All Posts in Category: Texas

The Importance of Ventilator Weaning in Recovery

There’s no question that mechanical ventilation has saved countless lives. It provides life-sustaining oxygen for patients who can’t breathe on their own – but weaning them off of a ventilator is a challenging task that requires a variety of skills, technologies, and teamwork.

Hospitals today are developing more effective weaning protocols while ventilator manufacturers are creating improved technology that helps better reach the goal of restoring full breathing function in patients whenever it’s possible. Here’s a look at the many factors that emphasize the importance, and challenge, of ventilator weaning.

The Challenges of Ventilator Weaning

Sedation is a fact of life for most patients on long-term ventilation, but sedation can prolong dependence on the ventilator, as well as impact cognitive functioning. Some doctors suggest using non-sedating medications, which allow for earlier weaning. The impact of heavy sedation includes not only cognitive effects, but also can result in long-term neurologic issues, and even post-traumatic stress disorder.

One of the challenges with sedation, however, is that it can affect every patient differently. Research has shown that patients who are typically calm in normal life will most likely remain calm on a ventilator, while patients who struggle with issues such as drugs, alcohol or anxiety issues can have more problems while on ventilation.

Another factor that has been shown to help hasten weaning is mobility. Hospitals that stress early mobilization programs for patients on ventilators have seen good results. It’s healthy for both the mind and body; in fact, the muscles in the diaphragm weaken because they don’t have to do any of their normal work during ventilation. Moreover, all of the muscles can weaken because they’re used much less than they were prior to the patient’s illness, and combined with sedation can result in weakness after just four or five days on a ventilator.

Enhanced Technology

The scientific community has made great strides in the past decade in terms of developing technology that prevents or limits complications associated with mechanical ventilation. Additionally, both safety and workflow have been improved to help enhance the ICU environment.

Additional improvements, such as the addition of microprocessor control and electronic medical record systems, have helped advance technology, as well. In general, devices today are more sensitive to patient interaction while capturing important patient clinical data. And having ventilator data remotely available provides access to clinicians with the necessary tools to make important decisions – whether they’re at the patient’s bedside or not.

The Importance of Teamwork

The process of successfully weaning a patient off of a ventilator is best served by a team approach that includes respiratory therapists, nurses, physicians, physical therapists and other clinicians. It’s important that all parties involved stick with protocols that may have been established by the respiratory therapist. Protocols also need to be reviewed periodically and compared with hospitals of similar size.

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Why Wound Care is a Critical Part of Recovery

To say wound care has been around a long time is an understatement. It can, in fact, be traced back to the earliest civilizations, and the ancient Greeks were among the first to stress the importance of wound healing.

Wound care has obviously come a long way since then, and it’s importance in the role of recovery cannot be stressed enough. Here’s a look at why would care plays such a vital role in the recovery process:

Wound Care: The Basics

There are two ways that wounds heal: regeneration or scar formation. During regeneration, tissue that has been damaged is replaced by tissue of the same type. This preserves the proper function of the area of the body that has been injured. In scar formation, the damaged tissue is replaced by fibrous scar tissue which doesn’t have the same properties as the original tissue.

The Importance of Wound Care in Recovery

Proper wound care prevents infection and other complications, and also helps speed up the healing process with less scarring.

 

  • Preventing Infection
    By keeping continual attention on the wound dressings and bandages the risk for infection and other complications is greatly decreased. A health professional can make medically-important decisions through changing the dressings, noting the wound’s progress, as well as by making observations of bleeding, temperature, discharge and smell. In general, wounds should be cleaned once a day with disinfectant specific to wound care, clean water or saline, as well as applying clean dressings.

  • Speeds Healing
    A potentially dangerous myth is that wounds heal faster if left uncovered, which simply isn’t true. Covering the wound throughout the healing process actually hastens the healing process. Moreover, properly maintained bandaging provides additional protection against infection.

  • Minimizes Scarring
    Keeping the wound soft through the healing process helps to minimize scars while not allowing hard scabs to form. Antibiotic ointments – and other treatment options recommended by your physician – applied during the early stages of healing will keep the skin around the wound soft and pliable.

 

Once the wound has healed enough that there’s no risk of infection, antibiotic ointment can be replaced with vitamin E oil, aloe vera gel, or petroleum jelly. Massaging the area while working with the thicker scar tissue to keep it from becoming stiff is also important. Softer skin will heal with a less noticeable scar.

