Lecture 12: CV Rehab Management Pt. 2

Question 1

CABG rehab protocol

Answer 1

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

Question 2

what are sternal precuations

Answer 2

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

Question 3

why do some people believe sternal precautions are unnecessary

Answer 3

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

Question 4

bed mobility for CABG rehab guidelines

Answer 4

pain reduction strategies - roll vs trunk shift

maintain precautions

use bed features

Question 5

transfers for CABG rehab guidelines

Answer 5

maintain precautions

think ahead to keep precautions in mind

appropriate DME choice

Question 6

ambulation CABG rehab management guidelines

Answer 6

activity pacing

monitor S&S

appropriate DME choice

Question 7

CABG rehab guidelines for stairs

Answer 7

use rails while maintaining sternal precautions

one rail instead of 2 may be easiest to not break precautions

Question 8

CABG rehab guidelines for functional endurance

Answer 8

apply knowledge of physiology and pt response to activity

Question 9

CABG rehab guidelines for balance

Answer 9

focus on fall reduction strategies to prevent FOOSH

Question 10

CABG rehab: things to education pt on

Answer 10

pain management via splints

edema control

ROM and HEP

DME needs

use of incentive spirometer

Question 11

standard pacer for post CT sx

Answer 11

external pacemaker
- set as backup (usually 60bpm)
- procedure of weaning away
- can mobilize pt

trans venous pacemaker = CONTRAINDICATION FOR MOBILITY

Question 12

things to keep in mind if a pt has a chest tube atrium (JP drain)

Answer 12

need to ensure no post op hematoma formation

sometimes connected to suction to encourage fluid drainage from surgical sites

Question 13

considerations taken if a pt has a true chest tube in the pleural space

Answer 13

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

Question 14

things to be aware of with a chest tube

Answer 14

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

Question 15

use of pulmonary artery catheter (PAC) and rehab guidelines

Answer 15

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

Question 16

use of central venous catheter and things to keep in mind

Answer 16

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

Question 17

use of arterial line and things to keep in mind

Answer 17

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

Question 18

general considerations for lines

Answer 18

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

Question 19

pacemaker precautions

Answer 19

*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

Question 20

general post op CV sx principles

Answer 20

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

Question 21

vascular sx post op precautions

Answer 21

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

Question 22

ROM limiting factor post op vascular sx

Answer 22

pain from incisions

important to slowly return to normal ROM to prevent contracture

neutral ankle DF and terminal knee ext typically is most challenging

Question 23

weight bearing status post vascular sx

Answer 23

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

Question 24

meds for heart transplant pts and things to keep in mind

Answer 24

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

Question 25

long term side effects of steroids

Answer 25

hyperglycemia

increased risk of fx or connective tissue injury

osteoporosis

HTN

weight gain

appetite changes

mood/behavior changes

slowed healing

Question 26

what are calcineurin inhibitors

Answer 26

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

Question 27

what are anti-proliferative agents

Answer 27

i.e. cellcept and azathioprine

interferes with normal lymphocyte production

side effects = bone marrow depression, liver dysfunction, GI distress

Question 28

important things to know about exercising with pts post heart transplant

Answer 28

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)

Question 29

early PT goals post heart transplant

Answer 29

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)

Question 30

how to monitor exercise intesity with heart transplant pts

Answer 30

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

Question 31

precautions/rehab timelines and exercise parameters for heart transplant (precautions, aerobic ex guidelines, resistance training focus, effect on VO2 max)

Answer 31

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)