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Cardiopulmonary Exam #2 > Hillegass Study Guide Material > Flashcards

Hillegass Study Guide Material Flashcards

1
Q

What is different about HR/BP responses in a normal patient vs one with an LVAD?

A

Normal Patient: palpable HR and BP

LVAD patient: NO palpable HR, NO systolic or diastolic blood pressure. ONLY have mean arterial pressure which is normally 60-90 mmHg (use doppler probe and syphygmomanometer)

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2
Q

Can you increase strength and aerobic power in patients with LVAD?

A

Yes

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3
Q

T/F LVAD patients are not at a higher risk of bleeding, clots and stroke.

A

False

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4
Q

Name the 3 categories of immunosupressants used for heart transplant

A

1) Antimetabolites
2) Antiproliferatives
3) Steroids

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5
Q

Describe effects/side effects of Category 1: antimetabolite immunosuppressant drugs used for heart transplant.

A

Effects: prevent creation of T & B immune cells (ex: azathioprine, cell cept, rapamycin)

Side effects:

  • azathioprine-low WBC count, bone marrow supression, liver issues
  • cell cept- nausea, diarrhea, low WBC
  • rapamysin (RAD)- low WBC, high cholesterol, high triglycerides, low platelets, nausea
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6
Q

Describe effects/side effects of Category 2: antiproliferative immunosuppressant drugs used for heart transplant.

A

Effects: inhibit expansion of cell lines that modulate rejection (cyclosporine, tacrolimus)

Side effects:

  • Cyclosporine: kidney problems, headache, tremor, high potassium, photosensitivity, gum thickening, hair growth
  • Tacrolimus (prograf/FK506): kidney problems, high potassium, seizures, headache, tremor, high BP
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7
Q

Describe effects/side effects of Category 3: steroid immunosuppressant drugs used for heart transplant.

A

Effects: prevents expansion of cell lines modulating rejection (prednisone)

Side effects:
-Prednisone- round face, DM, bone weakening, obesity, m weakness, cataracts, mood swing, increased cholesterol (ANTICIPATE WEAKNESS TO PREVENT LOSS)

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8
Q

In general name the 3 ways that immunosuppressants reduce tissue rejection and list 5 side effects.

A

1) bind w/ DNA
2) limit DNA and RNA synthesis
3) inhibit IL-2 cytokines

Side effects:

  • renal damage
  • cancer
  • HTN
  • high cholesterol
  • high triglycerides
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9
Q

Name 4 signs of heart transplant rejection

A

1) weakness
2) fatigue
3) fever
4) decreased exercise tolerance

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10
Q

List some PT implications when working with patients with LVAD/heart transplant who are on heart transplant medications

A
  • prior LVAD: can lead to increased risk for infection, clotting, bleeding
  • immobilze LVAD w/ abdominal binder
  • hemodynamic/vital monitoring is necessary
  • aware of infection and rejection signs
  • sternal precautions
  • wound management
  • pulmonary impairments may result
  • wear protective garmets due to immunosupression
  • proximal m weakness
  • decreased endurance
  • post heart transplant they will have increased HR due to cut vagus inhibition so use BORG/RPE
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11
Q

What effect does diabetes have on a patient with shoulder issues?

A

A diabetic with a cardiac history has previous surgeries that could have limited ROM in the shoulder initially. The elevated blood glucose can lead to adhesive capsulitis with decreased ROM and pain.

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12
Q

How does diabetes affect your exercise prescription for a patient with shoulder issues (ie frozen shoulder)?

A

Make sure their blood sugar is within range and not too low when you start exercise because exercise will only decrease it more. Always be assessing sensation as well

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13
Q

Compare and contrast a pacemaker and an AICD.

A

AICD: automatic implantable cardiac defibrillator used to DETECT/CORRECT LIFE THREATENING ARRHYTHMIAS (couplet, triplet or vtach), these are picked up with a Holter monitor. Indicated for LVEF <35%, NYHA class II, III, etc. Patient may experience minor shock when they fire and be careful with electromagnetic interference!!

