Final Study Guide Flashcards
Blood Pressure Guidelines
Normal: z120/z80
Prehypertension: 120-139/80-89
Hypertension Stage 1: 140-159/90-99
Hypertension Stage 2: >160/100
Hypertensive crisis! >180/110
Metabolic syndrome factors
3 out of 5
Waist circumference >35/40 TG > 150 HDL z40/50 BP >130/85 Glucose > 100
BP=
CO=
BP= COxTPR
CO= SVxBP
Cardiac Rehab STABLE parameters
- No episode chest pain last 8 hrs
- No sign uncomp HF: dysp at rest, bilat cracklers 1/2lung, hypotension
- No new ECG last 8hrs
- Speak comfortable and RR2L
- Central venous pressure z12mmHg
Basic Acute Tolerance to exercise Guidelines
HR 20-30-40 bpm above resting
No hypoactive BP response drop 10-20
No dysrhythmia/dyspnea
RPE 11-13 (3-5 light to somewhat hard)
Characteristics CHF
DYSPNEA/cough -paroxys, orthop, exercise S3 HEART SOUND Fatigue Exercise intolerance Periph edema -JVD -pitting
[[tachy, cold, pale, cyanotic extemities, weight gain, cracks]]
tubular sounds
NYHA Functional Classifications HF
Class 1
No limitation exercise, no symptoms with normal activity
-poor prognosis
Class 2
Slight limitation to exercise, symptoms with normal activity
-bad prognosis
Class 3
Marked limitation with exercise, symptoms with easy activity
-awful prognosis
Class 4
Inability to carry out activity w/out discomfort, sx at rest
-Terminal prognosis
ACC/AHA New Classification HF
A
At risk for HF without structural heart disease/sx
B
Structural disease without HF
-NYHA 1
C
Structural disease with prior/current HF sx
-NYHA 2/3
D
Refractory HF needing specialized interventions
-NYHA 4
CXR reason
Cheap/fast way
Look at abnormalities of heart/lungs
Blood Cell Count reason
RBC: O2 transport
Hemoglobin: oxygenation
Hematocrit: impedes blood flow-> chest pain, dizzy, SOB
WBC: infection response-> ex intol, fever, sweat
Platelets: clotting ability
Electrolyte reason
Sodium: fluid levels in body
Potassium: dysrythmia risk/cardiac evens
Calcium: due to renal insufficiency-> dysryth/muscle weakness
BUN/creatanine: shows kidney function
Cardiac Markers reason
Shows necrosis- releases enzymes when tissue death
Trop 1 in striated muscle
CK-MB: peaks 12-24hrs
Myoglobin: peaks 8-10
Troponin: peaks 12 hrs-> last up to 10 days
Echo reason
Heart function: valve function, motion of wall. EF
Heart anatomy: size ventricles, thickness of walls, valves
Vital Signs
BP HR via ECG Auscultations Temp RR Pulse ox (SpO2) RPE Pain
Sternal Precaution Risk Factors
Obesity Diabetes COPD Smoking Female big boobs Increase CP bypass Increase time on vent Limited functional capacity
Universal Sternal Precaution
Pain free ROM ASAP
- log roll bed mobil; avoid active curl up
- splint chest when coughing
- limit 10 (20) lb lifting; use bilateral
Common Medications
-olol: B blockers (arythmias, MI prevention, HTN) Digoxin: (heart failure) -prils: ACE inhib (CHF, HTN) Medtormin: anti-diabetic Statins (cholesterol) Heparin/Coum (anti-coag)
Angiogram reason
Percentage of occlusion in cardiac arteries
-CAD/MI risk
Cardiac Rehab Risk Stratisfication
HIGH: z5 Mets
- EFz40%
- survivor cardiac arrest
- complex vent dysrythmias
- abnormal hemodynamics with exercise
MOD: 5-7 METS
- EF 40-49%
- angina with mod exercise or in recovery
LOW: 7+ METS
- EF >50%
- absence of induced dystrythmias, uncomplicated ME
- normal hemodynamics with exercise
- no angina
ABSOLUTE Contraindication to exercise
Unstable angina
Active endocarditis
Uncontrolled cardiac arythmias w/ hemodynam compromise: VT, 3rd hb, New SVT, New brady,tachy
Severe/sx aortic stenosis
Decompensated symptomatic HF
Acute PE
SBP dropp more than 10
Sign/sx of exercise intolerance: angina, marked dyspnea, pallor, cyanosis
Relative Contraindications to exercise
Acute myo/pericarditis
Left main coronary artery stenosis
Mod steontic valvular disease
Electrolyte abnormal
New brady,tachy without compromise
Afib with uncontrolled vent rate
Resting BP 200/110
RPE 15+
Uncontrolled diabetes Glucose 400+
Post-Op Intervention
Mobilize: graviatational stress
Establish cough: prevent aspiration, increase ventilation
Ventilate: improve inspiratory capacity
Ambulate: increase FRC
Phase 1 Cardiac Rehab
POD 1: 1-2 METs
- UE/LE warm upo
- OOB to chair
POD 2: 2-3 METs
- UE/LE warm up
- Ambulate/gait
POD 3-5: up to 3-4 METs
- ambulate 5-10 min 2-4x/day
- 1-2 flights stairs
When to treat a DVT?
