF - when the filtration percentage is so low that basically the person is going to die unless blood is purified in another way When BP is high, it takes a big toll on your kidneys The 5th stage is chronic renal failure (CRF) - also known as end stage renal disease

Cardiac Rehabilitation & OT After cardiac events patients often have occupational dysfunction and need graded activity for recovery OT can guide patients toward gradually increasing activity levels and becoming more independent A cardiac rehab (CR) program, if received, is a comprehensive program and usually involves many disciplines (that coordinate care together), including: nursing, physical therapy, dietary, and speech therapy if applicable MET levels (posted on Canvas) Borg Rate of Perceived Exertion (6-20)

Not every patient, but a lot get cardiac rehab Good evidence that this is really beneficial Multidisciplinary - nursing, speech, OT, PT Have to think about what are we asking from the patient

The need for research • Falls are very difficult to predict, and therefore, more research needs to be done in order to improve the quality of prevention efforts and reduce overall frequency of falls in the elderly population

Nursing are kind of the leaders in fall prevention OT doesn't have a lot of research into this but needs to be further addressed

Cardiac Rehab & OT OT Goal is to help patient build strength and functional activity tolerance to allow maximum ADL & IADL independence safely, without increasing cardiac symptoms

OT can help by providing self-care retraining, adaptive equipment, UE strengthening (as tolerated) and stretching, education regarding energy conservation, cognitive retraining (as needed), and education regarding fall prevention and cardiac precautions OT must work with patients regarding lifestyle modification and redesign to promote wellness and adjustment to cardiac condition

How could fear of falling and deconditioning be related?

People who are scared of falling move less - Become sedentary and become weak and deconditioned - Now they try and stand up from the couch and FALL

Cardiac Conditions** Orthostatic Hypotension (postural hypotension): Fall in blood pressure when changing to a more upright position; e.g., from lying down to sitting and from sitting to standing. Symptoms: difference of 20 points or more when changing body position; dizziness, nausea, confusion and sometimes loss of consciousness occur if the body cannot adjust BP Etiology is autonomic dysfunction and is related to heart function, circulatory health and blood volume; can occur with dehydration, diabetes, Parkinson's, and cardiac dysfunction; if taking of psychiatric, cardiac, or anxiety medications this can be a side effect

Orthostatic hypotension Heart is dropping in different positions A lot of different causes - need to determine the cause, medicate them

Pulmonary Rehabilitation & OT** Self-care retraining and functional activity tolerance are areas of OT focus Lifestyle modification may be necessary to increase activity and participation in occupation

Oxygen level should be monitored during therapy with pulse oximeter; oxygen saturation level should be 90% or greater at rest and during activity

* Peripheral Artery Disease (PAD): lack of blood supply (usually lower extremities) as a result of stenosis or occlusion within the arteries. Symptoms include: * Cold extremities * Occasional numbness and tingling * Absence of hair * Painful ulcers on pressure points * Claudication (cramping pain, exercise-induced)

PAD is a type of PVD - a stenosis or occlusion within arteries Peripheral vascular disease (PVD) Absence of hair -b/c hair growth relies on good circulation Claudication- when exercise get this cramping pain- a sign you are having compromised circulation

Documenting Evaluation/DAILY NOTES: EVENT OF FALL (WHERE, CAUSE, LOC, ETC)

POST FALL NOTIFY MEDICAL STAFF; CHANGE IN MEDICAL SIGNS AND COGNITION In general (many settings), always want to document the fall or reported fall In general (many settings), always want to document the fall or reported fall If they got more dizzy and fell- this is important to know so we can help doctors adjust meds Have to file a facility report after a fall happens- have to include a lot of details about this too- especially if this happened during your session

Early Intervention: OT * Positioning/Splinting * Bed positioning: protect bony prominences to prevent skin breakdown by rotating patients every 2 hours, minimize edema by elevating injured limbs * Adaptive positioning: prevent pressure on specific areas (e.g., PRAFO to protect heel) * Splinting: prevent deformity (e.g., use of resting hand splint to prevent contractures caused by moderate hypertonicity)

PRAFO is a foot brace that takes pressure off heel If someone has tone, may do splinting to prevent permanent deformity

Diagnoses at high fall risk

Parkinsons, MS, hip replacement, TBI, Alzheimer's, amputees - Anyone with impulsivity is a big fall risk b/c they won't go through the steps of how to complete things in a safe way

Other Testing Stress test

Patient walks on a treadmill during EKG; can trigger angina, arrhythmias (can stress heart medically as well for those who can't tolerate activity Angina is chest pain Arrhythmia can be a sign of other problems If there is too much strain on the heart

Cardiac Function: Ejection Fraction (EF)** & Hospice Care An EF of less than 40% may confirm a diagnosis of heart failure, however someone with diastolic failure can have a normal EF An EF of less than 35% increases the risk of life- threatening rapid and/or irregular heartbeats that can cause sudden cardiac arrest (loss of heart function) and sudden cardiac death; an implantable cardioverter defibrillator (ICD) may be recommended for these patients, they may be put on hospice if heart function is considered terminal (consider etiology)

Patients have been placed on hospice when their ejection fraction is less than 35% b/c very difficult for patients to even get up and move around - Usually a combination of multiple cardiac diagnoses - Cardiac ejection fraction can be low and get better - Their EF may go down to 40 or 38 but a lot of times in younger people they can rebound to a normal level - Treated a lady who was 90 with an ejection fraction of 33% and was placed on hospice - Can decide to have a defibrillator put in - Defibrillator is different than pacemaker - Pacemaker- Regulates beat of heart - Defibrillator- shocks the heart when they go into cardiac arrest or A-fib- pretty forceful- provide this big charge on your chest- patient fell off toilet - So what you see is that they can have a combination of pacemaker this is pretty intense

Clinical Note re: Orthostatic Hypotension Special care should be given to patients experiencing orthostatic hypotension, as they can easily fall and lose consciousness; many times physicians want BP taken in supine, sitting and standing to verify that correct BP adjustments are happening

Pay attention to these postural hypotension patients

Other Pulmonary Disorders Asthma: a reversible or reactive airway disease; incresed airway resistance results from obstruction from mucous, smooth muscle constriction, inflammation and broncial edema. Causes symptoms such as wheezing, dyspnea, early morning or nighttime coughing, and shortness of breath (SOB) with activity Bronchiectasis: abnormal dilation of the bronchi resulting in bronchial wall thickening, inflammation and airway obstruction; is multifactorial and eventually leads to chronic infection and bacterial colonization. Symptoms include purulent sputum, cough, hemoptysis, SOB, and decreased exercise tolerance