Pacemaker: sends electrical signal when heart activity is slowed/absent, SENSES CARDIAC ELECTRIC POTENTIALS, SA (brady)/AV disorders. Be careful with electromagnetic interference!!

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14
Q

How do you develop an exercise prescription from an exercise test?

A

-monitor vitals, BORG, RPE, change in symptoms at all times
-If you get a max heart rate from a thalium stress test of 136 bpm then use that as their max HR when determining Karvonen method:
((220-age) -RHR) x training intensity %) + Rest HR = Training HR (NOTE: 40-60% FOR CARDIAC ISSUES, 60-80% EVERYONE ELSE)

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15
Q

What is the national coverage determination for cardiac rehab?

A

Must have a supervising physician and meed medial requirements for cardiac rehab. (NOTE PT CAN WORK WITH CR PATIENTS BUT IT HAS TO BE FOR PT RELATED IMPAIRMENTS OTHER THAN CARDIAC SPECIFIC ISSUES)

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16
Q

What are diagnoses covered for cardiac rehab?

A
  • MI in the last 12 months
  • CABG surgery
  • stable angina
  • percutaneous transluminal coronary angioplasty
  • heart valve repair or replacement surgery
  • heart transplant
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17
Q

How much is covered for cardiac rehab? intensive cardiac rehab?

A

36 sessions covered under Medicare if they show medical need
-limited to 2 one hour sessions per day max

72 one hour sessions over a period of 18 weeks

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18
Q

What are components of cardiac rehab?

A
  • Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished.
  • Cardiac risk factor modification, including education, counseling, and behavioral intervention, tailored to the patients’ individual needs.
  • Psychosocial assessment.
  • Outcomes assessment.
  • An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician every 30 days.
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19
Q

What are outcomes of cardiac rehab?

A
  • improved exercise tolerance
  • control sxs
  • improve blood lipid levels
  • decreased body weight
  • decreased BP
  • reduction in smoking
  • psychological well being
  • reduction of stress
  • return to work
  • reduced mortality
  • reduce return to hospital
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20
Q

How many lung lobes are there are on the right and left and where are they located?

A

Right (3 lobes)

  • upper=front
  • middle=front lower
  • lower=low lateral/posterior

Left (2 lobes)

  • upper=front
  • lower=low lateral/posterior
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21
Q

What is the ventilation equation?

A

Minute ventilation=Tidal volume x Respiration rate

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22
Q

What happens to ventilation when there is decreased volume?

A

When the volume decreases the respiration rate will increase to make up for it

23
Q

Compare and contrast restrictive and obstructive lung diseases?

A

Restrictive: trouble getting air IN (atelactasis, scoliosis, decreased lung volume). Some exercises would be incentive spirometry, posture, exercise, hold deep breaths.

Obstructive: trouble getting air OUT (COPD: barrel chest, emphysema, asthma ). Some exercises would be smell the roses, blow the candles, breathe out with pursed lips.

24
Q

How would PFT (pulmonary function tests) differ between restrictive and obstructive diseases?

A

Restrictive: low static lung volumes, low TLC, low IRV, low ERV, low RV. SEE GRAPH FEV1/FVC>70, FEV1<80%

25
Q

How would ABGs (arterial blood gases) differ between restrictive and obstructive diseases?

A

Restrictive: Hypoxema, tachypenea is a compensatory measure leading to decrease in PaCO2 (hypocapnia)

Obstructive: increased resistance, increased air retention, low alveolar O2, high alveolar CO2, decreased PaO2 (hypoxemia) and increased PaCO2 (hypercapnia)

26
Q

How would diagnostic tests (CXR etc) differ between restrictive and obstructive diseases?

A

Restrictive: Scoliosis, pregnancy or obesity pushing up on the lungs, infiltrates, fluid, tumor etc

Obstructive: Barrel chest with flattened rib angles, flattened diaphragm, hyperinflation

27
Q

How would symptoms differ with restrictive and obstructive diseases?

A

Restrictive: difficulty breathing in, difficulty breathing at rest

Obstructive: difficult breathing out, difficulty breathing with exercise

28
Q

What are some diagnostic tests for pneumonia?