It’s important to note that the wound healing process is complex and fragile. Interruption or failure can lead to non-healing chronic wounds involving factors such as diabetes, arterial or venous disease, infection, and the metabolic deficiencies of old age.

 

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The Importance of Palliative Care

When people think of palliative care they often think hospice. But they’re actually two different things. Palliative care is a new medical specialty that doesn’t focus only on the dying.

Here’s a look at what palliative care is, who’s it for, when it’s appropriate, and more.

What Is Palliative Care?

Palliative care refers to a form of medical care for people with serious illnesses. Provided by a team of doctors, nurses, social workers and others, palliative care focuses on relief from the symptoms (and stress) of serious illness. Improving the quality of life for both the patient and his or her family is the overall goal of palliative care.

How Is It Different From Hospice Care?

Patients that are eligible for hospice care must be suffering from a terminal illness, or be within six months of death. Hospice care generally relies upon a family caregiver, as well as a visiting nurse. Round-the-clock care is provided in a nursing home, a hospice facility, or occasionally in a hospital.

 

Palliative care, on the other hand, can be received by patients at any time, regardless of the stage or their illness or whether it’s terminal or not. While palliative care can be received and administered in the home, it’s most common to receive it in a hospital, nursing home or extended care facility.

Improving Quality of Life

Treating the stress and symptoms of people who are suffering from serious illnesses such as cancer, kidney disease, Alzheimer’s, Parkinson’s, COPD, and congestive heart failure is the focus of a palliative care team. Symptoms vary and may include depression, pain, nausea, loss of appetite, sleeping difficulties, fatigue, and so on.

 

Your palliative team will help give you control over your own care by helping you define your goals and understand your treatment options. They’re committed to helping you improve the quality of your life, as well as finding the strength to carry on with daily living. A palliative care team may also include a chaplain, psychologist or psychiatrist, dietitian, occupational therapist and others, depending on the patient’s needs.

When is Palliative Care Appropriate?

Again, palliative care doesn’t signal that a patient has given up all hope of recovery. In fact, some patients recover and move out of palliative care, while others – such as those with chronic diseases like COPD – may move in and out of palliative care as the need arises. Palliative care can transfer into hospice care when a cure proves elusive and death draws near.

 

By The Numbers

There are more than 1,400 hospital palliative care programs in the United States. The majority of large U.S. hospitals (more than 300 beds) now have a palliative care program, while more than half of smaller hospitals also provide palliative care.

 

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COPD Sufferers: What to Ask Your Healthcare Provider

If you’ve been diagnosed with chronic obstructive pulmonary disease (COPD)  you understandably have a lot of concerns. Aside from the breathing difficulties you’re experiencing, you have a lot of questions for your healthcare provider, including what is COPD and what are your treatment options. The bottom line is that your respiratory health is too important to not get all the information you can about COPD. Here are some important questions to ask your doctors.

What is COPD?

Your healthcare provider will tell you that COPD is a broad term to describe a variety of progressive lung diseases, including chronic bronchitis, asthma and emphysema. As you’re already aware, COPD’s primary symptom is increasing breathlessness as your body is unable to properly process oxygen through your lungs. You’ll also learn that you may have had COPD for longer than you think because you may not have noticed earlier symptoms. When it comes to their respiratory health, many people associate breathlessness as a natural part of aging, which isn’t true.

What causes COPD?

While your healthcare provider will tell you that smoking is the number one cause of COPD, he or she will also explain that there are other risk factors, as well. Those risks include genetic factors (AAT deficiency), working in high-risk industries that expose you to non-organic dust, such as mining and plastic manufacturing, as well as indoor pollution, such as second-hand smoke and radon.

What happens if I quit smoking?

If you’re a smoker, you’re well-aware of its dangers and harmful effects to your overall health, especially respiratory health. But here are some other facts you’ll want to take into consideration:

  • When you stop smoking the level of carbon monoxide in your blood is cut in half within 12 hours.
  • Your lungs will begin to repair themselves within a few weeks after you quit smoking.
  • By your 10th year of non-smoking, your lung cancer risk will be cut in half.

Will my medication have side effects?

Ask your doctor about any side effects that may occur from taking COPD medication. One important concern you should have is whether treatment for your condition could potentially damage other, healthy parts of your body.