Persistent cough

HIV & AIDS Treatment (HAART)

Persons on ART take 3 different drugs from 2 different classes of medication in addition to any prophylaxis needed for their decreased immune system. Important to assess people with HIV in many different areas b/c have so many deficits

A 24 year old adult man begins prosthetic training with a right transradial prosthesis. To learn how to operate the terminal device, the occupational therapist implements interventions using therapeutic activities. Which activity is best for the therapist to include during intervention on his first day of therapy? Buttoning his shirt Playing cards Loading heavy groceries into the cupboard Picking up large pill bottles, then putting them down

Picking up large pill bottles, then putting them down

Diseases of the Pleura** Pneumothorax: air lodged between the lungs and chest wall caused by lung puncture; may cause lung collapse; treated by addressing wound and/or chest tube Hemothorax: Bleeding in the pleural cavity; treated by chest tube or surgery

Pleural effusion: Build up of fluid within the pleural space; treated with chest tube, oxygen therapy, diuretics, and antibiotics

Medical Treatment: Post-Exposure Prophylaxis

Post-exposure prophylaxis - if you think there was an exposure, then want to report that right away - Want to promote this Post-exposure to make sure you don't' contract HIV

Medical/surgical management Glycemic control & monitor for all types Diet modification for all; oral meds Type 2 Insulin replacement (mix of long and short acting insulin) for Type 1 and some Type 2 Prevention/treatment of complications Lifestyle changes (e.g., frequent snacks, regular exercise) Patient/family education Monitoring for BP, wounds, cholesterol, etc. Surgery (e.g., transplant or amputation)

Regular exercise LOWERS blood sugar May need a transplant if your kidney had poor circulation or amputation if had necrosis in the foot

During an outpatient visit, a patient with fibromyalgia comes into your clinic with increased joint pain in both arms, especially her hands. When asked about her recent activities at home she states she spent all afternoon yesterday making tamales for her friends at church and never took a break during the entire activity. You decide she needs some therapeutic advice to avoid having increased symptoms in the future. You advise your patient to follow this principle of energy conservation in the future to avoid increased pain after activity: Maximize physical endurance Use hot packs to reduce pain Sit to work Rest 10 minutes of every hour

Rest 10 minutes of every hour

Case Study Steve is a 88 y/o male with a history of CAD, COPD, and recently had a triple bypass CABG surgery. You are seeing him for OT treatment 3 days post-op. During your session, you notice a change in signs and symptoms after transitioning from supine to sitting EOB. He has suddenly become very dizzy, confused, and become extremely nauseated. 1. What should you do immediately with your patient?

Return to supine immediately- maybe not completely flat- may raise head of bed Take vital signs Stop treatment- get nursing!! (these are not good signs) - want to make sure he is safe What are you going to do before you get help -****Give him the call button CAD and COPD go together often times Had a triple bypass CABG surgery

Pacemaker Precautions** No overall vigorous activity and limit weight bearing in involved in UE: no heavy lifting (greater than 10 lbs) for 6-8 weeks Shoulder elevation of involved UE is limited to less than 90 degrees 6-8 weeks after placement

Same kind of limitations, not flexing your shoulder past 90 degrees Not lifting heavy weight - Has to do with not dislodging the pacemaker

Before and after lymphedema treatment:

See how huge left arm is on left picture Left arm is still larger than right arm in right picture but much smaller Once lymphedema starts, hard to get completely rid of it

In acute care you have a patient who is in the hospital following a CABGx4. He has a sternal scar that is about 12 inches long that seems to be healing nicely. He is about two days post-surgical and is referred to OT at this time due to his inability to do ADL unassisted. You enter the patient's room ask him to sit up but he is unable to do this without max assist; he can sit unsupported with supervision. A good preliminary OT treatment activity for this patient could be: Sit unsupported while catching and throwing a ball Sit at edge of bed & wash face with washcloth (setup provided) Put on a pair of pants in standing Stand at the side of the bed while catching and throwing a ball

Sit at edge of bed & wash face with washcloth (setup provided)

Raynaud's Disease(Smith-Gabai & Holm, 2017) * Condition in which cold temperatures or strong emotions cause blood vessel spasms that block blood flow to the fingers, toes, ears, and nose * Can be secondary (older than 30 yrs) or primary (younger than 30 yrs); referral to rheumatologist for treatment * http://www.nlm.nih.gov/medlineplus/ency/article/000412.htm * Etiology is varied -- includes vascular disease, arthritis, others * Medication can be given to open up blood vessels; patients should avoid smoking, cold and caffeine intake; keep body parts warm; wear comfortable, roomy shoes

Some of the fingertips are pretty white

Pulmonary Conditions Dysfunction relating to the respiratory system Risk factors include cigarette smoking and environmental irritants, such as air pollution and chemical exposure Pulmonary dysfunction affects all aspects of ADL & IADL due to reduced levels of oxygen, activity tolerance is reduced Conditions discussed will be COPD, pneumonia, pneumothorax, hemothorax, pleural effusion, tuberculosis, and obstructive sleep apnea

Sometimes people have BOTH cardiac and pulmonary conditions - So have to think about both - Even work with people who have COPD, may work with people with other disorders like pneumonia, sleep apnea

Cardiac Rehab & OT) Examples of OT Treatment Could Be: Washing face in bed Getting patient up to go to the toilet Education regarding energy conservation and MET levels, talking about permitted activities and those to avoid Education regarding avoiding symptoms of cardiac distress Working on standing tolerance during activity Others?

