Exercise/Intervention with Cardio Flashcards
Considerations with exercise with angina pectoris
- Rate on angina scale
- if experience angina during activity…discontinue activity and rest in sitting or recumbent position
- Encourage them to take their meds as instructed
- If angina isn’t relieved by termination of activity or 3 nitros (1 every 5 mins) go to the ER
- Exercise THR for aerobic exercise should be > 10 beats/min below the know ischemic or anginal threshold
Cardiac Rehab (Phase 1) basics
- when pt is medically stable
- family education, self-care evaluation, continuous monitoring of vital signs, group discussions, and low- level exercise
- Average 3-5 days
Cardiac Rehab (Phase 1) when are they medically stable and when does exercise need to discontinue
- Medically stable to begin:
- No new or recurrent chest pain in 8 hours
- No new signs of uncompensated heart failure (no dyspnea at rest with B basilar crackles)
- No new significant, abnormal heart rhythm or ECG changes in 8 hours
- Stable creatine kinase and troponin levels
- Discontinue for the following:
- HR >130 bpm or > 30 b/m above resting HR
- DBP >110 mmHg
- Decrease in SBP >10 mmHg
- Significant ventricular or atrial dysrhythmias
- 2nd or 3rd degree heart block
- S&S including angina, marked dyspnea, and ECG changes suggesting of ischemia.
Cardiac Rehab (Phase 1) Active and Aerobic exercises
Active Exercise
. Active upper and lower extremity exercises may begin 24 hours after bypass graft surgery and two days after infarction.
. Active exercises progress from sitting to standing (1 - 4 METs).
. Upper extremity exercise should not stress the incisions of post-surgical patients.
Aerobic exercise
* Mode:
- Progressive, supervised level walking (2 - 3 METs) to walking up and down steps or treadmill walking (3 - 4 METs).
* Intensity:
- RPE < 13 (6-20 scale)
- Post infarction: heart rate < 120 beats/minute OR < 20 beats/minute above resting heart rate
- Post surgery: < 30 beats/minute above resting heart rate
* Duration:
- Intermittent bouts of three to five minutes, progressing to 10 to 15 minutes of continuous activity.
* Frequency:
- First three days: three to four times per day
- After three days: two times per day with increased duration
*Progression:
- Progress varies according to patient tolerance and risk stratification
- Activity may be progressed provided:
* Adequate increase in heart rate
*Adequate rise in systolic blood pressure
(10 - 40 mm Hg)
* No new dysrhythmias or ST changes on the ECG
* No cardiac symptoms are observed (e.g., palpitations, dyspnea, angina, excessive fatigue)
Cardiac Rehab (Phase I) Expected outcomes of inpatient cardiac rehabilitation
- Prevent the harmful physiological and psychological effects of bed rest during hospitalization
- Walk 5-10 mins continuously (1000 ft), 4x daily
- Walk down and up one flight of stair independently
- Know safe heart rate and RPE limits for exercise
- Recognize abnormal signs and symptoms suggesting intolerance to activity
- Promote a more rapid and safe return to activities of daily living within the limits imposed by their disease
- Prepare the patient and home support system to optimize recovery following discharge
Cardiac Rehab (Phase 2) what is included and how long it last?
- Outpatient
- prescribed exercise, cardiac risk factor modification, education, and counseling about diet and disease management.
- Can begin immediately after hospitalization and up to 12 weeks.
Cardiac Rehab (Phase 2) medical evaluation
An exercise test with ECG is recommended for patients entering an outpatient program, and as changes in the patient’s condition warrant, to assess:
• Heart rate and rhythm
•Signs and symptoms
• ST segment changes
•Exercise capacity
•Risk stratification
• Target heart rate for exercise
• Initial level of work for exercise
Before beginning formal physical activity, a physical examination of the patient should include:
• Medical history
• Cardiovascular disease risk profile
•Body mass index or waist-hip ratio
Resting ECG and blood pressure
• Auscultation of lung sounds
• Palpation and inspection of extremities for arterial pulses, edema, and skin integrity
• Examination of chest and leg wounds in patients after CABG or PTCA
• Orthopedic and neuromuscular status (e.g., ROM, strength, posture, balance, activities of daily living)
Cardiac Rehab (Phase 2) monitoring and safety
For low risk patients with known stable coronary artery disease, 6 to 12 sessions of ECG and BP monitoring and medical supervision are recommended to ascertain desirable exercise levels.