What other changes can I make?

Quitting smoking will have a significant effect on the progression of COPD. But diet and exercise can also have a positive impact on your respiratory health. Ask your doctor about exercise programs designed specifically for COPD sufferers.

Will I need to be on oxygen?

Your doctor will measure the amount of oxygen in your blood by using a pulse oximeter, or by drawing blood. The goal is to keep your oxygen saturation level above 88 percent.

What stage am I in?

COPD is divided into four stages: mild, moderate, severe and very severe. Your doctor will determine what stage you’re in by using a pulmonary function test called spirometry. It’s important to note that COPD affects everyone differently, and can be determined by a variety of factors – including whether you smoke, how much you exercise, and your diet.

What shots or vaccines will I need?

It’s recommended that everyone with COPD should get a pneumonia shot – generally every five years – because pneumonia can easily deteriorate lung health. Flu shots are also important because the flu also weakens your lungs.

 

Choosing the right health provider is important in treating your overall respiratory health.

 

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Asthma Symptoms: 5 Signs Your Shortness of Breath is Serious

If you suffer from shortness of breath, you’re not alone. It’s a common symptom and one that prompts many people to see a doctor or seek other medical treatment. Knowing when your shortness of breath is an emergency isn’t always easy. It can be the result of hyperventilation, acid reflux, or a panic attack – cases when shortness of breath usually recedes on its own – or more serious issues involving your respiratory health. There are many possible causes of shortness of breath, as well as signs that it’s time to seek medical help.

Shortness of Breath and Its Causes

There’s no clear definition of shortness of breath, but most people describe it as a feeling of being unable to get enough air, or that breathing takes more effort than usual. Some people may feel chest tightness. Shortness of breath may come on in a matter of minutes, or develop chronically over much longer lengths of time.

In the vast majority of cases, shortness of breath is because of conditions related to the heart and lungs. Some of the more common causes include:

  • COPD (Chronic Obstructive Pulmonary Disease)
  • Asthma
  • Serious heart conditions, such as heart attacks or congestive heart failure
  • Pulmonary embolism (a blood clot that travels from another part of the body to the lungs)
  • Obesity
  • Lung disease
  • Bronchitis or pneumonia
  • A collapsed lung
  • If shortness of breath is chronic – meaning it has lasted for weeks or longer – it’s often due to any of the above causes.

Signs That You Should Call A Doctor

Your respiratory health is too important to ignore shortness of breath symptoms, but some signs should never be ignored:

  • Swelling in your feet and ankles
  • Trouble breathing when you lie flat
  • High fever, chills and cough
  • Wheezing
  • When your pre-existing shortness of breath worsens

COPD

COPD is a chronic lung disease that, as mentioned, is one of the most serious causes of shortness of breath. It’s considered a progressive disease in that its symptoms may be mild at first but become more severe over time. The symptoms of COPD may vary and include:

  • Chronic cough
  • Coughing up mucus
  • Labored breathing during both exercise and resting
  • Wheezing
  • Frequent colds or flu
  • Fatigue
  • Frequent morning headaches
  • Weight loss

People who suffer from COPD are also likely to have episodes known as exacerbations in which their symptoms suddenly become worse and persist for several days.

Asthma

Asthma is caused by inflammation of the bronchial tubes. This inflammation also results in the production of sticky secretions inside the tubes. When it comes to your respiratory health, asthma – like COPD – should never be taken lightly. Its symptoms are very similar to those associated with COPD: coughing, wheezing, chest tightness and, of course, shortness of breath.

As with COPD, asthma sufferers may go extended periods without experiencing any symptoms before having periods of systems (or asthma attacks). Others may only experience asthma during exercise, or when suffering from viral infections such as colds.

Evaluating Shortness of Breath

Depending on your symptoms, your doctor may evaluate your shortness of breath by using pulse oximetry to estimate the amount of oxygen in your blood, an EKG, a chest x-ray, blood work, or pulmonary function tests.

It’s important to note that while you may suffer from COPD or asthma, your symptoms can still be managed – and allow you to lead a normal life – with the right health care team working with you.

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A Day in the Life of a Speech-Language Pathologist

It can be difficult to fully describe the role of a Speech-language Pathologist, as the rehabilitative work they do throughout their days is extremely varied and complex. In order to give our readers a more accurate idea of what an SLP does, we asked one to tell us a little more about her patient work here at an Ernest Health Hospital, as well as walk us through her activities throughout the day.