Sometimes the treatment that we do is really simple Energy conservation and MET levels- educating about this this Working on standing tolerance Others? Medication management Diet Getting dressed washing up

Goals for the Rehabilitation Consult Team * Identify trauma patients with rehabilitation needs within 48 hours of admission * Identify rehabilitation needs and develop a plan of care to address those needs * Institute the plan as soon as patient's medical condition allows * Evaluate the success of plan and modify as needed * Discuss the plan with patient and family * Contribute to and facilitate timely discharge to appropriate setting

Sometimes these patients aren't always stable but let's start therapy ASAP to improve outcomes

OT Treatment of Patients with Cancer (Fleming-Castaldy 2012) • When treatment fails, palliative care and hospice care can be provided. OT can have limited involvement with: • Supporting quality of life as disease advances and functional status declines • Providing equipment to enhance comfort at end of life • Helping adapt environment for safety, training caregivers with transfers

Sometimes training caregivers- in transfers or adapted equipment for patients Washburn thinks OT could make a bigger difference if they were allowed Palliative vs. Hospice- what is the difference? Both end of life care - Palliative - varies more from location to location - Hospice care- the care that has the clearest guidelines- have to have a doctor saying the person has 6 months or less to live - get care through a Medicare program - people can do Hospice at home or through a facility - Hospice does not cover the cost of a facility - medical people can come in to a home - No more chemo to cure the cancer in Hospice- basically you let this person pass away - Their chance of survival is so small that its more passionate to go through the Hospice route - You are not continuing measures to prolong life- usually DNR orders

OT Treatment of Lymphedema • Best efficacy is with a complete program including manual lymphatic drainage and compression therapy with low stretch bandages: • To learn manual lymphedema treatment continuing education is needed (Level I is taught in a six day course); the reason is that this treatment is very complex and significant harm can be done with people who have precautions against its use Check out listings for Lymphedema courses:

Specific manual therapy technique for drainage- not the same as manual edema mobilization

Cancer Staging (Fleming-Castaldy, 2012) • Stage I • 5 cm or less; no invasion • Stage II • 5 cm in size; no invasion • Stage III: • greater than 5 cm in size; no invasion • Stage IV • Primary tumor outside organ in fat and surrounding soft tissues, or tumor invading adjacent organs with positive regional nodes; can be distant metastasis present • Please note that staging for leukemia and lymphoma uses different systems (see Canvas for links)

Stage 1 is the least serious- mass is 5 cm or less- no invasion- it is contained Stage 2- mass is bigger- 5 cm in size- no invasion Stage 3- greater than 5 cm in size; no invasion Stage 4 When we see primary tumor outside organ in fat and surrounding tissues and going other places - There are patterns in metastasis - ***The higher the stage, the more likely the cancer will kill that person - Does get more worrisome at stage 4 but does not define their prognosis

Sternal Precautions (for 6 weeks)**

Sternal precautions have to do with if you had a bypass surgery, sometimes they will cut the sternum down to open up chest and do surgery - Have to do with limitations of movement after that type of surgery - Kind of controversial like you can't lift heavy things, you are going to limit how far you raise up your arms - Has to do with limiting activity after surgery

Pulmonary treatment** Non-invasive Medication: steroids or anti-inflammatories Bronchodilators or albuterol, Flovent Expectorants Oxygen therapy (to bring SpO2 to 90%) and use of inhaled steroids Invasive?

Surgery Intubation Trach VATS- remove of lung tissue Thoracotomy Lobectomy- remove lobe Decortication- remove restrictive fibrous tissue Pleurodesis- Drain fluid (chest tubes)

Cardiac Function: Ejection Fraction (EF) Causes of low ejection fraction often include:

Systolic heart failure Myocardial infarction Coronary artery disease Cardiomyopathy Heart valve disease

Course and prognosis for diabetes Temporary remission after diagnosis Reduced life expectancy Damages multiple organ systems & affects blood circulation Periods of: ¡ Hyperglycemia (too little insulin causing abnormally high blood glucose levels) ¡ Hypoglycemia (too much insulin and not enough glucose in the bloodstream)

Temporary remission doesn't always last Tissues are not getting glucose in a usable form because of lack of insulin A really hard disease to manage- may have these up and down levels even if doing all the right things

HIV Infection in the US • 1.1 million people in the US & its territories have HIV/AIDS as of today, with gay and bisexual men being the most affected (70% of new infections each year); 1 in 7 are unaware of diagnosis • Each year about 38,000 are diagnosed with HIV • In 2018, African American and Latinx people accounted for 69% of HIV diagnoses but only 31% of the US population HIV/AIDS infection rates are far greater in other less developed nations with fewer resources

The social determinants of health are at big play here - Not as much access to patient education or access to services - Need to do what we can to educate people when we come into contact with them

Gastroenterology: What is bowel obstruction? Bowel obstruction occurs when liquid and solid food cannot move through the intestine (small or large). https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/syc-20351460 If necessary, a surgery is done and part of the intestines are removed; a stoma is made for solid waste to exit the body A stoma is placed for short-term or long-term use Ileostomy: if waste cannot move through the large intestine Colostomy if waste can move through the small intestine but large intestine is blocked

The standard is that we are supposed to have a bowel movement at least once a week - If not, that's a sign that something is obstructed - Dehydration or not eating can contribute to that - As the stool progresses through the large intestine, the water does too - Surgery can be done if there is no way to get the bowels moving - a stoma will be placed (a HOLE) somewhere in the abdomen that will let the stool out - Could be an ileostomy (small intestine) higher up or a colostomy if the waste got through the small intestine but large intestine was blocked

Case Study Steve is a 88 y/o male with a history of CAD, COPD, and recently had a triple bypass CABG surgery. You are seeing him for OT treatment 3 days post-op. During your session, you notice a change in signs and symptoms after transitioning from supine to sitting EOB. He has suddenly become very dizzy, confused, and become extremely nauseated. 2.What should you do after your session has ended and the patient is safe?

Then see from there if he was having an orthostatic hypotension episode Usually the session ends and you have the patient rest

You are working in the hospital (acute care) and come into a patient's room; he has had a recent bout of COPD is appears very frail and weak. You ask him to participate in occupational therapy and he responds that he needs to rest to recover so he will not be doing OT today. You tell him that OT is important (according to the Killewich article cited in class) because He will continue to lose muscle and bone mass if he does not get out of bed His mood will not be as good if he does not get out of bed Therapy will help him to improve blood circulation as well as stop muscle & bone mass loss. His blood circulation will not be as good if he does not get out of bed

Therapy will help him to improve blood circulation as well as stop muscle & bone mass loss.

