Lecture 11: CV Rehab Management Pt. 1 Flashcards

1
Q

describe activity tolerance of pts with CV dysfunction and APTA recommendations

A

poor activity tolerance and physical inactivity = increased risk mortality

decreased walking/standing tolerance; inability to perform ADLs

APTA recommends increased physical activity by increase in total activity, number of steps, and total time out of bed

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2
Q

ASCM/AHA/CDC guidelines for activity

A

150-300 min/week of moderate intensity aerobic exercise

OR

75-150 min/week vigorous exercise throughout week

moderate intensity strength at least 2 days/week

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3
Q

what does research say about activity tolerance for CV pts

A

variety of literature on when and how much activity

most research is only on exercise with treadmill/cycle

poor definition of parameters

may have to look at similar but not exact diagnoses

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4
Q

ASCM guidelines for older adults

A

when older adults cannot do >150 of moderate aerobic activity due to chronic conditions, they should be as physically active as their abilities/conditions allow

perform balance training in addition to aerobic and strength

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5
Q

strength training considerations for pts with CV dysfunction

A

ACSM/AHA recommends 10-15 reps of RPE 11-13/4-6

slower progression of exercise weights and reps

lower 1RM

decreased resistance tolerance with these pts

limited research on resistance training post op CV pts due to beliefs about sternal precautions

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6
Q

known benefits of strength training

A

decreased insulin resistance

SVR

BP

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7
Q

CABG ACSM guidelines on resistance training

A

wait 4-8 weeks

start low weight high reps

12 weeks or more until higher weight is added

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8
Q

PCI/stent ACSM guidelines for resistance training

A

wait 2-5 weeks

gradual increase in weight

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9
Q

valve repair/replacement resistance training guidelines

A

wait 4-8 weeks

start with low weight and high reps

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10
Q

MI resistance training guidelines

A

wait 3-4 weeks

start <30-40% 1RM

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11
Q

HF guidelines on resistance training

A

wait 3-4 weeks post event

start with 8-10 reps of low weight

gradual increase in resistance based on symptom response

focus on weight for pt to perform high reps

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12
Q

guidelines for addressing ROM limits in pts with CV dysfunction

A

if pt has prolonged sx precautions they may present with decreased ROM that can affect chest wall movement and posture

pain free ROM beneficial post sternotomy, especially unilateral, to prevent adhesions during healing

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13
Q

things to keep in mind when addressing balance impairments with pts with CV dysfunction

A

take neuropathy or PVD into consideration; how will it affect balance

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14
Q

implications of cognitive impairments in pts with CVD

A

1/3 pts with CVD present with some type of cognitive impairment

potential causes:
- hypotension
- alterations in CO affecting cerebral hypo perfusion
- micro emboli
- O2 desaturation
- cardiopulmonary bypass “pump head”

implications = ability to follow instructions for rehab/precautions, med compliance, performing ADLs, and qualification for post acute rehab

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15
Q

% of pts with HF with mild cognitive impairments (MOCA scores 17-25)

A

74%

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16
Q

interventions for CVD pts with cognitive deficits

A

family involvement
frequent reorientation
healthy sleep/wake cycle
structured schedule
increased mobility and ADLs

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17
Q

things to keep in mind regarding pain with CV pts

A

intercostals = highly innervated; pain very common with chest sx

post op lines = irritate parietal pleural

LE vein graft site can be very bruised/swollen

sx positioning can cause neck/shoulder pain

post op pain has major effects on respiratory function

higher pain levels = stimulate SNS

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18
Q

what does SNS activation look like in pts with higher pain levels

A

decreased peripheral autonomic function (i.e. GI tract)

increased stress hormone release

decreased immune function

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19
Q

barriers to CV rehab

A

baseline functional capacity, disability, or frailty

poor exercise tolerance

decreased knowledge of condition, poor health literacy

poor medical compliance

frequent hospitalization

QOL, depression

lack of resources or access to resources

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20
Q

implications of HTN meds

A

more HTN meds pt is on, the more you need to be aware of side effects

context is important

anti-HTN meds lower resting BP but might now have the same effectiveness during exercise or isometric activities

21
Q

pharm implication of thiazides and loop diuretics

A

higher risk of hypokalemia

mm cramps/fatigue

ST depression

GI slowing

22
Q

K-sparing diuretics and BB pharm implications

A

higher risk of hyperkalemia

mm weakness/paralysis, hypotension, bradycardia, ventricular arrhythmias, ST elevations

only intervention for critically elevated K is emergent dialysis

23
Q

how much of a reduced exercise capacity do pts with HTN have

A

15-30% reduction in exercise capacity

watch for exaggerated response to exercise even if on anti-HTN meds

24
Q

APTA rec for monitoring BP

A

monitor BP in pts >35 with HTN risk factors in any setting

25
Q

things to look out for during rehab with pts who have HTN

A

watch for hypotension with position changes, post exercise, long term standing tasks, or in hot/warm environments

avoid valsalva

focus on low weight, high reps for strength

26
Q

medication implications for patients with Hyperlipidemia (HLD)