EH: Can you share with us what a typical day looks like for you?

SLP: I get to work around 7 or 7:30 a.m. to help patients with using their safe swallow strategies during breakfast.

We have a short staff meeting at 8:00 to quickly discuss appointments, discharge plans, medical complications, etc. I treat patients from 8:30 to 12. I personally have more energy in the morning, so I try to see my patients then and save documentation for the afternoon

I document daily/weekly progress notes during lunch and begin therapy again at 1:00. I have 2-3 sessions in the afternoon, and then I need to write daily/weekly notes. Part of my role in the afternoon is to look at the patients we will have in the evening and which therapists will be coming in for the evening shift and get the patients signed out to a therapist accordingly.

Some of the things that I have to think about as I’m evaluating patients is: Are the patients sticking to their diet? Are they ready for advancement? How are they handling the diet?

EH: What does the majority of your work involve at Ernest Health, and how would you describe the majority of the patients you work with?

SLP: I provide individual sessions and group therapy sessions two days a week. The majority of my patients have cognitive impairments that limit their ability to make safe decisions.

Stroke and head injury are the majority of the causes.

EH: What treatments/therapies do you use to work with your patients at Ernest Health?

SLP: For dysphagia (swallowing issues): I use myofascial release therapy and e-stim (electrical stimulation) modalities.

Myofascial release therapy is a treatment for patients with dysphagia that aims to loosen up muscles in the cervical area to allow for more contraction in swallowing.

E-stim modalities are used for neuromuscular re-education, which is a technique used to help the patient contract the muscles used in swallowing to teach the patient what it should feel like. E-stim machines can be used for a variety of purposes, though, and all depends on the settings (pain management, muscle contractions, etc.).

One of our SLP’s main focuses is keeping the patient safe by educating them and family members on things like locking the wheelchair and using the call light for help. In addition to these practices, she also does her best to find fun and fresh ways to help retrain patients to their former levels of functionality. Using music therapy and technology like iPad games, for instance, allows the patient to learn in a way that feels less like work and more like recreation.

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Her empathy for the patients, dedication, and caring personality are shining examples of the qualities that Ernest Health values in its team members.

EH: Why did you choose Speech-Language Pathology as a career?

SLP: I chose to be an SLP because I wanted a career that would make a positive impact on someone’s life.

My first semester in undergrad, I, by chance, saw a class schedule with a class about Communication Disorders.  I decided to take it and knew from the beginning this was what I wanted to do with my life.

EH: What hobbies or interests do you have?

SLP: I teach fitness classes before and/or after work. My alarm usually goes off at 4:30 so I can fit in my hobbies. My husband and I enjoy traveling, skiing, and fly fishing together.

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Speech-Language Pathology’s Role in Stroke Recovery

Stroke recovery is a complex process that varies from one patient to the next. Because of this, speech-language pathologists play an important role in a stroke patient’s rehabilitation. Last week, we discussed how a speech-language pathologist could help a stroke survivor regain their ability to read. However, with one fourth of stroke patients suffering from language impairments, an SLP usually plays a sizable role in most stroke patient’s recovery. Here are a few of the responsibilities you can expect them to take part in during the recovery process.

They make a plan.

Because every stroke is different, and every patient is different, it is only natural that every recovery plan is different as well. Speech-language pathologists work with their inter-professional team but also work with a patient’s case history and their family to come up with a plan that will work for every individual patient. Creating a successful rehabilitation plan requires an SLP to know the patient medically and personally. A speech-language pathologist’s close involvement throughout the treatment allows them to alter the rehabilitation plan if necessary.

They help patients relearn how to communicate.

Depending on which area of the brain is affected by the stroke, patients may either have difficulty communicating their thoughts through words or writing, or have difficulty understanding spoken or written language. Either way, an SLP’s education equips them with the ability to help both of these conditions. They use different techniques and exercises to help patients circumvent their disabilities such as making symbol cue cards or simply repeating phrases with their patient. All of this is done with the end goal of helping the patient relearn their communication skills or learn new methods of communicating. 

They help patients with self-awareness.