Myocardial Infarction (MI): Heart muscle dies as a result of lack of oxygen; this means the heart stops pumping (cardiac arrest) Metabolic waste products accumulate in the damaged myocardium, causing electrical irregularities There are 2 types:

There are 2 types: ST Elevation MI (STEMI), which involves complete blockage of an artery & needs immediate cardiac cath; and Non-STEMI, which involves partial blockage of an artery https://www.sharecare.com/health/heart-attack/what-is-the-difference-between-stemi-and- 90% of persons who have suffered an MI will have other cardiac problems Physical activity is restricted for 6 weeks until scar tissue forms OT is frequently recommended to guide the patient toward a safe level of activity Myocardial infarction is a heart attack - doesn't get oxygen for a time so part of heart muscle dies - The way the heart muscle fires is electricity - Fires different at different chambers - Circuits are off and don't fire as they should in a heart attack - STEMI names these in terms of the rhythm you see in the testing EKG - involves complete blockage of an artery Non-STEMI is incomplete blockage of an artery - MI is often the beginning of other things

Cardiac Rehab & OT: Evidence Mortality decreases with exercise-based cardiac rehabilitation

There is evidence that mortality decreases with exercise-based cardiac rehab

Carotid Artery Stenosis * Carotid arteries develop fatty deposits and harden over time, decreasing the circulation to the brain and in particular to the areas for thinking, speech, personality, and sensory and motor functions (risk of stroke or transient ischemic attack) * Can be treated with anticoagulants, carotid endarterectomy or carotid artery stenting (risk of stroke)

These are the arteries on either side of your neck - supply your brain Endarterectomy- basically trying to remove all of the particles out of the artery - But particles that are let loose in this process could cause a stroke - Very risky procedure - Patients on anticoagulants sometimes need to be monitored for their INR level- bruising on extremities is common- can be really bad - If their blood is thinner could be prone to a brain bleed- if start getting confused want to rule out something that is going on with the brain

Type 1 diabetes you have to have insulin

Type 1 you have to have insulin b/c insulin is the replacement for how we are not having enough natural insulin produced in the body - Introducing synthetic insulin into the body - That manages the glucose in the body - TYPE 1 is always insulin dependent

Other urinary dysfunction Urinary Tract Infection: Symptoms can include a frequent urge to urinate, pain or burning in the bladder or urethra during urination, and cloudy or reddish urine; also can cause fever, nausea, altered mental status, and even sepsis http://diabetes.niddk.nih.gov/dm/pubs/sup/ Urinary Incontinence: Difficulty with bladder control (involuntary urination), remember urine leakage on the floor can cause falls! OT can work with patients to improve muscle strength of pelvic floor (specialty area)

UTI- especially in elderly people it tends to manifest as confusion - Something to know - Urinary incontinence- see this a lot with elderly population- that urinary leakage can leak on the floor and lead to falls!! Keep this in mind and have whatever they need to keep urine in as they are walking - Specialty area is pelvic floor strengthening

Gangrene * Tissue death or necrosis caused by interrupted or absent blood supply to an organ or tissue * Etiology can be trauma, poor circulation or diabetes * Symptoms include blue or black discoloration, fever, numbness, edema, foul smell once infected; can cause sepsis then organ failure - should report to nurse/MD asap * Treated with antibiotics, pain meds, surgery to repair blood vessels, amputation, hyperbaric oxygen therapy, wound vac

Understand the signs Diabetics can have toes start to turn black - could lead to amputation

The etiology of essential hypertension is most often: Unknown Renal or endocrine diseases Papilledema Increased urine output

Unknown

Circulation Assist: Extracorporeal membrane oxygenation (ECMO) ECMO machine replaces the function of the heart and lungs ECMO is used in the ICU and ideally only for a few hours or days

Used when the lungs cannot provide enough oxygen to the body even when given extra oxygen Lungs cannot get rid of carbon dioxide even with help from a mechanical ventilator Heart cannot pump enough blood to the body Circulation assist: Heart is pumping so poorly need an assist

Compartment Syndrome(Smith-Gabai & Holm, 2017) * Occurs when nerves and blood vessels are compressed within a fascial compartment * Acutely this occurs with trauma and fractures - this requires immediate surgery * A sudden rise in pressure restricts blood flow and tissue oxygenation, which causes necrosis of the muscles and nerves in the involved compartment * Most common areas are forearm and leg

Usually happens with a motor vehicle accident Usually an internal injury which restricts blood flow and tissue dies

Medical Management** of Cardiac Conditions Coronary artery disease (CAD): Treated with non-surgical balloon angioplasty (also called percutaneous transluminal coronary angioplasty or PTCA) and stenting (insertion of metal mesh tube to open artery) or coronary artery bypass grafting (CABG) may be done (extra vessels in LE/UE are harvested, then sutured back together, e.g. CABGx4)

Usually in ICU for 2-3 days- then decision if person needs a pacemaker Coronary artery disease- artery on the heart gets clogged - Person is not getting oxygen to heart muscle itself - Can do angioplasty and open it up - Stenting is a tiny little tube of mesh to get circulation to go through vessel that Is clogged - Sometimes have to do bypass - Why do you think they don't just go in and clear out all the junk from the vessels? - Biggest concern is if you clear out that clot, it can move to your heart or brain- when you clean it out, where does all of this stuff go?

Cardiac Precautions/Guidelines for OT Treatment During OT treatment you must monitor vital signs: Maximum heart rate: 220 - your age Usually physicians want to know if HR is greater than 120 or less than 60 For blood pressure, 120/80 is a normal level

Usually physicians want to be notified if systolic BP is more than 150 or less than 90, and if diastolic BP is greater than 90 or less than 60 Manual muscle testing is contraindicated for most cardiac patients due to valsalva manuever (holding your breath makes BP elevate) Always take vitals - and during and after activity HR if greater than 120 or less than 60 BP want to know if greater than 150 or less than 90 and diastolic greater than 90 or less than 60 Don't want to do MMT with recent cardiac events- b/c paitents b/c hold their breath

Circulation Assist in Heart Failure: Ventricular Assist Device (VAD)** A mechanical device that assists the ventricles in normal pumping action for patients with end-stage heart failure as a bridge to transplant. OT's must be certified with VAD to work with these patients.

