Cardiopulm Unit 5 HF CPG Flashcards
In the Translation Framework for optimizing PT in pt with Heart Failure article, What is the ABCDE?
Assessment of Stability
Behavior Modification
Cardiorespiratory Fitness Training
Dosage of Interventions
Education
What is Decompensition?
New or worsening of Sx of Dyspnea, fatigue or edema that leads to hospitalization or unscheduled medical care (doctor visits or emergency department visits)
In the Translation Framework for optimizing PT in pt with Heart Failure article, what is Assessment of Stability?
This assesses stability at rest and during activity from an Absolute and Relative Prespective
- Decided whether a patient is appropriate for exercise-based interventions
Stability is defined as the physiological process required for the maintance of Homeostasis
WIth the assessment of Stability, what will the patient Self-Assess with “Red”? What do we do?
Patient Self-Assesses:
- Difficulty breathing even at rest
- Unrelieved SOB
- Wheezing, chest pain or chest discomfort
- Feeling faint
- Confusion
What to do:
- Call physician immediately or immediate visit to the emergency department
With the Assessment of Stability, if the patient self-assesses as “Red” what should happen next?
Overt decompensation: an immediate visit to the ED or call physician office immediately
WIth the assessment of Stability, what will the patient Self-Assess with “Yellow”? What do we do?
Patient Self-Assesses:
- Weight Gain > 2lbs in 1 day or 5lbs in one week
- Increase swelling
- Increase cough
- Increase in SOB with activity
- Increase in the number of pillows needed
What to do:
- Communicate with physician as the patient may need adjustment to medication
With the Assessment of Stability, if the patient self-assesses as “Yellow” what should happen next?
A physical exam takes place,
-We assess Pulmonary Crackles, S3 auscultations, and JVD
- If the patient does not have any of these,
-This may indicate need for an adjustment in meds and therefore warrents communication with the physician - If they do have these,
-Overt decompensation: an immediate visit to the ED or call physician office immediately
WIth the assessment of Stability, what will the patient Self-Assess with “Green”? What do we do?
Patient Self-Assesses:
- No SOB
- No weight gain
- No swelling
- No chest pain
- No decreased in ability to maintain activity level
What to do:
- Proceed with interventions, exercises, and activity as planned
In the Translation Framework for optimizing PT in pt with Heart Failure article, what is Behavior Modification?
- 5 A’s: Ask, Advise, Assess, Assist, and Arrange
- 5 R’s: Relevance, Risk, Roadblock, Rewards and Repition)
- Motivational Interviewing
In the Translation Framework for optimizing PT in pt with Heart Failure article, what are some examples of Cardiorespiratory Fitness Testing?
- Seated step test
- 6 min arm test
- 2 min step test
- 2 min walk test
- 6 min walk test
- Submax Graded Exercise Test
- Maximal Graded Exercise Test
In the Translation Framework for optimizing PT in pt with Heart Failure article, what are different ways to Dose Interventions?
- Aerobic Exercise
- Interval Training
- Strength Training
- Inspiratory Muscle Training
- Electrical Stimulation
In the Translation Framework for optimizing PT in pt with Heart Failure article, what should we provide as education?
- Educate on disease self-management
- Nutitional recommendations
- Medical management
What is Absolute Stability?
Involves the appreciation of the absolute indicators of decompensation that need to be assessed and documented in their own right.
What is Relative Stability?
This considers whether the patient is on a stable temporal trajectoryand the relative changes in hemodynamic parameters over time. In other words, relative stability considers alterations that occur on a day-to-day or visit-to-visit basis relative to the patient’s baseline.
The patient presents to the clinic with 78/40 mmHg, a heart rate of 110 bpm at rest, respiratory rate of 34 breaths per minute, oxygen saturation of 86% on room air, and bilateral
rales heard on auscultation. They report difficulty breathing even while sitting still. Is this an example of Absolute or Relative Stability at Rest?
Absolute Relative Stability
- This patient is not absolutely stable at rest, as their vital signs and symptoms at this visit show acute decompensation that is not evaluated based on previous sessions. These signs and symptoms are serious on their own, regardless of his historical readings or conditions. This patient’s condition is critical, warranting immediate MD consultation and an emergency visit
to address acute decompensation and potential respiratory distress
The patient has a typical resting blood pressure in the 140s/80s mmHg and often reports fatigue. Today, the patients blood pressure is 102/68 mmHg and reports significantly more
fatigue than usual. Is this an example of Absolute or Relative Stability at rest?
Relative Stability at rest
- This patient appears relatively unstable at rest, as there is a negative change over time from one visit to the next, relative to their individual baseline, even though their BP is considered WNL. The patient may not require an emergency visit but likely benefits from an MD consult
What is Absolute Stability with Exercise?
The absolute degree of change in hemodynamic parameters including but not limitied to a drop in BP or rapid increase in HR that might occur with exercise
What is Relative Stability with Exercise?
The relative changes in exerices response that occur at the same intensity of exercise from one visit to the next
The patient begins a supervised exercise program. During the initial session, they exhibits signs of exercise intolerance including severe shortness of breath, chest pain, and a drop in
blood pressure with minimal exertion. Is this an example of Absolute or Relative stability with exercise?
