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76 Cards in this Set
- Front
- Back
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Cardiac Rehabilitation
defintion |
Cardiac rehab is a combination of interventions that enable pts with heart disease to improve their functional abilities, particularly their tolerance for physical activity, to decrease their symptoms and to achieve and maintain optimal health while returning to a full and productive life.
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what kinds of patients may benefit from cardiac rehab?
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1. CAD
2. Acute MI 3. Angina 4. Cardiovascular surgery 5. Cardiomyopathy / CHF 6. PVD 7. HTN |
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what type of "heart disease" is the leading cause of death in the US?
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Cardiovascular disease / coronary artery disease (CAD)
leading cause of death in the USA today 1 million deaths each year (43% of all deaths) 70 million Americans have one or more forms of heart and blood vessel disease |
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what are examples of "modifiable" risk factors for heart disease?
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high blood pressure
high blood cholesterol Smoking physical inactivity diabetes mellitus Obesity stress |
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what are examples of "non- modifiable" risk factors for heart disease?
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Heredity
male sex increasing age |
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Arteriosclerosis
main idea? |
hardening of the arteries; characterized by thickening, hardening and loss of elasticity of the walls of the arteries
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Atherosclerosis
main idea? |
characterized by plaques of fatty deposits that form between the wall layers of the arteries
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Arteriolar Sclerosis
main idea? |
affects small blood vessels by thickening the walls of the small arteries; blood flow is reduced and hypertension results
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thrombus
main idea? |
blood clot within a vessel
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embolus
main idea? |
a blood clot that forms in the blood vessels in one part of the body and travels to another
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what leads to arteriosclerosis?
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atherosclerosis
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Clinical Manifestations of CAD
ischemia- main idea? |
temporary oxygen deficiency of the tissues (in the heart)
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Clinical Manifestations of CAD
angina pectoris- main idea? |
: episodes of pericardial discomfort or pressure, typically precipitated by exertion and relieved by rest or sublingual nitroglycerin
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Clinical Manifestations of CAD
angina pectoris- common cause? |
Most commonly caused by critical coronary artery obstruction due to atherosclerosis.
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Clinical Manifestations of CAD
infarction- main idea? |
cell death that occurs when the blood supply is severely reduced (>75% of the supplying artery) or stopped
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Clinical Manifestations of CAD
infarction- what is it often associated with? |
It is often associated with an acute thrombus. It is rarely caused by an embolus
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The long term prognosis for the survivors of CAD depends on what two factors?
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the extent and the location of the existing disease
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Acute MI
what is it? |
MI is the death of myocardial tissue secondary to prolonged ischemia. It is the result of thrombus formation with complete occlusion or severe stenosis of a coronary artery
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Acute MI
symptoms include? |
uncomfortable pressure, fullness, squeezing or pain in the center of the chest lasting more than a few minutes
radiating pain to the shoulders, neck or jaw chest discomfort with light headedness Fainting Sweating Nausea SOB |
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Acute MI
what does the prognosis depend on? |
The damage is permanent and the prognosis depends on the artery involved, the amount of cardiac tissue involved, and the patency and adequacy of the remaining circulation
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Angina
main idea? |
Angina pectoris is pain secondary to temporary, localized ischemia.
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Angina
symptoms include...? |
substernal pain
radiating pain to left shoulder and arm retrosternal burning, numbness or discomfort onset may be gradual or sudden Dyspnea Indigestion Dizziness syncope (fainting , could be caused by decreased cerebral blood flow due to decreased cardiac output caused by arrhythmias. Anxiety ST segment depression on ECG (below the normal baseline of the ECG) |
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how is ANGINA generally precipitated?
how is it managed? |
Angina is chiefly precipitated by physical exertion; it can be relieved by rest or removal of the precipitating cause
. It can also be managed with drugs (i.e. nitroglycerin: a smooth muscle relaxer and vasodilator, it brings the myocardial O2 supply and demand back in balance) |
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Cardiomyopathy or CHF:
main idea? |
Cardiomyopathy is any structural or functional abnormality of the ventricular myocardium except for: congenital defects, valvular disease, vascular disease, conduction disease or epicardial coronary artery disease
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Cardiomyopathy or CHF:
how do these patients present? |
usually present with effort dyspnea and fatigue due to elevated L ventricular diastolic pressure and low cardiac output. Pts with CHF or cardiomyopathy are often incapacitated as a result of significant ventricular dysfunction and decreased cardiac output.
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PVD
main idea? |
Vascular diseases of the extremities involves the arteries, veins and lymphatics. Pts with occlusive PVD often have atherosclerosis
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what are some of the benefits of Cardiac Rehab?