A
  • CXR: infiltrates mean infection

- Lung auscultation: bronchial breath sounds mean consolidation in the lobe BELOW. No sound means consolidation

29
Q

For an assessment of pneumonia what kind of things would you want to check?

A

B excursion, exhalation time, symmetry, use of secondary muscles, chest expansion, dull percussion where fluid exists, sputum amount, sputum color, auscultation, breath sounds, percussion, CXR, 6 MWT, BORG, PaO2, SpO2, fever

30
Q

What are symptoms of pre-pneumonia?

A

cold/flu-like symptoms

31
Q

What are symptoms of acute pneumonia?

A

Develops quickly and lasts less than 3 weeks (“walking” if mild)

Bacterial: upper respiratory infection, flu, coldlike, cough, fever, shaking, fatigue, SOB, productive cough

Viral: fever, cough, SOB, non productive cough

32
Q

What are symptoms of post pneumonia?

A

breathing issues, fatigue

33
Q

How do you measure HR with a 6 second ECG strip? without 6 second ECG strip?

A

6 second strip: count big boxes between R-R and divide 300 by that #. (1 small box=3bpm). If different then average two.

Without 6 second strip: count for a minute

34
Q

Describe normal sinus rhythm

A

-p wave before QRS
-PR interval less than 5 small boxes
-QRS less than 2.5 small boxes
-R-R are equidistant
-Rate is between 60-100
(BENIGN)

35
Q

Describe atrial fibrillation

A

NO P WAVE, IRREGULAR RATE, IRREGULAR RHYTHM, SV is decreased 20%,

  • Controlled: less than 100 bpm (BENIGN)
  • Uncontrolled: greater than 100 (SERIOUS if HR above 120)
36
Q

Describe supraventricular/junctional tachycardia

A

NO P WAVE, normal QRS, conduction is from AV NODE

SERIOUS DUE TO HEART RATE

37
Q

Describe PVCs

A

WIDE QRS (3+ small boxes), NO P WAVE,

(BENIGN IF LESS THAN 6/MINUTE, SERIOUS IF MORE THAN 6/MINUTE)

(SERIOUS IF COUPLED OR TRIPLED)

38
Q

Describe VTACH or ventricular tachycardia

A

MORE THAN 6 PVCS/MIN, FAST, NO P WAVE, WIDE QRS, CO=10%

SERIOUS!! CAN LEAD TO V FIB

39
Q

What are problems with working with patients in the ICU?

A

medications, deconditioning, weakness, medical instability, IV lines, tubes, ECG, risk factors, other diseases

40
Q

What are the results of decreased activity during hospitalization?

A

decreased functional capacity (increase HR, decreased strength) leading to increased cost, increase LOS, wounds, DVT, delirium, depression

41
Q

What systems are affected by decreased activity during hospitalization?

A

CV, Pulm, MS, Renal, Integ, GI, Metabolic, Psych

42
Q

What are adverse CV effects of inactivity?

A

elevated HR, decreased SV, decreased LVEDV, orthostatic hypotension, decreased RBC mass, decreased total blood volume, venous stasis, DVT risk

43
Q

What are adverse pulmonary effects of inactivity?

A

increased resistance/work, decreased intake volume/ciliary function, increased RR

44
Q

What are adverse musculoskeletal effects of inactivity?

A

atrophy of type 1 fibers, atrophy, altered electrical activity, decreased strength/flexibility, DECREASED OSTEOBLAST, INCREASED OSTEOCLAST, stasis of synovium, ankylosis

45
Q

What are some other adverse effects of inactivity?

A

-skin breakdown
-psychological problems
-urinary problems
-bowel problems
-sleep deprivation
-sensory problems
-

46
Q

What is mobility?

A

ability to move (ambulate, limb mvmt, rolling, sitting, stand, transfer)

47
Q

What precludes initiation of early mobility?

A
  • HR too high
  • HR too low
  • standing orders
  • O2 above 90
  • Pain
  • Lab values
  • Unresponsive

need to monitor these things

48
Q

What are some early activity requirements?

