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76 Cards in this Set

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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.
what kinds of patients may benefit from cardiac rehab?
1. CAD
2. Acute MI
3. Angina
4. Cardiovascular surgery
5. Cardiomyopathy / CHF
6. PVD
7. HTN
what type of "heart disease" is the leading cause of death in the US?
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
what are examples of "modifiable" risk factors for heart disease?
high blood pressure
high blood cholesterol
Smoking
physical inactivity
diabetes mellitus
Obesity
stress
what are examples of "non- modifiable" risk factors for heart disease?
Heredity
male sex
increasing age
Arteriosclerosis

main idea?
hardening of the arteries; characterized by thickening, hardening and loss of elasticity of the walls of the arteries
Atherosclerosis

main idea?
characterized by plaques of fatty deposits that form between the wall layers of the arteries
Arteriolar Sclerosis

main idea?
affects small blood vessels by thickening the walls of the small arteries; blood flow is reduced and hypertension results
thrombus

main idea?
blood clot within a vessel
embolus

main idea?
a blood clot that forms in the blood vessels in one part of the body and travels to another
what leads to arteriosclerosis?
atherosclerosis
Clinical Manifestations of CAD

ischemia- main idea?
temporary oxygen deficiency of the tissues (in the heart)
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
Clinical Manifestations of CAD

angina pectoris- common cause?
Most commonly caused by critical coronary artery obstruction due to atherosclerosis.
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
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
The long term prognosis for the survivors of CAD depends on what two factors?
the extent and the location of the existing disease
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
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
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
Angina

main idea?
Angina pectoris is pain secondary to temporary, localized ischemia.
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)
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)
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
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.
PVD

main idea?
Vascular diseases of the extremities involves the arteries, veins and lymphatics. Pts with occlusive PVD often have atherosclerosis
what are some of the benefits of Cardiac Rehab?
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)
what are the 3 phases of Cardiac Rehab?
inpatient (phase 1)
outpatient (phase 2)
community programs (phase 3)
how long does PHASE I of cardiac rehab generally last?
This phase occurs in the hospital usually lasting 3-5 days following stabilization of the patient 'S cardiovascular status after MI or surgery
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
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
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
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
The chart Review should include

4 key points
medical history
medications
laboratory studies
diagnostic studies
how often should the patient's chart be reviewed?
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.
what are some of the goals of a patient interview?
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
why should a patient be questioned about pain?
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.
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).
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.).
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).
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.
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)
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
how are exercise activities described/measured?
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
how many METs to most impatient programs begin with and what to the progress to?
Most inpatient programs begin with activities of around 2 to 3 METs and progress to 3 to 5 METs by DC.
what are some initial activities for exercise programs for inpatients
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.
Specific Exercise progressions

when does resistive exercise begin
after passive and active
Specific Exercise progressions

when should distal joint exercises begin?
before intermediate and proximal
Specific Exercise progressions

should we begin with the trunk or the extremities?
begin with extremities
Specific Exercise progressions

put these in order: standing, lying, sitting
Lying to sitting to standing exercises
Specific Exercise progressions

when should stair climbing begin?
Progressive increases in ambulation distances and progression to down then up stair climbing
how can the metabolic cost of an activity be increased?
1. Altering the specific type of activity
2. Increase the time duration spent on the activity
3. Altering the position of the body
how long and how often should a patient be exercised during PHASE 1?
: initially 2 to 4 times a day for 5 to 10 minutes (as tolerance increases: increase duration and decrease frequency)
Once the Exercise program is initiated the following signs would dictate intolerance and a need to modify or stop the exercise program
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
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
Signs and Symptoms of Exertional Intolerance (during or after session)
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
Responses that may be delayed for as long as several hours after exercise...
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
Monitoring Exercise Response

what is the gernal allowable increase in standing resting HR during PHASE I?
+ 10-20 BPM
Monitoring Exercise Response

when should BP be taken?
Routinely taken before, during and after each exercis
Monitoring Exercise Response

above what systolic/diastolic BP would exercise be contraindicated?
>200 mmHg (Sys)/ >110 mmHg (Dias)
what happens with isometric exercises greater than 20% of voluntary contraction?
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
what kinds of data should be recorded and charted during PHASE I exercise plans?
Date
Time
Activity
Intensity
Duration
Pt response
Vital Signs
ECG changes
Any significant Pt comments or problems
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
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.
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
GOALS of Phase II

average frequency and duration of treatment?
3-4 times a week for 10 to 60 minutes.
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
Phase II exercise prescription

what are the 3 components?
1) Aerobic Conditioning Ex

2) Strength Training

3) Relaxation training
in regards to exercise, how is intensity generally prescribed and what is it based on?
is typically prescribed as a percentage of functional capacity and is based on the results of the GXT
when can HR not be safely used to prescribe safe work loads?
1. Isometric exercise
2. Valsalva maneuver
3. Heavy arm work
4. Environmental extremes
5. Beta blockade medications
6. Pacemaker
Exercise prescription by perceived exertion

on a scale of 1-10, where should patients in PHASE II be exercising at?
4-6
how can target work intensity be calculated by a given prescription in METs?
.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
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
what are the goals of PHASE III ?
1. Maintain Function
2. Promote lifelong commitment to physical fitness and personal health management
what is the unique focus of PHASE III?
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.
what are the benefits of Cardiac Rehab?
improved functional capacity, decreased heart rate and blood pressure, effects of physical training