VAD- device that assists in normal pumping- hooked up to heart but battery on side OTs need to be certified with VAD - Think about it, a battery change could kill someone

Cardiac Conditions** Valvular disease: heart valves may become diseased or infected; this can cause volume over load (fluid in the lungs, atrial fibrillation) and/or pressure overload (aortic stenosis) Cardiomyopathy: heart muscle becomes enlarged, thick, or rigid; this makes the heart weak and can lead to failure or arrhythmias; happens related to other conditions such as autoimmune diseases, cancer treatment, or drug use Endocarditis, vegetation, myocarditis: bacteria enter the heart through the bloodstream causing an infection in the heart tissues (dental procedures, UTI, drug use)

Valvular disease- can become enlarged Cardiomyopathy- Heart muscle can become enlarged and get failure or arrhythmias

Falls statistics • 30-40% over 65 fall & 50% over 80 fall • Falls are the leading cause of injury and accidental death in adults over age 65 9 • More > 1/3 of community-living adults ages 65 Yr > fall each year 10 • Costs $30 billion annually • 13 million injuries due to falls in 2010, 20% of those people had serious injuries (TBI & Fractures)

Very expensive to treat falls

Tests: Heart Rate and Blood Pressure Heart rate: Usually 60-100 beats per minute at rest Blood Pressure: Normal - systolic (less than 129) AND diastolic (less than 80) Prehypertension - systolic 120-139 OR diastolic 80-89 High blood pressure - Stage 1 - systolic 140-159 OR diastolic 90-99 - Stage 2 - systolic 160 or higher OR diastolic 190 or higher

Want to do vital signs for sure if doing an assessment with a cardiac patient Gives you ranges of what is appropriate and what is not Always measure heart rate

OT Intervention Implementation (in cooperation with medical team) Preparatory Methods Manual therapy Therapeutic exercise (UE) Assistive technology Therapeutic use of occupations & activities Patient and family education Energy conservation & work simplification ADL Retraining Psychosocial interventions Therapeutic activity Cognitive retraining

We may be doing exercises, AT, ADL retraining

Basic UE prosthetic procedure includes all the following except: Socket daily maintenance Harness adjustment Component Maintenance Weekly cleaning in washing machine and dryer

Weekly cleaning in washing machine and dryer

Vascular Conditions & OT Treatment * OT Assessment: What are potential deficit areas? * In general, OT treatment with these conditions involves working with patients on: * Keeping patients safe and preventing further harm * ADL/IADL retraining * Remediation of decreased function, e.g. improving AROM in the hands, increasing standing tolerance, etc. * Working with patients regarding lifestyle modification and increasing activity to promote wellness and adjustment to condition

What are potential deficit areas? Any extremities that could be affected would be affected in any activities they do and use these extremities Keeping patients safe and preventing further harm - like PE

What can OT do to prevent falls? • use the 2010 AGS/BGS Clinical Practice Guideline to screen and assess patients to prevent falls (posted on D2L) • Collaborate with interdisciplinary team for evidence-based, comprehensive fall prevention programming

What can OT do to prevent falls? • Advocate!! • ambulation, balance, or mobility = referral to PT • side-effects of medications/overmedication = consult physician to consider consolidation or alternate meds • chronic medical conditions are causing risk for falls, the physician should be consulted If they are having strange side effects that are going to impact mobility need to reach out to doctor about new symptoms so meds can be altered to prevent falling

Blood Tests: How is blood clotting - international normalized ratio (INR), was cardiac muscle injured?

Will also do a series of blood tests to determine if pt suffered a heart attack. Monitor electrolytes of K, magnesium, calcium. Cardiac Troponin- specific enzyme released with muscle injury or infarction in the blood - used to dx a heart attack. Should be trending down

Pulmonary embolism: CT Scan

Will see clot in lungs in a CT scan if PE is suspected A PE Is fatal!! - Will appear fine but will fall over dead

HIV/AIDS and Joint Pain • People with HIV/AIDS can experience joint pain as well, and can get fibromyalgia and other joint disorders as a result despite healthy viral loads • In outpatient therapy, people with HIV/AIDS are often referred to OT due to joint pain and stiffness

Woman with HIV presented like someone with really bad arthritis- had multi-joint pain

Other Testing - X-ray, Echocardiogram, CT scan

X-ray: can show if heart is enlarged (cardiomegaly), fluid in lungs Echocardiogram: ultrasound showing a moving picture of the heart and how it is functioning CT scan: gives 3-D images of the heart, can check for coronary artery disease, pericardial disease, aortic disease, cardiac masses If there is too much strain on the heart CT scan can ID if anything is going on in the heart Any of these may be in the medical chart

Challenges and Potential Barriers to Intervention * Medical Issues/Precautions * Weight bearing precautions (UE or LE) * Braces: Halo, Thoraco-lumbo-sacral orthosis (TLSO), Aspen collar * Ventriculoperitoneal (VP) shunts (to decrease intracranial pressure): progress gradually to upright over 48-72 hours, bedrest * More info in OT 718 -- OT in Acute Care course

b/c of all this trauma, WB precautions may prevent some therapies

Prognosis is better if blood glucose is better!! CGM will help patients!!-

continuous glucose monitor is !!- sort of a plastic disc on the upper arm embedded in the arm (minor surgical procedure) - what people can do now is wave their smartphone over the disc and immediately tell them their BG number Will help BG levels stay more under control People with really hard time managing glucose- will get insulin pump with tube entered to body -insulin is dispersed based on continuous blood glucose monitoring- really costly but could be done for these people **Weight loss early on is starting to be understood can bring BG back to normal ranges and STOP diabetes - Not enough research on this - Type 1 tends to be less responsive to weight loss

Diabetes Prognosis Tight control of glucose levels will result in less complications and a longer life

many are using a continuous glucose monitor to help For "brittle diabetes" insulin pumps are available but extremely expensive if not covered by insurance Sometimes weight loss early on can bring BG back into normal ranges and stop DM (see article on Canvas) Prognosis is better if blood glucose is better!!

Deep Vein Thrombosis (DVT)(Smith-Gabai & Holm, 2017) * Blood clot that develops usually in the deep, large veins of the lower extremity (LE); occasionally in UE * DVT symptoms include LE edema, tenderness, pain, LE warmth and/or redness, pulmonary embolism symptoms, and positive Homan's sign https://www.youtube.com/watch?v=2cp2DikKRwg -- need MD orders doppler (ultrasound) to medically diagnose * DVT can cause death if clot travels to the lungs or internal organs; treated with anticoagulants (warfarin, heparin, etc), then can return to activity with MD order once appropriate INR level is reached * OT treatment should be withheld if DVT is suspected & MD/nursing notified

positive Homan's sign- where you basically dorsiflex the foot quickly and you see if people have pain in their calf - b/c if have a DVT its usually in the calf - If this is positive need to refer to physician as soon as possible - b/c DVT can cause death if travels to lungs, heart or brain - Can return to normal level of activity once INR level (blood clotting) is reached - Why is it important to withhold therapy if a person has a DVT? - b/c more movement could make the DVT travel to other places of the body - How do you tell the difference between DVT in the LE and edema from another source? - DVT is warm, tender, red, Homan's sign - And PAIN is more prominent in DVT - Edema can occur b/c of other things but DVT would have these other symptoms

What Does the Evidence Say? Coordinated early interventions conducted by acute trauma, pain and rehabilitation teams working in collaboration show promise for

show promise for reducing long-term disability among recently injured trauma patients.