A

-Neurologic criteria: patient responds to verbal stimulation
-Respiratory criteria: FiO2 (fraction of inspiration of oxygen) no greater than 0.6 (60%) and PEEP (positive end expiratory pressure) <10 cm H20
PEEP- the back pressure into lungs to keep alveoli open, normal is 5 cm of water, allows greater gas exchange (NOTE: patients who don’t have normal PEEP, their air sac shut down and poor gas exchange occurs. These patients need to perform pursed lips, which causes a back pressure during exhalation to keep air sacs inflated)
-Circulatory criteria: absence of orthostatic hypotension and catecholamine drips

49
Q

List the 18 indicating factors for lack of readiness for early mobility.

A 
○	—Pulmonary Measures
—SpO2 < 88% or 10% desat below rest
—RR  > 35  breaths/min
—PEEP >10 cm H2O
—FiO2 > 0.59
—Cardiovascular Measures
—MAP 120 mmHg or > 10 lower than NL--LVAD
—RHR 140 bpm
—Systolic BP 200 mm Hg
—New arrhythmia developed
—New onset angina like chest pain
—Laboratory Values
—HCT < 8 g/dL   NO exercise , may want to limit exercise, Dr. Hillegass doesnt agree with NO EXERCISE
—Platelets < 20,000/mm3  NO exercise
—Anticoagulation  INR .>2.5-3.0  discuss with physician
—Metabolic Measures
—Glucose levels < 70 or > 200 mg/dL
50
Q

What are some outcomes for early mobility

A 
–	Days to first out of bed
–	Ventilator days
–	ICU LOS days
–	Hospital LOS days
–	Total direct inpatient costs
–	Avg cost per patient
–	Sit to Stand
–	Respiratory rate with activity
–	Need for other surgeries and procedures
51
Q

What are some contraindications for early mobility?

A 
—Significant change in resting ECG
—Unstable angina
—Uncontrolled cardiac arrhythmias, severe
—Uncontrolled symptomatic heart failure
—Suspected or known dissecting aneurysm
—Uncontrolled active bleeding
—Acute respiratory failure
—ACUTE PULMONARY EMBOLUS: NOT ON ANTICOAGULANTS
—Acute neurological changes
—Severe combativeness
—Acute, unstable fracture
—Acute untreated compartment syndrome
too much sedation, neuro changes
52
Q

What are some yellow and red flags for early mobility?

A

– impaired cognition
– PA catheter in place
– IABP in place
– Excessive PEEP (>10 cm) or >60 % FiO2 on venilator setting
– life threatening arrhythmias and no ICD in place
– SPO2 100 at rest)
– increase in HR with decrease systolic BP during activity
– Drop in SPO2 ( <88%) with activity and with an increase in HR and/or increase in RR
– symptoms of angina

53
Q

Which lines/tubes are contraindications to mobility? Ex: arterial line, central venous pressure line, femoral line, permanent pacemakers, chest tube drain, pulmonary artery catheter, transtracheal O2, LVAD, hemodialysis, IABP, intracranial monitoring

A

-arterial line (in wrist/forearm)= no WB on that arm, no extension on that arm, platform on that side with walker
-Central venous pressure line- no contraindication just for having this, MEDICAL STABILITY IS THE CONTRAINDICATION.
-Femoral Lines-CANT DO MORE THAN 70 DEGREES HIP FLEXION, more than 90 would kink it off, have straight leg, WB in contralateral and higher seat
-Permanent Pacemaker/ ICD=can mobilize
-Chest tube drain= can mobilize patient, with medical stability
-catheter into chest wall= do not unattach.
-pulmonary artery catheter=
can mobilize, as long as patient is stable
-Transtracheal oxygen:
-LVAD-able to mobilize
-Hemodialysis= able to mobilize if in jugular and subclavian NOT in femoral
-IABP- no WB on LE if femoral is used
-Intracranial pressure monitoring

Cardiopulmonary Exam #2 (1 decks)

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