202430 EHR519 Week 2 Meeting the client part A GB.pdf

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Warning This material has been produced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the copyright act (Act). The material in this communication may by subject to copyright under the act. Any further reproduction or communication of this material by you may be the subject of copyright protection under this act. Do not remove this notice 1  Week 2 Meeting the Client (A) Relevant to your written assessment Important components: Informed consent Health screening and CV risk factor analysis = identify at risk of adverse exercise related CV events Ability to predict these rare events by assessing risk factors is low because: – High prevalence of CVD risk factors among adults – Exercise related sudden cardiac death and acute MI are rare Important in determining the appropriate objective physiological tests to devise intervention program Not just older healthy adults Additional reports Severely deconditioned 2  Learning outcomes be able to outline the risk factors, complications and co- morbidities that must be accounted for when applying exercise interventions to individuals with cardiopulmonary conditions; be able to describe the effects of commonly prescribed medications on acute and chronic exercise responses that must be accounted for when applying exercise interventions to individuals with cardiopulmonary conditions; 3 Interview 2 steps: Interview Assessment/ examination Two main steps: 1 General interview = subjective information 2 assessment and evaluation = objective measures (anthropometric, BP, CV fitness, strength, mobility…….) Used for the action plan (intervention exercise program) 4 Interview Environment Minimise interruptions (let them talk) Quiet, secure environment Limited distractions Language is understandable (lay terms) and appropriate Start with general/open questions and become more specific Ask for clarification when needed Be mindful of yours (and their) non-verbal communication Empathy and trust 5  Reason for Referral Usually self-explanatory, i.e. increase exercise tolerance, improve ROM or behavioural changes Bridge the gap between the nature of the referral and the client’s interpretation Critical for a good working relationship with your client Education about the reason is sometimes required i.e. clients referred for cardiac rehabilitation must understand that CAD is a progressive disorder that requires lifestyle changes 6  Demographics Age, sex and ethnicity Related to their risk of cardiovascular conditions and/or co- morbidities Age is an independent predictor of survival in almost all cardiopulmonary conditions May effect the client’s ability to engage in exercise Sex may be related to exercise compliance and disease management CVD onset is generally 10 years later in women Morbidity and mortality following revascularisation procedures is higher in women Ethnicity differences are often related to difference in SES and access to care Obesity, hypertension and LVH are more common in African 7 American  History of Present Illness Record and convey the primary information related to the condition that led to the referral Chief complaint Summary of manifestations (pain, mobility, nervous system dysfunction or organ system functions Information pertaining to: Date of onset Chronicity of symptoms Types of symptoms Exacerbating or alleviating factors Major interventions Current disease status Ask more specific questions about symptoms OPQRTS and A O = Onset P = Provocation and palliation Q = Quality 8 R = Region and radiation S = Severity T = Timing A = Associated signs and symptoms Medications and Allergies Current medication list is essential Think about how they align with their current and previous medical history Example. A client with chronic heart failure is likely on a β-adrenergic blocking agent (β-blocker) and a vasodilator such as angiotensin-converting enzyme inhibitor. If they do not mention these medications, ask about them or their history of these medications Ask about (as they may affect your exercise prescription) Dose Administration route Frequency Time of day taken Allergy history nka – no known allergies 9 Medical History Concise, relevant list of past medical problems Including dates All conditions, injuries etc. as one may influence another and exercise prescription CHD must record severity of coronary lesions, types of conduits used if bypass was performed, target vessels and most current assessment of LV function (EF) Lung disease: identify asthma or COPD (attributed to smoking). Help explain why some meds are used when symptomatic and others as part of a long term plan. 10  Family History/Social History Family history should be restricted to heritable disorders in first-degree family