Presentation Summary Systemic medical conditions complicate all OT interventions Comprehensive medical history is essential to successful intervention

¡ Is there a primary medical condition(s) that is underlying the treatment diagnosis? ¡ Is the general medical condition being adequately treated? ¢ Physician recommendations? ¢ Recent visit with physician re: condition? ¡ Systemic inflammation of many chronic diseases affects how OT is delivered Some people may be too sick to see us because of underlying conditions

Occupational therapy intervention with diabetes Patient and family education

¡ Need for glucose monitoring & control ¡ Lifestyle readjustment to complications if they occur: ¢ Low vision ¢ Safety assessment and intervention ¢ Physical adaptations ¢ Peripheral neuropathy: safety, skin inspection, pain management ¢ Foot problems (leading to amputation) Super important point to make to patients that insulin is not the problem here, the problem is POOR CONTROL OF GLUCOSE level which leads to insulin - Super important that its not the insulin making these bad things happen, it's the poor management of the glucose - Keeping that glucose in a normal range

Deconditioning & OT • deconditioning creates a need for rehabilitation

• "Debility" is a very common OT rehab diagnosis • Generally deconditioning plays a greater role as patients age and as general health & mobility deteriorate Generalized weakness, debility diagnoses are indicators that they need help getting back to the things they need to do

What is deconditioning?

• "The multiple changes in organ system physiology that are induced by inactivity and reversed by activity."1 • "Deconditioning is a complex process of physiological change following a period of inactivity, bed rest or sedentary lifestyle. It results in functional losses in such areas as mental status and ability to accomplish activities of daily living." 2

Cancer & Lymphedema • Oftentimes cancer treatment results in damage to the lymphatic system, due to radiation and/or surgery; can occur in any area of the body where the lymphatic system is not intact, and may occur in patients without cancer history

• 3-15% increased risk after sentinel node biopsy • 10-12% increased risk after axillary dissection, and • 30-50% increased risk with subsequent radiation • Fife et al 2012 • Treatment of lymphedema is a growing specialty area for OT practitioners and requires continuing education certification Lymphedema is something that can occur after someone has cancer Radiation can damage lymphatic vessels There are a lot of reasons why cancer patients would be at a greater risk of lymphedema

OT Treatment of Patients with Cancer (Fleming-Castaldy 2012) • Deconditioning: OT can help patients (who are cleared for therapy) to regain strength and functional activity tolerance

• ADL and IADL impairment: OT can help patients work on impairments to achieve the maximum independence possible, and can recommend durable medical and adaptive equipment when appropriate (must get doctor's order) • Maintenance of health: OT can help in the development of health-supporting behaviors with follow-up support (diet, exercise, stress management, vocational support, or assistance to change job skills) • Psychological: OT can support and enhance coping ability during recovery from cancer treatment phase

Cancer (CA) Growth & Effects • The immune system normally protects the body from cancerous cells but sometimes cells mutate and grow abnormally; this malfunction creates cancer cells which continue to divide even when colliding with other cells

• Approximately 100 cancer genes (oncogenes) exist • Tumors occupy space and affect organ function; they can cause pain and fatigue • Tumor cells can secrete hormone-like substances that can sometimes be detected through blood tests; in this way tumors can sometimes cause paralysis Ex. There are some breast cancer genes- genetic predisposition to some stuff When there is a tumor on an organ it won't function as well

Deconditioning- What can we do about it?

• As rehab professionals we need to prevent disability and preserve functional ability in our patients. • how we can reduce deconditioning in our patients? - Get our patients moving - Provide them with Ae to keep moving - Help them engage in IADL/leisure that they enjoy - Preventive care

AIDS-Defining Illnesses

• Bacterial infections, multiple or recurrent* • Candidiasis of bronchi, trachea, or lungs • Cervical cancer, invasive§ • Cytomegalovirus disease (other than liver, spleen, or nodes), onset at age >1 month • Cytomegalovirus retinitis (with loss of vision)† • Encephalopathy, HIV related • Herpes simplex: chronic ulcers (>1 month's duration) or bronchitis, pneumonitis, or esophagitis (onset at age >1 month) • Others (see website)

Human Immunodeficiency Virus (HIV) & Acquired Immunodeficiency Virus(AIDS) Transmitted via--sexual contact, blood transfusions, needle sharing, and from infected mother to newborn

• Because of manner of transmission the virus carries a stigma • Health professionals are at very low risk of transmission as long as universal precautions are used (gloves, masks, and gowns for contact with bodily fluids); accidental needle/sharp stick poses the highest risk for health care workers b/c of the transmission it carries a stigma

How is HIV/AIDS Transmitted?(Fleming-Castaldy 2012) • Through contact with bodily fluids, including:

• Blood • Breast milk • Secretions of vagina/rectum/penis, during birth, during sex, during hygiene activities • Urine or feces • Tears (low % of infection) • Sweat (perspiration) Want to be aware of how it is transmitted and use universal cautions

Oncology: The Study of Cancer

• Cancer is a broad grouping of diseases, all of which are linked by the presence of malignant tumor cells in the body (Pendelton, p. 1159) • Metastases ("mets") are pieces of tumor or cancer cells that have broken off from the main tumor, traveled in the circulatory system, and reseeded themselves in new organs and tissues in the body (Pendleton, p. 1159) • Many types of cancer exist; please review Smith-Gabai reading for specifics Metastases is when the same kind of cancer moved to other places in the body

HIV Diagnosis: Disease Progression • Category A: Individuals who have been asymptomatic except for persistent, generalized lymphadenopathy seroconversion syndrome

• Category B: Individuals who have never had an AIDS-defining illness but have had some symptoms of HIV infection such as candidiasis, fever, persistent diarrhea, etc. • Category C: Individuals who have or have had one or more of the AIDS-defining illnesses

