Cardiac and Pulmonary Rehabilitation

Question 1

What is the role of OT in working with cardiac and pulmonary clients?

Answer 1

Coronary Artery Disease (CAD)- ie with stroke pts

• Damage to the internal wall of an artery
• Plaque and platelets collect on the damaged area of the artery
• Narrowing of artery=Atherosclerosis

Myocardial Infarction (MI) heart attack :First 6 Weeks

• Activity restrictions for first 6 weeks- you help with safety/ checking vitals is critical/ how much is activity is too much/ you help as OT with how they can do ADLS with energy conservation
• Balance of rest and activity
• OT guides client toward a safe level of activity and occupation

OT can help client

• Recognize signs of fatigue
• Identify when to take rest breaks
• Choose activities to be performed safely
• Monitor response to activity
• Education on the disease process
• Education on risk factors
• Education on lifestyle management
• Encourgae to buy pulse oxi

Myocardial Infarction: After 6 Weeks

• A graded exercise program strengthens the healthy part of the myocardium and improves cardiac output.

Question 2

What are common cardiac conditions?

Answer 2

Congestive Heart Failure (CHF)

• Controlled with diet, medication, and rest.
• A gradual resumption of activity will promote improved function
• Activity resumed too quickly, may result in another acute episode

Coronary Artery Bypass Graft (CABG)(ie x 3, is how many times they had to around vessel)

• Valvular disease can lead to CHF or ischemia and surgery may be required to repair or replace valves.
• Clients with heart transplants can be rehabilitated to a higher level of function than months prior to surgery. (one group that can be d/c to a higher level of function)

Question 3

What are sternal precautions?

Answer 3

Sternal Precautions- 6-8 weeks for bone to heal/ be VERY careful with them

• Avoid Valsalva maneuvers
• Examples - straining during BM, transfers, sneezing, coughing.(cough pillow to hug) with transfer don’t hold breath!!
• Do not hold your breath with activity.
• Avoid rapid movement of upper body
• No pushing or pulling with arms when getting in and out of bed.
• No pushing up with arms from a chair when standing. ​
• No flexing shoulders above 90 degrees.
• No raising elbows higher than shoulders.
• Avoid long periods of over shoulder activity. ​
• Avoid reaching too far across body.
• Avoid twisting or deep bending.
• Do not reach behind your back.
• 10 lb lifting restriction
• Wear compressive hose
• Refraining from driving (secondary to upper body torque)
• Avoid traveling in a seat without an airbag when riding in a car
• Stop activity if you feel any pulling or stretching.
• Report any clicking or popping noise around chest.

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Question 4

What are some of the psychosocial considerations when working with a client with a cardiac condition and when working with a client with a pulmonary condition?

Answer 4

Psychosocial Considerations

• Depression
• Anxiety- sometimes will get labeled as non-compliant but really they are just scared they will suffocate
• May lack basic skills in in coping and setting limits with self and others
• OTs role is to increase client’s participation in activities that develop skills and promote resumption of occupations that are valuable and meaningful.

Coping Mechanisms:

• Smoking
• Drinking
• Consuming Fatty Food

Question 5

What are normal and abnormal vitals, and what are activity restrictions for clients with cardiac and pulmonary conditions?

Answer 5

Monitoring Response to Activity

Heart Rate (HR)

Adults: Beats per Minute

Normal: 60-100

Blood Pressure:

Adults Stystolic Dia

Normal <120 <80

High Normal 130-139 85-89

Elderly (65+) 120-140 80-90

(HTN) Stage 1 140-159 90-99

HTN Stage 2 160-179 100-109

HTN Stage 3 STOP!! 180-209 110-119

HTN Stage 4 >210 >120

How to calculate breaths per minute

• Sit down and relax.
• Place your hand on your chest or stomach.
• Breathe normally (one rise and fall of the chest/stomach is one breath, another rise and fall is two breaths, etc).
• Do this for 60secs.

Question 6

Identify signs of cardiac and pulmonary distress.

Answer 6

Signs and Symptoms of Cardiac Distress

• Angina- chest pain
• Dyspnea- SOB
• Orthopnea- SOB in supine
• Nausea/emesis
• Diaphoresis- sweating
• Fatigue
• Cerebral Signs
• Orthostatic
• Abnormal heart activity
• Pain or pressure in chest, arm, or jaw
• Dizzy, light-headed, or faint
• Confused
• Blurred vision
• Clumsy

Stop Activity

• Heart rate is still high 10 minutes after exercise.
• Fatigue and extreme tiredness 24 hours after exercise
• Pain in joints, heels, or calf muscles- DVT signs!! Red Flag
• Increased swelling in legs and feet.

Question 7

What are the stages of cardiac rehabilitation, in what setting does each stage occur, and what are the activity limitations at each stage?

Answer 7

Acute Phase

• Days 1-3
• Stabilization of Medical Condition

Intervention Phase 1: Inpatient Cardiac Rehab (OT works here)

• Early Mobilization
• Monitored low-level physical activity
• Self-care
• Reinforcement of cardiac and post-surgical precautions
• Instruction in energy conservation and graded activity
• Guidelines for appropriate activity level at discharge

Intervention Phase 2: Outpatient Cardiac Rehab

• If they can tolerate car ride
• Usually begins at discharge
• Exercise is advanced while the client is closely monitored on an outpatient basis

Intervention Phase 3

• Community-based Exercise Programs
• Alternative: Home health care if patient cannot tolerate outpatient.