A

statins are most prescribed bc most effective for lowering cholesterol, despite their side effects

type/dose of meds is important

acute MSK symptoms if statin just started should be differentially diagnosed

27
Q

statin drug interactions

A

ETOH + statin increases risk of side effects

selected HIV meds, antivirals, anti-rejection transplant meds, vibrates, and grapefruit juice all affect how statins are broken down and metabolized

28
Q

purpose of wells criteria

A

gold standard for determining DVT likelihood

29
Q

what may happen if a pt presents with recently unprovoked or provoked VTE

A

if pt on prophylactic dose of anticoagulant (half dose) , they increase the dose to full amount if pt develops VTE

catheter based thrombolysis may be indicated and planned

if pt with LE DVT cant be anticoagulated, IVC filter placement may be indicated and planned

30
Q

APTA VTE action statements related to pharm

A

9: with recently diagnosed VTE treated pharmacologically, confirm medication class and date/time initiated prior to mobilizing pt

10: when pt recently diagnosed LE DVT reaches therapeutic threshold of anticoagulant, mobilize the pt

31
Q

INR <2. mobilize or not?

A

no mobility

risk of clot too high

32
Q

INR >5. mobilize or not?

A

proceed with caution vs hold mobility

risk of bleeding too high

33
Q

if an IVC filter is present in a limb with DVT is it okay to mobilize?

A

yes

34
Q

if an acute PE is present with any R heart failure (via echo) is it okay to mobilize?

A

no

do not mobilize

35
Q

if an acute PE is present with unstable or increasing O2 requirement is it okay to mobilize?

A

no

do not mobilize

36
Q

S&S of post thrombotic syndrome (PTS)

A

edema or swelling
chronic leg or arm pain
skin changes
heaviness of limb affected by DVT

20-50% LE DVT results in PTS>2 years s/p acute DVT

37
Q

what does the CPG say about pts who present with S&S of PTS

A

recommend mechanical compression (i.e. intermittent pneumatic compression and/or graduated compression stockings)

38
Q

should compression be used with every pt diagnosed with DVT to prevent PTS or recurrent DVT

A

no, not every pt

should be decided on a case by case basis

crucial to understand risks of compression, especially with pts with CV pathologies

39
Q

what type of evidence is there for compression with pts with PTS

A

low certainty

40
Q

what type of evidence is there for use of compression with pts with venous and lymphatic disorders for the treatment of PTS

A

high certainty

41
Q

indications for LE compression

*when in contact of the entire medical picture of each individual pt

A

chronic venous insufficiency

post sx or interventional treatment of varicose veins

prevention of VTE

prevention and treatment of PTS

chronic lymphedema

superficial thrombophebitis

pregnancy

dysautonomia/POTS

42
Q

corresponding pressures to strengths of compression

A

low = <20 mmHg

medium = 20-30 mmHg

high = >30 mmHg

43
Q

ABSOLUTE contraindications for compression

A

peripheral arterial disease

any peripheral vascular bypass revascularization

heart failure

severe peripheral neuropathy

local skin or soft tissue condition (skin grafts, cellulitis, infections, etc)

extreme deformity of leg or unusual size/shape preventing correct fit

pt discomfort

44
Q

edu for pts/caregivers regarding LE compression

A

purpose for Rx

benefits of regular use

how to apply- no wrinkles

how long to wear - >12 hours; depends

when to take off; immediate removal if SOB, LE numbness, acute pain

daily hygiene- remove at least 2x/day for hygiene and skin inspection

signs of potential problems/when to remove; if unsure, always remove

what to do/who to contact if problems occur

45
Q

what happens with PAD

A

results in inability to balance supply with increasing demand of exercising mm

ischemia develops and produces lactic acid

46
Q

difference in S&S of lactic acid in mm vs in circulation

A

lactic acid in mm = claudication pain

lactic acid in circulation = respirator stimulated = SOB

47
Q

intermittent vs resting claudication

A

resting = higher risk for limb ischemia/loss

intermittent = more predictable

48
Q

claudication pain scale

A

0 = no pain = resting or early exercise effort

1 = mild = 1st feeling of any pain in legs

2 = moderate = pain level at which exercise training should cease

3 = intense = near max pain

4 = unbearable = most severe pain ever experienced

49
Q

PAD rehab management tips/implications

A

exercise to tolerable level of pain bit not over for best benefits

interval training
- start with equal intervals 1-5 min of exercise to rest
- slowly progress exercise intervals and decrease rest intervals

walking is most functional/convenient

non-impact exercise allows for longer duration and higher intensity

colder temps require longer warm up periods

emphasize good footwear/hygiene