Signs and Symptoms of Cancer • According to the American Cancer Society, the 7 cancer warning signs that should prompt people to seek medical attention are (CAUTION):

• Change in bowel or bladder habits • A sore throat that does not heal • Unusual bleeding or discharge • Thickening or lump in breast or elsewhere • Indigestion or difficulty swallowing • Obvious change in a wart or mole • Nagging cough or hoarseness We should know these warning signs and understand them B/c if the patient mentions any of these, its important they get medical attention

OT Treatment of Patients with Cancer • OT may need to observe precautions when treating patients, e.g. no scapular retraction for S/P bilateral mastectomy; PPE (gloves etc.) after chemotherapy • OT may be given to treat effects of the cancer itself or to treat bothersome side effects of some treatments

• Chemotherapy Side Effects: Fatigue, GI problems, fluid retention, alopecia (hair loss), increased risk of infection, others • Radiation Side Effects: GI problems, alopecia, increased risk of infection, changes in urinary frequency/quality, skin changes, others • Biotherapy Side Effects: GI problems, fluid retention, increased risk of infection, anemia, memory changes, steroid induced myopathy Often times OT is treating side effects more than the cancer itself

OT Intervention for People with HIV/AIDS • Non-judgmental acceptance of patient is helpful in the therapeutic process due to frequent discrimination

• Deficits can occur an all areas of functioning: • Sensory, Motor, Edema, Pain, Neurological, Cognitive, Psychological, Others • Universal precautions must be followed for protection of the therapist • Approach must be determined for intervention, remediation vs. adaptation (determined by prognosis) • Health promotion is very important Important not to pass judgment

GENERAL OT fall prevention strategies cont.

• Education on proper AE use: sitting vs. standing • Proper AD use within environments: tight spaces • Adaptive strategies for dressing: sitting vs. standing • Slowing down speed of completing tasks; think it through • Strategies to incorporate affected side • Proper transfer training; modifying transfers

Elephant in the room is deconditioning- really big problem that needs to be addressed Medical strategies to minimize deconditioning

• Effective care coordination among interdisciplinary providers • Appropriate medication management • Proper nutrition management • Minimally invasive surgery

Rehabilitation strategies to minimize deconditioning • Include indicators of deconditioning in OT/PT assessment

• Encourage patient mobility with giving "independent ambulation & transfer" status when granted by OT/PT staff • Prescribe exercise programs to either prevent deconditioning or reverse it • Medical evaluation to determine if appropriate • Some physical activity is better than none • Exercises should require minimal equipment & adapted to perform in bed • "Walk to dine" programs & get patients out of bed • Restorative programs Even self ROM is better than not moving at all Restorative program- allows therapy to communicate to nursing to perform ROM programs OUTSIDE of therapy to maintain ROM - orders OT put in place to reduce deconditioning b/c an hour of therapy a day is not enough- they need to do this as much as possible

HIV/AIDS Symptoms(More severe with higher viral loads)

• Fatigue and shortness of breath • Myelopathy (spinal) & peripheral neuropathy • Visual deficits (cytomegaloviral or CMV infection) • Sensory deficits & neuropathies • Cardiac problems • Muscle atrophy • Pain • Poor coping ability, guilt, anger • Depression & anxiety

Lymphedema Rehabilitation and OT Treatment General goal is

• General goal is to restore ADL & IADL Independence to PLOF if possible for restorative therapy • OT treatment varies widely depending on the effects of the lymphedema

Medical Management of Cancer: Treatments (Fleming-Castaldy 2012) • Biotherapy:

• Immunotherapy: use of substances that block the response of the immune system or that heighten the response (Interferon). • Hormone Therapy: used to block estrogen receptors or prevent the body from producing estrogens (Tamoxifen). • Transplantation of bone marrow (side effects are recovery from surgery) (treatment for leukemia, lymphoma, and multiple myeloma) • Amputation (prosthetics may be necessary) Cancer is known as a maladaptive immune response

Rehabilitation strategies to minimize deconditioning

• Increase awareness of functional implications of long periods of bed rest and promote increase activity for hospital/rehab patients whenever possible 2 • Modify the hospital/rehab environment to make it functional and safe • Replace high hospital beds with geriatric beds • Install soft-non-slip flooring • Create day room space for leisure activity • Proper lighting with use of night lights • Patients encouraged to wear own clothing People depend on others to take care of them. Caregivers needs to provide appropriate level of assist to maintain independent. Ex. Why would they use a ceiling lift when they are doing slideboard Min A? - Patients wearing their own clothes can really motivate people to prevent deconditioning

The Reality • Many elderly people are at the threshold of strength required to perform the ADL essential to independence 2

• Just because an elderly person is hospitalized for and achieves recovery from a dysfunction/illness does not mean they will return to their prior level of function (PLOF) and independence in daily living 1 • Add Mr. W example. IND PLOF, fell, hospitalized with complex medical issues (rhabdo, A-Fib, SCI), now need 2-3 just to roll, small progress (4 wks to state date) - Mr. W ended up having a fall and complex medical issues - prostate cancer, A-fib - He is very deconditioned - took 4 weeks of therapy to say the right date - Being hospitalized does impact people's independence

Deconditioning & aging • "The aging process itself produces deconditioning." 1 Factors that contribute to deconditioning:

• Loss of muscle mass and strength (sarcopenia) • Demineralization and other changes of bone • Loss of aerobic capacity • Loss of vasomotor stability • Changes in respiratory function Osteopenia, osteoporosis

Lymphedema and OT Treatment • Lymphedema can occur at any point after cancer treatment, even up to 20 years afterward

• Lymphedema precautions are necessary to avoid this type of edema and avoid further compromising the lymphatic system OT's can be trained to do manual lymphatic drainage, and this requires continuing education (after 135 hours of training can apply to be a Certified Lymphedema Therapist or CLT Swelling of scrotum and breasts occur too Very personal kind of a connection you develop with patients

O.T. Treatment of Patients with Cancer: Focus on Impairments and Effect on I/ADL • Rehabilitation could occur with many impairments:

• Motor: wristdrop and footdrop (chemotherapy): OT can help with ROM, exercise and strengthening, splinting • Sensory: peripheral neuropathy, burning and tingling (chemotherapy): OT can help with sensory reeducation, improving ability to hold objects • Cognitive: deficits in planning, sequencing, memory and insight can create problems with safety (brain cancers): OT can help with cognitive retraining and enhancement of safety and fall prevention • Neurobehavioral: fatigue (all treatments): OT can help with energy conservation techniques • Pain: an issue with all cancers: OT can help with guided imagery, splinting, encouragement of AROM and edema reduction ***Understand there are so many different impairments

Downward spiral of deconditioning • Patient acquires illnesses/injuries which: • Limit their ability to move about their home and community • Limit independence with ADL/IADL • Cause social disengagement • Because of this:

• Muscle mass and strength may decline • Patient may spend large amounts of time in bed • Patient can become incontinent & mental status can decline • All of these factors can ultimately lead to falls, which can start the cycle over again 2

Deconditioning & hospitalization • patients spend large amounts of time in bed and rely on staff help to prevent falls • Bed rest is associated with negative changes 1

• Muscle mass lost is 5% per week of bed rest, and up to 40% loss of muscle strength can occur in 6 weeks • Bone mass, especially lower limb • Cardiac deconditioning results in orthostatic intolerance (resting & activity heart rate increase, venous return is reduced)

Cancer: Prevention • OT's do not always have the opportunity to intervene at this stage but can provide positive reinforcement for healthy behaviors

• OT's can encourage patients to do screenings are specific to type of cancer: • Mammograms for women aged 40 and older; • Prostate and testicular exams for all adult men; • Frequent skin checks for everyone with history of skin cancer or frequent sun exposure; • Family history of colon cancer indicates screening and follow-up colonoscopies as recommended • Depends on epidemiology of the disease when to do screening of the disease

Treatment of Patients with Cancer • In general, OT intervention may occur in a hospital, sub-acute center, long-term care, home health, community health, or hospice setting at the following times:

• Post-diagnosis: Adjustment to diagnosis and loss of function • Pre-operative: Functional level and patient/family education • Post-operative: Help with return to function level (blood values (Hg) or surgical precautions affect treatment) OT can occur in a lot of different places

Medical Management of Cancer: Treatments (Fleming-Castaldy 2012) • Radiation: use of radioactive material directly in tumors or surrounding tissue to kill cancer cells; can be delivered by different methods

• Radioactive seeds (small pieces or pellets of material) can be implanted for a short time in the body encased in flexible tubing (brachytherapy). • External beam of radioactivity to a generalized area of the body via a linear accelerator machine (can damage lymphatic system). Will implant radioactive seeds to surround the tumor to make it die

GENERAL OT fall prevention strategies

• Remove clutter and throw rugs • Never stand on furniture to reach items; rearrange instead • Don't use towel bars etc. for support as they could break • Use a nightlight in the bedroom and bathroom • Immediately wipe up spills of the floor • Stay active Towel grab bars can break - so never use them to help with balance - Install grab bars or use sink instead - Night lights to make walkway at night safe and well-lit

OT Treatment of Patients with Cancer • It is important to understand that not all patients who need OT receive it due to lack of doctor referral (63% do not receive needed rehabilitation per study cited in Pendleton, p. 1218)

• Research in the UK (2013) has shown that when OT needs are identified and addressed among cancer patients, patient goals are usually met in occupational therapy (usually in the area of self-care): • When OT is involved, it is important we be advocates for needed rehabilitation services for patients with cancer

Deconditioning & surgery • Pain, fatigue, and depression are associated with surgery

• Stress response: increased secretion of cortisol, which contributes to protein catabolism (breakdown of skeletal muscle protein to rebuild proteins in visceral tissues and preserve essential functions) 1 • Medications can alter patient consciousness and therefore limit mobility

Medical Management of Cancer: Treatments

• Surgery: When tissue is removed, the lymphatic system can be damaged especially with breast cancer (lumpectomies/mastectomies, lymph node removal); amputation necessary at times. En bloc resection for bone cancer, results in partial joint replacement. • Chemotherapy: delivered by IV, shunt, or orally; toxic chemicals often cause the patient to feel nauseous and have low energy, therefore participation in therapy can be difficult if not impossible.

Screening for falls • Other disciplines, can use as resource (Besides functional reach test for OT)

• TUG • Berg balance scale • 5x sit to stand • Snellen eye test Using other disciplines for getting the answers that you want - May not have time for this or if other disciplines are doing it - Using those scores gathered from others to get a nice full picture of how they are functioning - 5X sit to stand - Snellen eye test- typical test an eye doctor would complete

Predicting Falls • What tools/Assessments can OTs use for determining fall risk?

• TUG, Berg Balance, Functional Reach Test

Evidence-based fall prevention programs • The Stepping On educational program is approved by the CDC (6 states)

• Training provided by Wisconsin Institute for Healthy Aging, 2 hours per week for 7 weeks with 3 month "booster" • The program includes strength & balance exercises, safe footwear and walking, vision and falls, home and community safety, medication review and management, bone health and coping after a fall

Lymphedema • Lymphedema: a persistent congestion of the lymphatic circulation which results in an accumulation of lymph in the interstitium; can cause inflammation and fibrosis

• When lymphedema occurs, skin will become shiny and more taut, losing wrinkles or joint creases • Color of the skin may also change: • Increased redness (erythema) • Bluish tinge (cyanosis) • Pallor (loss of normal color) The interstitium is the area outside of the lymphatic system- has fluid but not part of any vessels

Acute interventions for falls

• environmental safety (hospital room) • Education: staff and patient • tailor interventions based on deficit areas Keeping walker as far away as possible to reduce temptation to get up on their own Keeping bed on the lowest setting so people don't fall out of bed

Outpatient interventions for falls

• tailor interventions based on deficit areas • Home eval/ environmental safety • Kitchen safety eval • Assessment and prescription of Ae • Education: patient & family/caregivers • Bowel/bladder schedules

Inpatient interventions for falls

• tailor interventions based on deficit areas • Home eval/ environmental safety (hospital room) • Assessment and prescription of Ae • Education: staff and patient • Bowel/bladder schedules • Therapeutic activities: • Kitchen safety eval • Standing/activity tolerance/balance training • Obstacle courses with modifications • Fall simulation Not having correct AE would lead to a fall; standing in shower causing fall instead of shower bench -Example of re-arranging rooms to optimize environment to better get to bathroom We are challenging them! So if they fall in therapy, it happens! Usually controlled falls