Although speech and language are in the title, speech-language pathologists help with much more than that. SLPs also help stroke patients regain their self-awareness. This can mean anything from helping a patient learn that they don’t swallow all of their food during meals, to learning how to comb their hair. A speech-language pathologist may set up different daily challenges such as basic cleaning, to personal grooming to help a patient recover their self-awareness. These skills will help a stroke survivor’s day to day life become less frustrating as their recovery goes on. 

The extensive duties of a speech-language pathologist in stroke recovery differ with each patient, but for every patient they make an incredible difference. We are committed to bringing the best care to our patients, and because of that, we appreciate the speech-language pathologist on staff!

 

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Stroke Survivors and Reading

When one experiences a stroke, many parts of the body are often affected, requiring physical therapy and exercise in order to reach a previous level of mobility. What this also means is that, in order to recover the energy used in various therapies, patients must spend a lot of time resting. In these periods, boredom and depression can settle in, making pleasurable distractions, like reading a book or magazine, a welcome escape.

Unfortunately, a frustrating discovery that many stroke patients experience is that reading (something they were likely proficient at before) has suddenly become a struggle. Words either seem to disappear or escape their grasp, and sentences are overwhelming.

Alexia- what it is:

Reading difficulties after a stroke are often referred to as “alexia” or “acquired dyslexia.” When the left side of the brain experiences damage or trauma, it is common for language abilities to suffer due to the fact that most language functions occur in the left hemisphere.

Reading impairments, along with the damage to language function, are also commonly caused by visual disruptions. Symptoms such as double vision or blind spots in words and sentences make even silent reading a struggle, and the act of communicating it verbally can seem almost impossible.

How a stroke affects reading:

Because Alexia occurs after a patient has fully developed their reading abilities, there are usually remnants of language skills still functioning. For example, many stroke survivors find it easier to read silently to themselves than to read aloud. Word retrieval is an incredibly common difficulty among stroke survivors, so coupling the act of visually comprehending with audibly reading can cause stress and confusion.

Depending on the extent and location of the damage, however, even silent reading can become severely impaired. Words that aren’t easily sounded out based on their letters, or those that are abstract in nature, commonly create frustration for stroke survivors.

How to work around reading impairments:

Couple listening with reading. One way to enjoy a favorite form of entertainment and work toward the correction of reading impairments is to pair media with printed words. By watching a TV show or movie with the captions turned on, a patient can experience the words through sight and sound simultaneously. Similarly, reading a physical book while listening to that same book on tape will provide an opportunity to match the look of words to their sounds and pronunciations.

Remove the written part of a task:

Another way to work around alexia is to simply remove the written part of a task to gain more independence. A task like visiting the grocery store in order to stock the pantry can become very overwhelming for someone who is having trouble reading. Rather than writing out a shopping list, many stroke survivors have found that creating a list using product logos and pictures allows them the independence to accomplish this previously simple task.

Talk to a Speech Language Pathologist. An SLP is trained to, among many other things, diagnose cognitive problems caused by strokes. By getting a formal diagnosis, an SLP will then be able to work with a patient and his or her needs, so that they may come up with a personalized treatment plan.

The SLP will use exercises, such as sounding out and naming letters, to help a stroke survivor work through their reading impairment and make progress toward reaching their previous level of ability.

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Circulation & Diabetes

The possible outcomes of poor circulation in diabetics can be quite scary, but the reality (as it is in most diabetic complications) is that the more dramatic results can often be staved off by positive lifestyle choices.

Exercise

The act of exercising your body is beneficial in countless ways, including increased blood flow through the dilation of the blood vessels. When you exercise, vessels open up to allow more blood to feed the muscles with much-needed oxygen. For someone suffering from poor circulation, this provides a much-needed boost of blood to parts of the body that may have been desperately needing it.

While there are certain full-body exercises that are especially good for circulation, such as Yoga and swimming, even a short-but-brisk walk will provide the extremities with more blood.

Exercising on a regular basis will allow your body to replenish limbs with blood frequently, and help prevent complications like sores and ulcers that are difficult to heal.

When dealing with poor circulation, it is incredibly important to speak with your physician about your exercise options. He or she might have exercise plans that are specific to your circulatory needs that will better aid you in your recovery.

Diet

Along with exercise, consuming foods that help control your blood sugar (especially those that inherently improve blood flow themselves) can keep the symptoms of poor circulation at bay. High-saturated fat, high cholesterol, and high-sugar foods all have the tendencies to clog arteries, and adding the blood vessel-damaging power of high glucose to the mix creates the perfect environment for poor circulation.