Above knee-> give medication
Below knee->
PE/severe cardiopul compromise? -> meds
DVT with risk limb loss? -> meds
If no->
Active/high bleed risk? -> meds
If no->
Treat!!! compression, early ambulation, meds
With coumadin if proper renal sufficiency
VTE tests
Wells prediction rule
Canadian Probability model
D-dimer if prediction rule says
Venous US
Computed tomography
Canadian Probability of DVT
Cancer Paralysis Surgery z4 weeks Thigh swelling Tendernous Edema
3+ points= assume DVT and treat with anticoags
Wells Prediction Rule for PE
Sx of DVT Pulse 100+ 4 weeks immob or surgery Previous DVT/PE Hemoptysis Malignancy
High risk 6+= 78% PE
Mod risk 2-6= 28% PE
Low risk 0-1= 3% PE
Heparin/Anticoag Side-effects
Bleeding
Hemorrage
Thrombocytopenia: life threatening increase platelet ag
-starts 5-10 days aftery start meds
– look for decrease platelet count 30-50%
Look for: new pain, discomfort Joint swelling Bruising Falls
Aerobic fitness based off MET levels
Low z7.9 -> higher rates mortality/CAD
Intermed: 7.9-10.8
High: 10.8+
Fall RIsk Stratification
Fall history 8
Live alone 3
Female 3
4+ meds 3
0-4= low risk 5-10= mod risk 11-16= high risk
Life space mobility assesment
bedroom home outside home neighborhood town further
points off of how often and if need help
z60= high risk for disability/ deacreased aerobic capacity
Duke Activity Status Index
measures FUNCTIONAL CAPACITY
12 y or no
-estimates VO2 peak
To maintain Independence:
Males: 18+ Vo2= 5.14 METS
Females: 15+ Vo2= 4.3 METS
SPPB Components
Balance:
side-side >10s= 1 point
semi-tand >10s= 1 point
tandem >10s= 2 points/ 3-9=1 point
Gait Speed:
4M no ramp up best of 2
Up to 4 points based off time
FTSS:
Pre-test first; Repeat 5 times with arms crossed
Up to 4 points based on time
>15 seconds= INCREASED FALL RISKx2
SPPB Rresults
0-3= severe limitations 4-6= moderate limitations 7-9= mild limitations 10-12= minimal limitations
0-4 5x increase risk Re-hosp/death
5-7 2.5x increase risk Reposh/death
MCID 1 point = 14% less risk
Walking Speed stratification
z0.4 m/s longer stays/nursing home or rehab discharge
z0.6 m/s risk hospitalization/falls/dependant in ADLs
>1 m/s dependant ADLS/no risk of falls
Disability factors: cognition, depression, gait speed
Hemodynamic Stability
Stable last 24 hrs
ACS/myopathy
Sepsis
Casopressors
Cause of compromise
EF
Fluid imbalance
Hemodynamic Values
Pulmonary artery pressure: 10-20
Central venous pressure: 2-8
Mixed venous sat: 60-80%
CO 5-7
Respiratory Stability
Oxygen therapy?
- increased over 8 hrs?
Respiratory reserve ratio (PaO2/FiO2)
> 300 to mobilize
-Shows arterial blood oxygenation
SpO2
>90
-STOP 6MWT if under 85
-PaO2 decreases to 60 means at risk for rapid decline in saturation
ABGs
ph 7.35-7.45
pCO2 35-45 (shows alveolar ventilation)
pO2 80-100 (z60= rapid dissociation)
Bicarb 22-26
Primary/Compensatory Acidocis/Alkalosis
LOW pH: Acidemia
if High PCO2-> respiratory acidosis (comp met alk)
-hypoventilating
if Low HCO3 -> metabolic acidosis (comp resp alk)
HIGH pH: Alkalemia
if Low PCO2-> respiratory alkalosis (comp met ac)
-hyperventilating
if High HCO3-> met alkalosis (comp resp aci)
Hypoxemia PO2
80-100 normal
60-80= mild
40-60= mod
z40= severe hypoxemia
AFib controlled vs. uncontrolled
Vent response less than 100= controlled if no symtoms
>100 response= fast/uncontrolled with symptoms
Activity MET guideline Phase 1
1-2 METS (day 1):
urinating, sitting, small exercises in bed
2-3 METS (day 2):
bathing, walking short bouts, UE/LE exercises
3-4 METS (day 3-5):
gait, stairs
MET level Exercise Frequency
3 METS: 2-3x/day
-walking, stationary bike no resistance
3-5 METS: 1-2x/day
-walking, biking, stairs
5-7 METS: 3-5x/week for 20-30 min
-walking, bike, jog
> 7 METS: 5-7x/week for 30-40 min
-anything :)
Interventions for Ventilatory Pump Dysfunction
UPRIGHT and MOVING!