members Parents, siblings, off-spring Relevant heritable include cancers, Type II diabetes, familial hypercholesterolemia, sudden death and premature coronary artery disease (before age of 55 in men and 65 in women) Social history includes information about the client’s lifestyle and living patterns Smoking, alcohol, illicit drugs, marital or significant other status, occupation, transportation, housing, routine and leisure activities Prior physical activity and exercise and quantify Nutrition 11 Sleep  Goals (SMARTER) Behaviour Smoking and alcohol Nutrition Physical activity Weight management Biomarkers Lipids (triglycerides, cholesterol) Blood Pressure Fasting blood glucose concentrations Medications Cardiopulmonary condition and associated symptoms 12 https://www.heartfoundation.org.au/images/uploads/publications/Reducing-risk-in- heart-disease.pdf Physical Examination 13 Informed Consent Informed consent from individuals before exercise testing is an important ethical and legal step Form which needs to be read and signed Opportunity to ask questions Must understand test purpose, procedures and risks Clients under 18 y must have a parent/ caregiver sign consent as well 14 Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain. The atria and ventricles are supplied with sympathetic sensory innervation. from the heart, sensory nerve endings connect to afferent fibers in cardiac nerve bundles; then to upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. In the SC, sympathetic impulses may converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Localisation of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Source: Cohn, P. F., Fox, K. M., & Daly, C. (2003). Silent myocardial ischemia. Circulation, 108(10), 1263-1277. Deedwania, P. C., & Carbajal, E. V. (1990). Silent ischemia during daily life is an independent predictor of mortality in stable angina. Circulation, 81(3), 748- 756. Causes and Diagnosis of Exercise-induced VasoVagal Syncope Risk Assessment “Add-Ons” to ESSA Questionnaire In addition to asking the client to answer question 4, you can complete the following: ✓COPD Assessment Tool (CAT): even though this questionnaire targets COPD, it uses same signs/symptomology of other pulmonary diseases ✓Medical Research Council (MRC) dyspnoea score: will permit you to identify the occurrence and rate the severity of breathlessness to establish whether the client is normal (maybe just unfit) or potentially diseased ✓Spirometry: to identify obstructive and/or restrictive traits, and in addition with the CAT and MRC scores, this will allow you to: ✓Risk stratify: identify likely impairment at rest and during varying intensities of exercise (that you may employ) – this helps identify need to refer, and ExRx (e.g. work: rest ratio) Visual inspection for deformities e.g. kyphosis, a barrel chest or pectus excavatum. Auscultation anterior and posterior of lungs, listening for decreased, course, wheezing or crackling. If noted postpone testing and refer back to GP. Some potential questions may include: ? Do you ever wake during the night with breathlessness or palpitations ? Do you ever have an abnormally slow or fast heart rate when at rest ? Do you ever have sudden or periodic changes of “energy” (fluxing) during the day ? Do you ever have swelling in your ankles, feet or hands, especially at warmer time of the year ? Do you ever get unexplained pains in your leg muscle when walking ? Have you noticed any lack of colour in your feet or feeling sensation in your feet in the past few years ? Do you ever have blood in your urine or faeces  Based on the ABS data from 2022; three in four adults with recent high blood pressure measures, did not know they had hypertension. Therefore, always conduct BP assessment as part of risk stratification even if the client says last time they had it measured it was “normal” – ensure you minimise “white coat” syndrome! Source: http://www.aihw.gov.au/risk-factors/high-blood-pressure/ Remember: Total cholesterol alone is not informative. HDL is required to calculate the cholesterol hazard ratio. LDL is calculated by the Friedwald equation, which is: LDL = total cholesterol – HDL cholesterol – (Triglyceride ÷ 2.2) In 2022, the ABS reported one in twenty Australians (5.3% or 1.3 million people) had diabetes. Since 2001, this rate has increased from 3.3%, however, has remained relatively stable since 2014-15 (5.1%). You can take a BGL measure. Particularly if client has symptoms. E.g. thirst, frequent urination, unexplained weight loss, headaches, leg cramps and blurred vision Random reading of 7.8mmol/L to 11.0 mmol/L refer to GP End part A Part B will cover: Major S&S of CVD Red flags (pre-and-during tests) Intro to GXT Common scales used and post-exercise monitoring Muscular fitness Flexibility Balance