Cardiovascular- Acute, Subacute, and post acute cardiac rehab, resistance training, and therex for the complex pt. Flashcards
Inpatient (Acute): typical length of stay in hospital for uncomplicated MI
3-5 days
Inpatient (Acute): exercise/activity goals
- initiate return of I w/ ADLs, typical 24 hours after pt. is stable, monitor activity tolerance
- combat neg.effects of bed rest: reduce clot risk, maintain muscle tone and joint mobility, reduce orthostatic hypotension
- help allay anxiety and depression
- provide medical surveillance
- provide pt. and family education
- promote risk factor modification
Inpatient (Acute): exercise/activity guidelines- program components
ADLs
selected UE and LE ther ex
early supervised ambulation
Inpatient (Acute): exercise/activity guidelines- intensity
Initial activity (2-3) METs progressing to 5 or less METs
Inpatient (Acute): exercise/activity guidelines- frequency & duration
short sessions 2-3 x day
gradually increase duration and decrease frequency
Inpatient (Acute): exercise/activity guidelines- post-MI
limited to 70% max HR and/or 5 METs until 6 weeks post-MI
Inpatient (Acute): exercise/activity guidelines- post surgical patients
- typically are progressed more rapidly than post-MI
- lifting activities restricted for usually 6 weeks
Inpatient (Acute): education goals
- understanding of cardiac disease, support risk factor modification
- self- monitoring procedures, warning signs of exertional intolerance, persistent dyspnea, anginal pain, dizziness
- energy cost and conservation techniques, fatigue monitoring, general activity guidelines, pacing, and HEP
- provide emotional support, may need to refer to LSW.
Inpatient (Acute): HEP
- gradual increase of ambulation time, goal is 20-30 min 1-2 x daily at 4-6 weeks post-MI
- UE and LE ther ex
- pt. should be able to self- monitor before performing HEP unsupervised
Absolute contraindication for inpatient or outpatient cardiac rehab
- acute MI (w/in 2 days)
- unstable Angina not previously stabilized by medical therapy
- uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
- acute PE or pulmonary infarction
- acute myocarditis or pericarditis
- acute aortic dissection
Relative contraindication for inpatient or outpatient cardiac rehab
- L main coronary stenosis
- Mod stenotic valvular heart disease
- Electrolyte abnormalities
- Severe arterial hypertension
- Tachyarrhythmias or bradyarrhythmias
- Hypertrophic cardiomypathy & other forms of outflow obstruction
- Mental or physical impairment leading to inability to exercise adequately
- High degree atrioventricular block
Stupid long list of possible effects of cardiac rehab
- Decreased HR (rest or activity), improved HR recovery after exercise
- Increased Stroke Volume
- Increased myocardial O2 supply and contractility, myocardial hypertrophy
- Improved respiratory capacity during exercise
- Improved fnctional capacity of exercising muscles
- Reduced body fat, increased lean body mass
- Decreased serum lipoproteins (cholesterol and stuff)
- Improved glucose tolerance
- Improved blood fibronolytic activity and coagulability
- Improved psychological status
- decreased angina in CAD patients
- Reduced total and cardiovascular mortality after MI
- Decreased symptoms of HF, improved L ventricle functional capacity
- Improved exercise tolerance and function in patients with cardiac transplantation
Outpatient Cardiac Rehab (sub-acute): eligible patients
- MI, ACS
- CABG
- PCI
- Stable Angina
- Heart valve repair or replacement
- Heart or heart/lung transplantation
- HF and PAD: not covered by insurance but pt. will benefit from supervised exercise program
Outpatient Cardiac Rehab (sub-acute): exercise/activity goals
- Improve functional capacity
- Progress to return of PLOF
- Promote risk factor modification/ life style changes
- Promote energy conservation, taking rest breaks
Outpatient Cardiac Rehab (sub-acute):what should be present in the clinic
- ECG monitoring
- trained personnel
- emergency support
Pts. weaned from continuous monitoring to spot checks to self-monitoring
Outpatient Cardiac Rehab (sub-acute): frequency and duration
2-3 x week
30-60 min w/ 5- min warm-up and cool down
Outpatient Cardiac Rehab (sub-acute): mode of exercise
- walking, cycling, Nu-step, combo of aerobic equipment
- circuit training
- strength training
Outpatient Cardiac Rehab (sub-acute): suggested exit point
- 9 MET functional capacity
- 5 MET capacity is needed for safe resumption of most daily activities
Outpatient Cardiac Rehab (sub-acute): Strength training in Phase 2 programs
- Guidelines: 3 weeks cardiac rehab, 5 weeks post-MI, 8 weeks post-CABG
- Begin w/ therabands and light weights (1-3 lbs.)