Eating foods that are high in antioxidants, vitamins, and whole sources of fiber have been known to increase blood flow, as well as help in waste removal from the blood. Raw seeds, oats, citrus fruits, and leafy greens are fantastic foods to add to your weekly menu, bringing anti-inflammatory properties and much-needed minerals to the plate.

As with exercise, speaking to your physician about diet changes (especially if a patient is diabetic) is imperative when trying to manage your circulation issues. If you’ve been honest and thorough when sharing your medical history, your doctor might be able to assign a more personalized diet to you that could provide you with a much speedier recovery than you had anticipated.

Other Treatments

If diet and exercise simply are not helping with circulatory issues, then medical or surgical intervention may be utilized. Certain diabetes, cholesterol, and blood pressure medications have been known to help with circulation, and medications that help prevent blood clots may be prescribed as well.

Surgical options are angioplasty (inflation of a small balloon inside an artery), stents, artery bypasses, and surgical plaque removal.

Simple Steps = Simple Success

Managing diabetes and diabetes-related circulation issues go hand in hand. Many of the lifestyle changes demanded by diabetes are the same as the ones that will help improve your circulation: increased exercise, healthy diet, and not smoking. Simple changes like taking the stairs instead of the elevator or a quick walk after dinner can make an immense difference in your circulation.

Sources:

http://www.diabetesselfmanagement.com/managing-diabetes/complications-prevention/diabetic-leg-pain-and-peripheral-arterial-disease/

http://www.livestrong.com/article/153025-exercises-to-increase-blood-circulation-for-diabetics/

http://www.onegreenplanet.org/natural-health/healthy-foods-that-improve-your-blood-flow/

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How Diabetes Relates to Heart Disease & Stroke

Being diagnosed with diabetes usually means you have to watch your blood sugar, mainly through diet, exercise, and medication. However, diabetes can cause a variety of complications throughout the entire body—but how?

The answer is the circulatory system.

The circulatory system is responsible for the transportation of blood throughout the body, providing nutrients and oxygen to cells, as well as transporting waste and carbon dioxide away from them. When the body begins producing and retaining too much glucose (blood sugar), the substance is not isolated to one sector of the body. The circulatory system pushes and pulls the glucose throughout the entirety of the body via the blood. The excessive amounts of sugar cause damage to blood vessels and the organs that are associated with those vessels suffer the consequences.

Diabetes and Heart Disease

One of the organs that most severely feels the effects of diabetes is the heart. Simply being diagnosed with diabetes dramatically raises a patient’s chances of encountering heart disease. The chances of getting heart disease at a younger age than most, as well as the severity of the heart disease itself, are increased when diabetes enters a patient’s life.

As the vessels supplying blood to the heart become damaged, clogged, or hardened by the high presence of glucose, the heart’s ability to receive (and therefore send out) blood is negatively affected. Types of heart disease that are specific to diabetes are Coronary Heart Disease (a buildup of a substance called “plaque” in the arteries), Heart Failure (when the heart is unable to pump the necessary amount of blood), and Diabetic Cardiomyopathy (a disease that damages the actual function and structure of the heart).

Diabetes and Stroke

Another major organ that suffers damage from diabetes is the brain. The brain thrives on oxygen-rich blood in order to function, and when the blood vessels that provide the blood are affected by excessive glucose, very serious complications can occur. When a vessel responsible for providing blood to the brain closes off or bursts, that part of the brain will become oxygen-deprived, and the cells will die. This can result in speech impairments, vision problems, and mobility issues, including paralysis. Like heart disease, being diagnosed with diabetes can significantly raise your chances of stroke.

We know the struggles that patients encounter as they work to regain lost abilities, and our goal is to help those patients overcome them. We feel it is also our responsibility, however, to educate our community about the causes of these conditions, in the hopes of preventing them.

We will continue to explore the topic of diabetes and circulation in our next post, as we learn about lifestyle changes and management techniques that may help patients cope with (and even prevent) these complications.

Sources:

http://www.diabetes.co.uk/body/circulatory-system.html

http://www.diabetes.org/living-with-diabetes/complications/heart-disease/

http://diabetes.niddk.nih.gov/dm/pubs/stroke/

http://www.nhlbi.nih.gov/health/health-topics/topics/dhd

 

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