Positioning/mobility Correct biomech impairments Breathing inhibition accessory muscle Facilitated breathing: pursed lips, diaphragm, sniff, segmental Clearance techniques Supplemental oxygen Exercise retraining
Gas Flow Rate Tests
Function of lungs, degree of impairment, and location of problem
- Obstructive: larger capacities
- Restrictive: smaller capacities
FVC: forced vital
-max amount gas patient exhale quickly
FEV1: forced expir in 1 second
- exhaled during 1st second FVC
- shows airflow in larger airways
FEV1/FVC: % vital capacity expired in 1 s
Hallmark signs COPD
4 risk factors: cigarret smoking >40 y.o. exposure to chemicals exposure to pollutants
SOB with phlegm couch/wheezing episodes
- previous diagnosis of bronchitis, asthma, emphysema
- increased wheezes or chest tightness
- brown sputum production
- episodic deterioration
- increasing limitations in ADL
Look cakectic (red small) or cyanotic (blue puffer)
FEV1 Measurements with Obstruction
Staging of COPD based on FEV1
Little/non: >2 L to normal
Mild-mod: 1-2
Severe: z1L
Staging:
I: 50-79% predicted
II: 35-49% predicted
III: z35% predicted
–present with high RR, wheezes, barrel chest, lower SpO2, accessory muscle use, dyspnea, and functional limitations
Global Initiative for COPD (GOLD)
Symptom based- management, treatment, and impact
Stage I: Mild
smoker cough, little SOB, no clinical signs
FEV1 >80%
Stage II: Mod
SOB on exertion, sputum produced, some clinical signs
FEV1 50-80%
Stage III: Severe
SOB on mild exertion
FEV1 30-50% predicted
Stage IV: Very severe
SOB on mild exertion, RCHF, cyanosis
FEV1 30% predicted
FEV1 and Mortality
z30% FEV1 predicted = 50% change dying in 2 years
z55% FEV1 showed half of those below died within 5 years
>55% FEV1 96% survived
BODE Index
Assess risk of death from COPD using weight, obstruction, dyspnea, and exercise capacity
- BMI
- FEV1
- dyspnea score
- 6MWT
4 year survival: 0-2 points= 80% survival 3-4= 67% survival 5-6= 57% survival 7-10%= 18% survival
5 Causes of Hypoxemia
Decreased inspired oxygen Hypoventilation Alveolocapillary diffusion problem V/Q mismatch Shunting (perfusion without vent)
4 Breathing Strategies for increased ventilation
Diaphragm:
- reduce accessory pattern/improve efficiency
- do it first :)
Pursed-lip:
- increases positive pressure in airways/promotes effective expiration
- prevents small bronchioles from collapsing
- reduces FRC
Segmental:
-localized expansion to specific area
Sustained max inspir:
- visual/audio feedback
- prophylaxis/treatment of atelectasis
Key pediatric Subjective
Birth history
Developmental history
Favorites/interests
Learning preference
Involve family
Oncologic Hematologic Guidelins
Hematocrit:
- Normal: 38-47%
- No exercise z25%
Hemoglobin:
- Normal: 12-16.9
- No exercise z8
- Resistive ex >10
- Anemia at 10; symptoms at 8-10; still PT but monitor symptoms
Platelets
- Normal: 200-400k
- No exercise: z5k
- Resistance ex > 50k
WBC
- Normal: 4-10k
- No exercise: z500
Absolute granulocyte
- High risk infection: z500
- Predisposed risk: z1500
- Protected: >1500
Oncology and Electrolytes
Sodium: z130 no exercise
Potassium: high or low still exercise; be aware possible muscle weakness
Calcium: Hyper causes weakness; still exercise- ambulation prevents further calcium loss
Thrombocytopenia Clinical Exercise Guidelines
Platelet normal 150-400k
50-150: PRE, walking, biking no grade
ALL below 50k at risk for bleed!
