Lecture 12: CV Rehab Management Pt. 2 Flashcards
CABG rehab protocol
post op day 0 (depends on stability)
-goal to have pt in chair position or EOB w/I 8 hours
- standing within 12
POD 1
- out of bed for breakfast
- short distance transfer/ambulation
POD 2-3
- progressive mobility and ambulation
- transfer out of CVICU
usually have an ambulation goal before discharge
what are sternal precuations
for pts s/p sternotomy for 8-12 weeks
avoid B pec major contractions on sternum
traditional:
- no pushing/pulling
- no lifting >5-10 lbs
- avoid shoulder flexion/abduction >90 deg
- very limited use of BUE w/ bed mobility/transfers
“keep your move in the tube”:
- if you do not move BUE outside of small frame of motion, shorter lever arm allows pts to perform previously contraindicated movements
why do some people believe sternal precautions are unnecessary
no regard for pt difference
in effort to promote healing, lack of sufficient stress on sternum and connective tissue may hinder optimal healing
limiting pts functional recovery promotes disuse atrophy and consequences
bed mobility for CABG rehab guidelines
pain reduction strategies - roll vs trunk shift
maintain precautions
use bed features
transfers for CABG rehab guidelines
maintain precautions
think ahead to keep precautions in mind
appropriate DME choice
ambulation CABG rehab management guidelines
activity pacing
monitor S&S
appropriate DME choice
CABG rehab guidelines for stairs
use rails while maintaining sternal precautions
one rail instead of 2 may be easiest to not break precautions
CABG rehab guidelines for functional endurance
apply knowledge of physiology and pt response to activity
CABG rehab guidelines for balance
focus on fall reduction strategies to prevent FOOSH
CABG rehab: things to education pt on
pain management via splints
edema control
ROM and HEP
DME needs
use of incentive spirometer
standard pacer for post CT sx
external pacemaker
- set as backup (usually 60bpm)
- procedure of weaning away
- can mobilize pt
trans venous pacemaker = CONTRAINDICATION FOR MOBILITY
things to keep in mind if a pt has a chest tube atrium (JP drain)
need to ensure no post op hematoma formation
sometimes connected to suction to encourage fluid drainage from surgical sites
considerations taken if a pt has a true chest tube in the pleural space
connected to wall suction to keep pleural space negative and keep lung inflated
water seal - hydrostatic pressure is enough to keep pleural space negative and keep lung inflated
things to be aware of with a chest tube
Atrium needs to stay upright and below Level of pt
be aware of where tube is located
be aware of output of tube pre/post mobility
orders in EMR for wall suction, water seal, and if pt can come off of suction for mobility
monitor for bubbling, indicating air leak
if it comes out, immediately plug hole in chest wall
use of pulmonary artery catheter (PAC) and rehab guidelines
invasive monitoring
used for pts who need very tight titration of certain critical care meds
held in place by sutures and adhesive dressing at neck
if dislodged = indwelling component can cause potentially fatal ectopy
no outright restrictions for mobility, but facility dependent and highly dependent on pt situation
very cumbersome, heavy, lots of attachments
use of central venous catheter and things to keep in mind
large IV placed in IJ, subclavian, femoral vein
allows for meds/fluids to be given directly
non-invasive blood draws
no restrictions for mobility, even if femoral
use of arterial line and things to keep in mind
invasive/instant BP measure
non-invasive arterial blood draw
usually in radial aa but can be femoral/brachial
pt can bleed if pressure in line is lost
no mobility restrictions, even in femoral
transducer must stay at apex level to produce accurate reading
has pressure bag to monitor connection
do not pull out
general considerations for lines
no mobility 2-4 hours post extubation to reduce risk of airway edema or stridor
hold mobility 2 hours following central line removal to reduce risk of hematoma (especially in neck/groin)
literature says femoral lines should not limit mobility but certain facilities have restrictions
pacemaker precautions
*for permanent or ICD placement
precautions:
- no driving
- no pushing or pulling on op side
- no lifting > 5-10 lbs
- no shoulder flexion/ABD >90
sling for comfort for first 24-48
use unaffected side for ADLs, overhead reach, holding onto railing/grab bars, use of DME
very physician dependent
general post op CV sx principles
splinted coughing/sneezing
use of incentive spirometer
daily mobility schedule
OOB to chair for meals
DVT prevention
DC/DME recs
pain and edema management
positioning, ROM
cardiac rehab
vascular sx post op precautions
open AAA repair or other major vascular sx require laparotomy incision
compensatory strategies:
- abdominal binder for comfort
- log rolling, semi fowler
- no lifting > 5-10 lbs
awareness of combo of large vascular sx combined with likelihood of strong pain meds
monitor incision, drains, dressing
sx incisions may be extensive; depends on type of revascularization
monitor for bleeding and hematoma
any vascular sx = risk for blood loss, compartment syndrome, neuropraxia
endovascular approaches still need arterial access
femoral cut down required to reach femoral aa
ROM limiting factor post op vascular sx
pain from incisions
important to slowly return to normal ROM to prevent contracture
neutral ankle DF and terminal knee ext typically is most challenging
weight bearing status post vascular sx
WBAT unless otherwise specified
NWB if there are non-healing wounds to weight bearing surfaces or amputation site
check EMR for MD orders, special orthotics/braces, etc
meds for heart transplant pts and things to keep in mind
steroids
- prednisone (deltasone)
- suppresses antibodies and immune function
statins
- monitor pt for side effects, especially with dose changes
anticoagulants/anti-platelets
- lifelong fall risk prevention
- reduce activity that could lead to bleeding
long term side effects of steroids
hyperglycemia
increased risk of fx or connective tissue injury
osteoporosis
HTN
weight gain
appetite changes
mood/behavior changes
slowed healing
what are calcineurin inhibitors
heart transplant anti rejection meds
cyclosporine and prograf most common
inhibit enzyme important for cytokine production
program used more often due to less side effects
cyclosporine has higher rates of HTN and renal insufficiency
what are anti-proliferative agents
i.e. cellcept and azathioprine
interferes with normal lymphocyte production
side effects = bone marrow depression, liver dysfunction, GI distress
important things to know about exercising with pts post heart transplant
vagus nn severed during sx
HR now controlled by hormone circulation rather than ANS (takes 5-10 min for circulating hormones to affect HR)
warm up and cool down are very important
pt will have higher resting HR, lower HRR, and higher resting BP (but at risk for orthostatic hypotension)
early PT goals post heart transplant
optimize pulmonary hygiene and chest wall mechanics to wean off any supplemental O2
increase strength and ROM in BUEs/thoracic region
improved exercise tolerance via ADLs and low intensity exercise (1-4 METs)
how to monitor exercise intesity with heart transplant pts
heart is denervated so…
BP, ventilatory thresholds, RPE, and S&S should be monitored to gauge intensity
close observation of sweating, color changes, mentation, etc can be helpful
precautions/rehab timelines and exercise parameters for heart transplant (precautions, aerobic ex guidelines, resistance training focus, effect on VO2 max)
sternal precautions first 8-12 weeks
15-60 min aerobic exercise for 4-6 days/week
cardiac rehab ~6 weeks post op if uncomplicated
resistance training = focus on large proximal mm with efforts to prevent OP and steroid myopathy
VO2 max and exercise capacity improves significantly post transplant (40-50% lower VO2 max than age matched norms)