- Progress to mod loads, 12-15 comfortable reps
Outpatient Cardiac Rehab (sub-acute): still provide education?
Yup
Community Exercise Programs (Post-acute): exercise/activity goals
- improve/maintain functional capacity
- promote self-regulation of exercises
- promote life-long commitment to risk-factor modification
Community Exercise Programs (Post-acute): locations and eligibility criteria
- YMCA, community centers, clinical facilities
- functional capacity of 5 METs, clinically stable angina, medically controlled arrhythmias
Community Exercise Programs (Post-acute): Progression and discharge
- progress from supervised to self-regulation
- progress to 50-85% functional capacity, 3-4 x week, 45+ min a session
- regular medical check-ups and ETT generally required
- discharge typically 6-12 months
Resistance Exercise Training: goals
- improve muscle strength and endurance
- enhance functional independence
- decrease cardiac demands during daily activities
Resistance Exercise Training: patient criteria- post MI
permitted if pt. remain under 70% max HR or 5 METs for 6 weeks post-MI, be cautious of valsalva
Resistance Exercise Training: patient criteria- cardiac surgery
LE resistance training can be initiated immediately, in the absence of peri-operative MI. UE resistance training should be avoided until soft tissue and bony healing has occurred: 6-8 weeks
Resistance Exercise Training: patient criteria- Post PTCA
min of 3 weeks after procedure and 2 weeks of consistent participation in a supervised CR endurance training program
Resistance Exercise Training: patient criteria- no evidence available for people with___
CHF uncontrolled dysrhythmias severe valvular disease uncontrolled hypertension unstable symptoms
Resistance Exercise Training: general prescription
- start w/ low resistance, 10-15 reps, and progress slowly
- Resistance: 50%+ of 1 rep max, therabands, 1-5lb cuff or hand weights, wall pulleys
- RPE 11-13, but needs to be correlated to hemodynamic response
- RPP should not exceed what is used for endurance training
Ther Ex Rx for pts. w/ special considerations: HF- criteria
- General: pts. demonstrate sig. ventricular dysfunction, decreased CO, low functional capacities
- compensated or chronic HF, no signs of acute HF
- exercise-induced ischemia and arrhythmias poor prognostic indicators
Ther Ex Rx for pts. w/ special considerations: HF- monitoring at rest and during activity
- Use RPE in tandem w/ HR, BP, RR, SPO2 to assure good correlation and assessment of exercise tolerance
- HR response may be impaired (chronic incompetence)
- At risk for persistent post-exercise vasodilation (and hypotension) w/ later stages of HF
Ther Ex Rx for pts. w/ special considerations: HF- exercise prescription
- use low level, gradually progressive aerobic training
- begin w/ 40-60% functional capacity, increasing as able
- gradually increase durations, w/ frequent rest periods (interval training)
- adequate warm-up and cool-down, may need longer than typical 5-10 min
Ther Ex Rx for pts. w/ special considerations: HF- other general considerations
- use caution w/ supine or prone exercises due to orthopnea
- avoid breath holding and valsalva
- respiratory muscle training, monitor w/ pulse ox
- emphasize energy conservation and self-monitoring techniques
Ther Ex Rx for pts. w/ special considerations: Cardiac Transplant
Patients may present w/:
- exercise intolerance due to extended inactivity and deconditioning
- side effects from immunosuppressive drug therapy are hyperlipidemia, hypertension, obesity, diabetes, leg cramps.