30-50: AROM, walking, aquatics, bike
20-30k: light AROM, walking
z20K: minimal AROM, ADL as tolerated
Hemoglobin Oncology Guidelines
Hemoglobin:
- Normal: 12-16.9
- No exercise z8
- Resistive ex >10
- Anemia at 10; symptoms at 8-10; still PT but monitor symptoms
Ex Intol Symptoms: tachy decreased DBP dyspnea on exertion gait disturbances patesthesia pallor angina
Neutropenia Oncology
Normal WBC 4.8-10.8k
5k: light exercise with progression as tolerated
z5k with fever: None
z1k: protective match/no activity
Guidelines:
Wear mask
No fresh produce/flowers
No contact with kids, URI people, big environment
Exercise Contraindication Oncology
Irregular pulse; resting >100 Recurring leg pain/cramps Chest pain/SOB Acute nausea Disorientation/confusion Bone, back, neck pain not relieved with rest Fever Unusual fatigue/weakness
Cancer Related Fatigue Intervention
Manage contributing factors: blood counts, nutrition, sleeping
Energy conservatioin techniques
Short bouts exercise
Schedule exercise around high energy time
Aerobic and strength training
Excercise Treatment Goals Oncology
First 3 months post treatment: 40-65% HR max Post-3 months: 65-80% 6 months post: above 80%
30-40 min aerobic 3x/day
2 day/week resistance
2-6 min intervals with 1-2 min rest 2-3x/day initially
RPE 11-14
No angina, exertional dyspnea
Breast Cancer Interventions
STM: skin, scar, fibrosis Mobs: grade II or III ROM Strengthening: decreases fibrosis Cores stability Neuromusc
NO heat or manips
Key Subjective Lymphedema
Where/when did swelling first start? Oncolog prox to dist
Better with elevation/exercise?
SINS of swelling
History of heart, kidney, liver disease
History of injections? Risk due to stagnant fluid
History blood clots? Probs with veins or arteries
Med changes recently?
Purpose of MLD
Stimulate superficial vessels Create negative pressure gradient Stimulate lymph-angion contraction Promote reobsorption of protein molecules Promote mvnt to healthy quadrant
MLD Contraindications
Untreated acute infections Undiagnosed malignancies Uncontrolled CHF Recend PE Acute TB, Renal failure, DVT
Purpose of Compression therapy
Increasing pressure/mechanical force on body part
Reduces edema, improves circulation, and remodels scar tissue
Pressure= tension/diameter
Compression Contraindications
ABI 0.6-0.8 without MD consent/z0.6 Untreated CHF, pulmonary edema Kidney disease Obstructed lymph nodes Infection Fractures Arterial insufficiency Undiagnosed blood clots
Compression Pressure Guidelins
20-30
varicose veins, DVT, mild edema, leg fatigue, lymphedema
30-40
severe varicose, mod CVI, lipidema, lymphedema (with or without CVI)
40-50->60
Severe CVI, lipidema lymphedema, lymph with CVI
Stages of lymphedema
0- latency
Reabsorption less than filtration but not symtoms
Stage 1 Disapears with bed rest/elevation Soft pitting with minimal resistance to pitting No stemmer Small protein accumulation
Stage 2 Protein rich edema No decrease at night/elevation CT/scar formation, becomes hard Non-pitting edema with normal pressure Positive Stemmer
Stage 3 CT/scar proliferation Hardening of dermal tissue Significant increase fibrosis Difficult to pit, refils RAPIDLY Fat deposits at joint sulci Thick protein tissue with collagen Positive stemmer
ABI Result interpretation
> 1.3 not reliable measure
seen in diabetes/arthosclerosis patients; use great toe pressure (normal >55mmhg; TBI 0.8-0.99 normal)
1-1.2 normal
- 8-1 minimal arterial disease; compression safe
- 6-0.8 Moderate arterial disease; possible intermitant claudication refer to MD for compression
z0. 6 severe ischemia with resting pain NO compression
HbA1C Risk levels
4-6 (60-125bg) : normal/no risk 6-7 (125-155): some risk 7-8.4 (155-195): monitor closely/take action 8.5-10 (195-250): elevated/take action 10.5+ (z250): seriously elevated
Blood Glucose Control Levels
Pre-diabetes Impaired fasting glucose: 110-126
Diagnosis diabetes fasting: >126
Wound healing needs z200
Hb1Ac 6.5+ diagnose diabetes!!
Diabetes Contraindication to Exercise
Active retinal Hemorrage/recent retinotherapy
Illness or infection
Glucose >250 and ketones present
Glucose z70- hypoglycemic risk
Skin Surface temps and wounds
4+ compared to other foot= potential for ulceration (Charcot)– restrict activity
Periwound temp 3+ other= infection
Deep Compartment Wound
Size increasing Temperature Osteomy New wound Erythmia Edema Smell
3 or more= systemic therapy
Superficial Compartment Wound
Nonhealing Exudate Redness Debris Smell
3 or more= treat topical
Post-Op Amputation Protocol
24-48hrs sterile dressings
Once epithelial dressings optional
Healing ridge by day 5
Bed rest 7-10 days depending on surgeon/healing
Focus on uninvolved extremities
Reasons for compression Post-amputation
Control edema
Shape residual limb
Pain control