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1. Increased exercise tolerance
2. Improved symptoms (decreased angina, decreased SOB and decreased fatigue) 3. Improved blood lipid levels (improved nutrition = decreased cholesterol levels) 4. Smoking cessation 5. Improved psychosocial 6. Reduced mortality (25% reduced in post MI pts) |
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what are the 3 phases of Cardiac Rehab?
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inpatient (phase 1)
outpatient (phase 2) community programs (phase 3) |
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how long does PHASE I of cardiac rehab generally last?
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This phase occurs in the hospital usually lasting 3-5 days following stabilization of the patient 'S cardiovascular status after MI or surgery
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Goals of Phase I
why should we initiate early physical activity? |
Return to activities of daily living (ADL's)
b. Offset the deleterious effects of bed rest |
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Goals of Phase I
what are some of the negative effects of bed rest? |
1. a decrease in physical work capacity
2. an increase in the heart rate response to effort 3. a decrease in adaptability to change in posture i.e. orthostatic hypotension (an excessive fall in BP on assuming upright) 4. a decrease in the circulation blood volume (with plasma volume) decreasing to a greater extent than red cell mass |
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Goals of Phase I
what are some of the goals of patient and family education? |
Alleviate anxiety, fears and depression
a. Outline the course of cardiac rehabilitation and plan for resumption of life at home b. Promote risk factor reduction c. CPR instruction of a family member d. Improve understanding of coronary disease and its management |
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ASSESSMENT in Phase I
how will the PTA assess the patient? |
chart review, Pt interview, physical examination, exercise, monitoring exercise responses and by signs and symptoms of exercise intolerance
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The chart Review should include
4 key points |
medical history
medications laboratory studies diagnostic studies |
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how often should the patient's chart be reviewed?
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The therapist should review the chart daily to reveal any changes in the patient's cardiac status from day to day. Changes in enzyme levels, ECG patterns, or other diagnostic data may herald the emergence of complications or an extension of the infarct.
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what are some of the goals of a patient interview?
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may be able to get a better picture of the pts present functional status, previous lifestyle and habits as the Pt begins to feel better, and a rapport between the patient and therapist has been established
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why should a patient be questioned about pain?
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The intense pain in infarction is usually time- limited, and generally lasts from hours to the first few days. Chest wall pain following bypass surgery is generally sharp and is influenced by respiratory movements.
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Physical Examination
what can pulse tell us? |
it may be weak ( decreased cardiac output), tachycardic (pts with CAD, fever, anxiety, severe deconditioning), bradycardia (caused by cardiac meds, vagal stimuli, or MI, irregular pulse (indicative of dysrhythmias).
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Physical Examination
what can an increased or decreased pulse tell us? |
increased( may be related to inadequate cardiac output associated with stress, pain, hypoxia, drugs, or CAD.), decreased(related to bed rest, drugs, dysrhythmias, shock, or MI.).
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Physical Examination
what can the respiratory rate tell us? |
dyspnea (common with left ventricular dysfunction), orthopnea (only able to easily breathe in upright positions.), exertional dyspnea (related to CAD and/or overall levels of deconditioning).
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Exercise
what is the initial prescription dependent on? |
dependent on the individual patients status and level of recovery. Careful monitoring is mandatory to ensure patient safety.
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Exercise
contraindications for entry into inpatient or outpatient exercise programs? |
1. Unstable angina
2. Resting systolic BP >200 mmHg or resting diastolic BP >100 mmHg 3. Orthostatic BP drop of >= 20 mmHg 4. Moderate to severe aortic stenosis (found on Echo) |
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Exercise
additional contraindications for entry into inpatient or outpatient exercise programs? |
5. Acute systemic illness or fever
6. Uncontrolled atrial or ventricular dysrhythmias (controlled by medication or pacemaker) 7. Uncontrolled sinus tachycardia(>120 bpm) 8. Uncontrolled CHF 9. 3rd degree AV heart block |
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how are exercise activities described/measured?
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Activities are described in MET's or metabolic equivalents ( this measures the energy requirements for basal homeostasis while the subject is awake and in a full sitting position
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how many METs to most impatient programs begin with and what to the progress to?
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Most inpatient programs begin with activities of around 2 to 3 METs and progress to 3 to 5 METs by DC.
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what are some initial activities for exercise programs for inpatients
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self-care, resumption of upright sitting, and selected arm and leg exercises designed to improve flexibility and muscle tone. These are generally begun 3 to 5 days after the event.
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Specific Exercise progressions
when does resistive exercise begin |
after passive and active
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Specific Exercise progressions
when should distal joint exercises begin? |
before intermediate and proximal
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Specific Exercise progressions
should we begin with the trunk or the extremities? |
begin with extremities
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Specific Exercise progressions
put these in order: standing, lying, sitting |
Lying to sitting to standing exercises
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Specific Exercise progressions
when should stair climbing begin? |
Progressive increases in ambulation distances and progression to down then up stair climbing
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how can the metabolic cost of an activity be increased?