Absolute Stability with Exercise
- The patient’s response to exercise is concerning irrespective of his previous capacity or sessions. Due to the acute and severe nature of the symptoms, the exercise should be stopped immediately, the intensity of future sessions should be reconsidered, and the patient may require an urgent medical consultation if their clinical status doesn’t improve
with rest
The patient has been participating in a cardiac rehabilitation program. Initially, they could tolerate 10 minutes on the treadmill at a moderate pace. Over the past few sessions,
they’ve only been able to manage 5 minutes before becoming excessively fatigued. Is this an example of Absolute or Relative stability with exercise?
Relative Stability with Exercise
Despite being stable in the short term, they show a decline in exercise tolerance across sessions, indicating they are not relatively stable with exercise. The exercise prescription
should be reassessed, potentially reduced, and the patient should consult with their physician to address the decline in her exercise capacity.
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO have Absolute and Relative stability at Rest?
Continue and assess Stability with Exercise
-Vitals with exercise
-Recovery time
-S/S of Exercise tolerance
If you are doing an Assessment of Stability at Rest with a patient (vitals, Sx of decompensation {red, yellow, green zones}, signs of decompensation, what would happen if they DO NOT have Absolute and Relative stability at rest?
MD consult Emergency Visit
After you do the Assessment of Stability with Exercise, what would happen if they DO have Absolute and Relative Stability with Exercise?
Increase the intensity/Dose of Exercise
What should a PT do if Maximal Exercise Testing is not feasible due to lack of expertise, monitoring or safety equipment?
Utilize submax exercise testing to determine a baseline for cardiopulmonary fitness
What is a Key Consideration for Dosing Exerise Intensity?
What can progression of exercise be based on?
The workload at which a given physiologic response is elicited
- Progression of interventions during subsequent visits within an episode of care can then be based on that workload and whether physiologic responses indicate a readiness for a higher intensity (Lower HR, RPE, etc) and progression towards goals of the patient
After you do the Assessment of Stability with Exercise, what would happen if they Do Not have Absolute and Relative Stability with Exercise?
Reduce intensity/Dose of exercise and/or MD consult Emergency Visit
What is the Application to Exercise Prescription with the Seated Step Test?
Activities with MET levels at or below those attained during test can be safely used in intervals with number and length of intervals adjusted to patient tolerance
What is the Application to Exercise Prescription with the 6 Meter Walk Test?
There is no direct application to exercise prescription but allows comparison to norms:
- Using distance walked to perdict peak oxygen consumption/MET level, select activities or treadmill speeds/grades that are a percentage of that MET level
- Perform 10 min interval of walking at a speed 80% of average speed walking during the 6 MWT
Goal: How far the pt can walk in 6 min down a straight, 100ft hallway
What is the Application to Exercise Prescription with the Submaximal Graded Exercise Test?
Prescribe intensity based on percentage of predicted peak workload
MUST KNOW
In the CPG, what is Action Statement 2?
Educate on and Facilitate Components of Chronic disease management
- PTs MUST make appropriate nutrition referrals, perform medication reconciliation and provide appropriate education on preventative self-care behaviors to reduce risk of hospital readmissions
- These include:
-Daily weight measurement to identify increases greater than 2 to 3 lbs in 24 hrs or 5 lbs over 3 days
-Recognition of S/S of an exacerbation
-Action plan with Red/Yellow/Green CHF tool
-Following nutrition plan
-Medication management/medication reconciliation
MUST KNOW
In the CPG, what is Action Statement 3?
Prescribe Aerobic Exercise Training
PTs MUST prescribe aerobic exercise training for patients with Stable, NYHA class 2 to 3 HF using the following parameters:
- Time: 20-60 min
- Intensity: 50-90% of Peak VO2 or Peak work
- Frequency: 3 to 5 x a week
- Mode: Treadmill or cycle ergometer or dancing
Total energy expenditure during the program was the most important determinant of improvement in peak VO2
MUST KNOW
In the CPG, what is Action Statement 4?
Prescribe High-Intensity Interval Exercise Training in Selected Patients
PTs SHOULD prescibe high intensity interval-based exercise (HIIT) for patients with stable, NYHA Class 2 to 3 HFrEF using the following parameters:
- Time: >35 total minutes of 1 to 5 minutes of high-intensity (>90%) alternating with 1 to 5 minutes at 40% to 70% active rest intervals, with rest intervals shorter than the work intervals
- Intensity: >90 of peak VO2 or peak work.
- Frequency: 2 to 3 times per week.
- Duration: at least 8 to 12 weeks.
- Mode: treadmill or cycle ergometer
Shorter HITT sessions may allow for the greatest long-term adherence
MUST KNOW
In the CPG, what is Action Statement 5?
Prescribe Resistance Training
Physical therapists SHOULD prescribe resistance training for the upper and lower body major muscle groups for
patients with stable, NYHA Class I to III HFrEF using the
following parameters:
- Time: 45 to 60 minutes per session.
- Intensity: 60% to 80% 1RM, 2 to 3 sets per muscle group.
- Frequency: 3 times per week.
- Duration: at least 8 to 12 weeks
Resistance training can be especially effective in patients that do not tolerate continuous or interval aerobic training or other therapeutic modalities. Accommodating patient preference for mode of exercise may increase patient adherence, and thus resistance training should be offered as an option