• For patients at moderate to high risk and/or unable to self-regulate or to understand recommended activity levels, continuous ECG and BP monitoring and medical supervision are recommended until safety is established, usually a 12 sessions.
Discontinue exercise for any of the following adverse
responses:
- Plateau or decrease in HR with increase in work
- SBP plateaus or falls with increase in work or > 250 mm Hg
- DBP > 115 mm Hg
- ST segment depression > 1 mm
- 2nd or 3rd degree heart block
- Ventricular dysrhythmias
- Angina or other symptoms of cardiovascular insufficiency
Cardiac Rehab (Phase 3/ Aerobic exercise) Mode
Rhythmic activities that use large muscle groups and can be performed continuously and safely (e.g., walking, hiking, running, jogging, bicycling, cross-country skiing, aerobic dance/calisthenics, rope skipping, rowing, skating, stair climbing, swimming, and various endurance game activities).
Cardiac Rehab (Phase 3/ Aerobic exercise) Intensity
Intensity can be prescribed based on heart rate, METs, and RPE
* Heart rate (HR)
- No stress tests: standing resting heart rate + 20 bpm may be used with caution.
- Percent of maximum heart rate (HRmax)
Lower and upper THR = HRmax × 55-90%
- Heart rate reserve (HRR) or Karvonen formula
Lower and upper THR = [(HRmax - HRrest) × 40%-85%] + HRrest
Cardiac Rehab (Phase 3/Aerobic exercise) RPE and Duration
Rating of perceived exertion (RPE)
* RPE is a useful guide for rating exercise intensity, especially when heart rate cannot be used to regulate intensity (e.g., after heart transplant, patients taking beta blockers, individuals who do not have an exercise test prior to entering cardiac rehabilitation, individuals who cannot feel their pulse, and for patients whose clinical status or medical therapy changes).
*RPE of 11 to 13 (“fairly light” to “somewhat hard”) is an appropriate upper limit during the initial phases of outpatient cardiac rehabilitation.
RPE of 14 to 16 may be appropriate for higher intensity training later in cardiac rehabilitation if there are no signs or symptoms of ischemia or serious dysrhythmias.
*RPE is specific to the mode of exercise.
Duration
* 15 to 20 minutes of continuous or intermittent exercise during the first month (initial training phase).
*25 to 30 minutes during the next three or four months (improvement stage).
* 40 minutes or longer after six months (maintenance phase).
* Interval training (exercise bouts of three to five minutes duration followed by equal rest periods) may be appropriate for patients who cannot exercise continuously.
Although both medical and nonmedical factors contribute to the decision to return to work after a cardiac event, the patient’s performance on a graded exercise test can help assess their prognosis. Which of the following average job demands would be the largest allowable to safely return to work?
1.25% of the peak METs achieved on the exercise test
2.50% of the peak METs achieved on the exercise test
3.75% of the peak METs achieved on the exercise test
4.100% of the peak METs achieved on the exercise test
50% of the peak METs achieved on the exercise test
- Most patients are considered to have the physical capacity to return to work if the average demand of their job is less than or equal to 50% of the peak METs achieved on an exercise test.
- Not necessary to be able to perform at 75% of the peak METs achieved on the exercise test to be able to return to most jobs. This would be too strict a requirement and would prevent some workers from returning to a job which they have the physical capacity to perform.
How to measure intensity of a pt receiving hemodiaylsis?
RPE.
Should work towards approx 20-30 min of low-level exercises using RPE
- HR is highly variable receiving HD due to fluid shifts
- BP will vary. HTN may exist prior to HD secondary to fluid retention and hypotension can exist immediate following (BP is also not a measure of exercise intensity)
UE vs LE exercise with cardiopulmonary
UE has a 30% greater hemodynamic response than the LE
- UE has more Type II fast twitch mm fibers (has less O2 consumption; more O2 demand/deficit)
- LE has more Type I slow twitch mm fibers (greater O2 consumption; less O2 deficit).
Cardiopulmonary Functions during the 3rd trimester
CO increase 30% to 60%
Oxygen consumption increase 15% to 20%
HR increase
RR does not change
