Management of medical problems

Care of A Patient with Chest Pain

In the event of a patient experiencing chest pain, the immediate aims are to stop the patient exercising, assess and manage the patient's symptoms and obtain medical help if necessary.

A local protocol should be in place, designating responsibility to the lead nurse to seat the patient and manage the situation, while the exercise leader and other/s continue the class if appropriate. The nurse should:

• seat the patient, away from the main exercising group, in a half-sitting position, with head/shoulders and legs supported (if preferred);

• reassure the patient and assess the nature, scale and duration of symptoms;

• if there is no relief of symptoms within two to three minutes of resting, the patient should be encouraged to administer, or be given, as appropriate, a glyceryl trinitrate (GTN) spray up to three times, at five-minute intervals, following the locally agreed chest pain management protocol. The nurse should monitor heart rate, check blood pressure and undertake a 12-lead ECG, if equipment is available;

• if the angina persists after 15 minutes, either an ambulance should be called, if the class is held in a community setting, or hospital medical help should be summoned immediately in order to assess, treat and admit the patient, as appropriate. The patient should be reassured and monitored closely until emergency medical help arrives, with staff ready to follow protocols for cardiac arrest, should the patient deteriorate. The patient's relatives should be advised of the incident and informed of hospital transfer or admission;

• if the angina symptoms resolve completely with the use of GTN spray within 15 minutes, and in the absence of any other symptoms and with satisfactory heart rate and blood pressure measurement, the nurse may decide that the patient is fit to return to the exercise group. Before resuming the conditioning component of the exercise session an appropriate warm-up must be undertaken, with close monitoring of the patient to ensure there is no recurrence of angina. The heart rate and workload at which exercise-related ischaemia occurred should be documented, and future exercise prescription adjusted by the exercise leader accordingly.

Care of a Patient with Diabetes

Given that exercise has an insulin-like effect, exercise-induced hypoglycaemia is the most common problem for exercising diabetics who take exogenous insulin or, to a lesser degree, oral hypoglycaemic agents. Hypoglycaemia can occur either during exercise or up to four to six hours after exercise. Guidelines from The Health Professional's Guide to Diabetes and Exercise (Berger, 1995; Gordon, 1995) cited in ACSM (2000) and AACVPR (2004) advised that:

• a diabetic patient's blood glucose level must be under control before beginning an exercise programme;

• patients should not exercise if blood glucose levels are >300mg/dL;

• an insulin-dependent patient should have a carbohydrate snack of 20-30g before exercise if blood glucose is <100mg/dL;

• blood glucose should be measured before, during and after exercise;

• adjustments in carbohydrate dose and /or insulin may be necessary before or after exercise.

It is most important that patients and staff are knowledgeable about the signs and symptoms of a hypoglycaemic attack. Prompt action in response to signs of weakness, faintness, sweating, pallor, confusion or belligerence can avoid a loss of consciousness.

In the event of a hypoglycaemic episode where the patient is still conscious:

• immediately remove the patient from the exercise environment and sit him/her down;

• administer a glucose drink or supplement to rapidly raise blood sugar level;

• if there is a good response, give more food and drink and allow the patient to rest until he/she feels fully recovered;

• encourage close monitoring of blood sugar level throughout the rest of that day;

• discuss the hypoglycaemic episode with a doctor and adjustment to exercise prescription and/or insulin and carbohydrate dosage, as required.

If the patient loses consciousness:

• summon emergency medical help immediately;

• maintain airway and resuscitation if necessary;

• monitor the patient in the recovery position until medical help arrives. (See more in Chapter 4 on diabetes and exercise.)

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