Question 8

What are common pulmonary conditions?

Answer 8

Pulmonary Diseases

• Chronic Obstructive Pulmonary Disease (COPD)
• Peripheral Airway Disease (inflammation, fibrosis)
• Emphysema (enlarged or ruptured alveoli)
• Chronic Bronchitis (mucus)
• Asthma (irritability, bronchospasms)

Signs and Symptoms of Pulmonary Distress

• Dyspnea****SOB
• Extreme fatigue
• Nonproductive cough
• Confusion
• Impaired judgment
• Cyanosis

Question 9

Identify intervention strategies for cardiac and pulmonary conditions.

Answer 9

Pulmonary Rehabilitation

• Goal: To stabilize or reverse the disease process and return the client’s function and participation in activity and occupation back to his or her highest capacity.

Intervention Techniques

• Dyspnea control postures- hopefully will bring O2 sats back up- note in notes with pulse oxi/ also need to know level of oxy- never touch O2 tanks
• Seated: Client bends forward slightly at waist while supporting upper body by leaning the forearms on the table or thighs.
• Standing: Client leans forward and props self on counter or shopping cart.

Pursed-lip Breathing (PLB)

• Purse the lips as if to whistle
• Slowly exhale through pursed lips. Some Resistance should be felt.
• Inhale deeply through the nose.
• It should take twice as long to exhale as it does to inhale.

Diaphragmatic Breathing

• Client lies supine
• Place a small paperback novel on the abdomen just below xiphoid process
• Client inhales slowly and makes book rise
• Exhale through pursed lips and make book fall

Relaxation

• Progressive muscle relaxation in conjunction with breathing exercises
• Tense muscle groups while slowly inhaling
• Relax muscle groups when exhaling twice as slowly through pursed lips
• Sequence: face; face and neck; face, neck, and shoulders ​

Question 10

Identify intervention strategies for cardiac and pulmonary conditions.

Answer 10

Cardiopulmonary Evaluation

• Review of Medical Record
• Medical History
• Social History
• Test Results
• Medications
• Precautions
• Patient Interview
• Observation
• Signs of anxiety
• Shortness of Breath
• Confusion
• Difficulty comprehending
• Fatigue
• Abnormal posture
• Reduced endurance
• Reduced ability to move
• Stressful family dynamics
• Patient Interview
• Clarify medical record and client’s understanding of his/her condition
• Ask client to describe typical day
• Identify activities that bring on SOB or angina
• How do physical limitations interfere with activities or occupations

Clinical Evaluation

• Establish client’s baseline –present functional ability and limitations

Clinical Evaluation

• Cardiac:
• Monitor HR, BP, symptoms and signs of cardiac distress
• ECG readings during an assessment of tolerance to postural changes and during a functional task

Clinical Evaluation

• Respiratory
• Signs and symptoms of respiratory distress
• Oxygen saturation monitor –ROM, strength, and sensation grossly assessed within context of ADL assessment
• Cognitive and psychosocial status

Cardiopulmonary Intervention

Progression and Energy Costs

• 1 Basal Metabolic Equivalent (MET) = amount of oxygen per kilogram of body weight
• Once a client tolerates an activity with appropriate responses, the client can progress to the next higher MET-level activity.
• Duration of sustained physical activity
• (Pendleton Schultz-Krohn, 2006, Table 44-1 & Table 44-5)

Energy Conservation and Work Simplificaiton

• Methods to conserve energy resources in order to perform at a higher functional level without expending more energy.
• Principles based on knowledge of ways specific factors cause cardiovascular response. ​

Energy Conservation

6 Variables that Increase Oxygen Demand

• Increased rate
• Increased resistance
• Increased use of large muscles
• Increased involvement of trunk musculature
• Raising one’s arms
• Isometric work/ Straining

Energy Conservation

• UE activity requires greater cardiovascular output than LE activity
• Standing requires more energy than seated activity
• Extremes of temperature, high humidity, and pollution make the heart work harder

Energy Conservation Techniques

• Time management = learning to plan one’s activity or participation in occupation so that tasks requiring high energy expenditure are interspersed with lighter tasks so that rest breaks are scheduled throughout the day.

Energy Conservation Techniques

• Exhaling with Exertion - Helps control systolic BP responses to activity
• Diaphragmatic breathing at rest, then progress during task performance
• UE exercise to increase exercise tolerance
• Activities with increasing levels of demand
• Light activities with and without UE support
• Adaptive Equipment
• Adapt and modify environment
• Organize activities and routine
• Organize environment

Lifestyle Modification

• Exercise education
• Graded program of increased activity and participation in occupation
• Stretching, strengthening, and aerobic activity
• Guidelines for monitoring HR, BP, and perceived exertion
• Cool down, safety issues related to clothing , environmental factors, and warning signs
• Plan for resuming exercise if it is skipped for a period of time
• Emergency guidelines.
• Lifestyle Modification
• Modifications of diet addressed through meal preparation activities.
• Stop smoking, refrain from excessive alcohol consumption, stop drug abuse
• Support groups , counseling, medical mgmt.

Patient and Family Education

• Cardiac and pulmonary anatomy
• Disease process
• Symptom management
• Risk factors
• Diet
• Exercise
• Energy Conservation Techniques

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