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1. Altering the specific type of activity
2. Increase the time duration spent on the activity 3. Altering the position of the body |
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how long and how often should a patient be exercised during PHASE 1?
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: initially 2 to 4 times a day for 5 to 10 minutes (as tolerance increases: increase duration and decrease frequency)
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Once the Exercise program is initiated the following signs would dictate intolerance and a need to modify or stop the exercise program
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1. increased HR above prescribed limit
2. marked change in BP with exercise 3. significant exercise dyspnea 4. myocardial ischemia, angina, or significant dysrhythmias 5. incisional pain 6. excessive fatique |
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Criteria for termination of an inpatient exercise session (during the session)
(first four of 14 listed) |
1. Fatigue
2. Failure of monitoring equipment 3. Light-headedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency 4. Onset of angina with exercise |
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Signs and Symptoms of Exertional Intolerance (during or after session)
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1. persistent dyspnea
2. dizziness or confusion 3. anginal pain 4. severe leg claudication 5. excessive fatigue 6. pallor, cold sweat 7. Ataxia 8. pulmonary rales |
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Responses that may be delayed for as long as several hours after exercise...
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1. prolonged fatigue
2. Insomnia 3. sudden weight gain due to fluid retention If the cardiac Pt begins exhibiting any of these signs the session should immediately be terminated |
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Monitoring Exercise Response
what is the gernal allowable increase in standing resting HR during PHASE I? |
+ 10-20 BPM
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Monitoring Exercise Response
when should BP be taken? |
Routinely taken before, during and after each exercis
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Monitoring Exercise Response
above what systolic/diastolic BP would exercise be contraindicated? |
>200 mmHg (Sys)/ >110 mmHg (Dias)
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what happens with isometric exercises greater than 20% of voluntary contraction?
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contraction results in an increased pressure load on the heart, as evidenced by increased vascular resistance and sudden increases in both systolic ands diastolic blood pressures
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what kinds of data should be recorded and charted during PHASE I exercise plans?
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Date
Time Activity Intensity Duration Pt response Vital Signs ECG changes Any significant Pt comments or problems |
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Phase II
what is the general time frame of this phase? |
includes the early at home period through the recuperation period (typically up to 8 to 12 weeks after DC
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PHASE II
what is the purpose of the GRADED EXERCISE TEST? |
Graded Exercise testing is the observation and recording of the pts cardiovascular responses during a measured exercise stress.
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GOALS of Phase II
3 main goals |
1. Improve functional capacity
2. Progress toward full resumption of habitual and occupational activities 3. Promote positive life-style changes |
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GOALS of Phase II
average frequency and duration of treatment? |
3-4 times a week for 10 to 60 minutes.
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in METs, what is the suggested exit point from PHASE II
what is the minimum MET level needed to safely conduct esential ADLs? |
One suggested exit point from Phase II is the attainment of 9 MET capacity. A 5 MET capacity is considered the minimum, safe level needed to meet essential ADL's
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Phase II exercise prescription
what are the 3 components? |
1) Aerobic Conditioning Ex
2) Strength Training 3) Relaxation training |
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in regards to exercise, how is intensity generally prescribed and what is it based on?
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is typically prescribed as a percentage of functional capacity and is based on the results of the GXT
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when can HR not be safely used to prescribe safe work loads?
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1. Isometric exercise
2. Valsalva maneuver 3. Heavy arm work 4. Environmental extremes 5. Beta blockade medications 6. Pacemaker |
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Exercise prescription by perceived exertion
on a scale of 1-10, where should patients in PHASE II be exercising at? |
4-6
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how can target work intensity be calculated by a given prescription in METs?
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.65 X Prescribed METs
There are many factors that can change the actual MET value, therefore it is not safe to use METs alone as an indicator for exercise intensity |
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Rate of progression
when is a change in the exercise prescription warranted? |
warranted when the individuals perception of exercise changes (it is easier), when the HR is lower for a given exercise intensity, or when symptoms of ischemia do not appear at the usual exercise intensity
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what are the goals of PHASE III ?
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1. Maintain Function
2. Promote lifelong commitment to physical fitness and personal health management |
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what is the unique focus of PHASE III?
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Exercise prescriptions are generally same as phase II. Their are high drop out rates for this program, so phase III focuses on addressing the specific concerns of compliance.
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what are the benefits of Cardiac Rehab?
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improved functional capacity, decreased heart rate and blood pressure, effects of physical training
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