Professional Documents
Culture Documents
Ellie Smith
Kathryn Webster
Carroll University
Heart
Rate
(bpm)
Respirations Fall
(#/min)
Risk
63
72
16
113
20.32
100
112/64
Yes
According to the American College of Sports Medicine (2014), Ellies body mass index
(BMI) classifies her at a normal healthy weight. This could be due to her POTS disease and her
regular exercise that she self reports getting at least three days per week. Ellie currently is at an
optimal blood pressure according to the ACSM, her blood pressure should be <120 systolic and
< 80 diastolic. Resting heart rate is also optimal as resting heart rate should be between 60-<100
beats per minute. Respirations per minute were also within normal range of 12-20 respirations
per minute. Ellie informed staff that she has fallen more than once in the last 12 months, and she
considers herself a fall risk, therefore, the clinical decision was made to make her a fall risk at
cardiac rehabilitation class as well.
Physical Examination
During the physical examination, the registered nurse performed an assessment that
covered multiple areas which will be further discussed in this and following sections. Each part
of the assessments is important factors when considering and designing an individualized
treatment plan. Ellie reported having blurred vision, which is a side effect on more than one of
her current medications but no hearing discrepancies. In the neurological assessment Ellie does
report fainting in February 2014 after rushing downstairs in the middle of the night to get her
daughter medicine. Patient states she was not on salt tablets at that time. In February of 2014
Ellie states she hit the kitchen floor and woke up vomiting after she had rushed down the stairs.
Ellies doctor checked her and said everything was alright. She also presyncopal episode at work
9/9/14 which could have occurred do to the amount of stress, pressure, and walking Ellie was
performing that day. The nurse also states that her lung fields sound clear and does not note a
cough. It was also noted that Ellie has a normal sinus rhythm with no ectopy noted as well as no
edema as she wears compression stockings. She also does not have any mobility concerns but
does state she feels steady on her feet most of the time. Patient does sit frequently because of
dizziness. However, she does self-report she has fallen within the last year.
2
Score out of 30
20.69
3
15.47
25.43
21.57
28.50
Patient Criteria
231 mg/dL
Triglycerides
150 mg/dL
148 mg/dL
LDL
130 mg/dL
144 mg/dL
HDL
<40 mg/dL
35 mg/dL
Medication
Currently on medication
Currently on medication
Medication compliance assessment. Ellie has discussed that she is 100% compliant in
taking her medications. For her medication compliance stages of change she is placed into the
action stage as she wants to get better and return to her daily activities with a reduction of her
current medications. Follow up questions might include: Are you still taking your medications as
described? Have you had any medication changes since your last cardiac rehab exercise session?
Have you been experiencing any side effects related to you medications? If so, can you please
describe what you are experiencing?
Blood pressure assessment. As stated in a previous section, Ellie does not have
hypertension based on ACSM criteria. Her blood pressure is displayed in Table 4. Ellie is
currently not on any blood pressure medication nor is she on a beta-blocker due to her POTS
condition.
TABLE 4. Patient blood pressure results.
Value
ACSM criteria
Systolic
140 mmHg
Patient criteria
112 mmHg
Diastolic
90 mmHg
64 mmHg
Medication
Currently on medication
Patient criteria
Total cholesterol: 231 mg/dL
LDL: 144 mg/dL
HDL: 35 mg/dL
Currently on medication
POTS
Known CV disease
Known CV disease
Exercise HR,
BP, Exercise
Capacity
HR: no affect
BP:decrease
EC: no affect
Side Effects
Drug/Food
Interactions
-Rash
-wheezing
-severe stomach
pain
-constipation
-heartburn
Moderate
interaction with
Florinef. Affects
the absorption of
fludrocortisone.
Questran
2 grams 2x/d
Cholesterol
lowering.
Celexa
10mg 1x/d
Anti-depressive
HR: decrease or
no change rest
and exercise
BP: variable rest
EC: no affect
-Confusion
-chest pain
-fast, uneven
heartbeat
-unusual
bleeding or
bruising
-dry mouth
Major interaction
with Zofran. Can
increase risk of
irregular heart
rhythm, more
susceptible to
congenital long
QT syndrome, or
electrolyte
disturbances.
Clobevate
PRN
Antiinflammatory
steroid
HR: no affect
BP: no affect
EC: no change or
increase
performance
dose related
-burning
sensation of skin
- dry skin
-flushing of skin
-hair loss
-thinning of hair
N/A
Medication Use
Florinef
100 mcg 2x/d
Exercise HR,
BP, Exercise
Capacity
Side Effects
Drug/Food
Interactions
Corticosteriod.
HR: no affect
Causes the
BP: no affect
kidneys to retain EC: no affect
sodium and
acting as a
replacement for
cortisone when
the body does not
produce enough.
-abdominal pain
-anxiety
-blindness
-blurred vision
-chills
-confusion
-convulsions
Moderate
interaction with
Questran. Affects
the absorption of
fludrocortisone.
Moderate
interaction with
ProAmatine. Can
lead to an
increase in blood
pressure and
intraocular
pressure.
ProSynbiotic
Daily
Probiotic
HR: no affect
BP: no affect
EC: no affect
N/A
Catalyn GF
Daily
Vitamin
HR: no affect
BP: no affect
EC: no affect
N/A
N/A
Zofran ODT
4mg 3x/d
Prevents nausea
and vomiting
HR: no affect
BP: no affect
EC: no change
with performance
-Confusion
-dizziness
-SOB
-decrease
urination
frequency
-cough
-painful urination
Major interaction
with Celexa. Can
increase risk of
irregular heart
rhythm, more
susceptible to
congenital long
QT syndrome, or
electrolyte
disturbances.
Pyridoxine HCI
1x/d
Vitamin B6
HR: no affect
BP: no affect
EC: no affect
-nausea
-vomiting
- headache
-loss of appetite
N/A
Medication Use
Exercise HR,
BP, Exercise
Capacity
Side Effects
Drug/Food
Interactions
Salt Tablets
10x/d
Increase sodium
retention
HR: no affect
BP: no affect
EC: no affect
N/A
N/A
(Drugs.com, 2014)
Return to work. Ellie is currently employed as a school counselor at a middle school.
Her job has physical requirements of which use a long of energy for standing and walking for
almost half of the school day.
Orthopedic limitations. Currently, Ellie has no orthopedic limitations that would hinder
her from and form exercise. She may feel more fatigued due to the POTS condition she currently
is suffering from, which also makes her deconditioned due to lack of regular aerobic exercise.
Exercises for each major muscle group will be encouraged as a way to improve her muscle
strength and endurance. Communication between the patient and staff will also be important to
ensure that the best results and benefits are achieved.
Personal goal. Through the cardiac rehabilitation program, aerobic and strength training
will be performed to aid in Ellies recovery as well as returning to work. Ellie has also stated that
she has other personal goals that she would like to begin accomplishing throughout the program
as well. These goals would include: blood pressure control, which can be done through exercise
and medication management, stress management which can be performed through the education
classes that are offered, increasing her exercise abilities, return to work, and lastly, overall
medication management. Medication management can be assisted with the increase in exercise
capacity and ability, but will ultimately be done through her physicians, with the cardiac rehab
exercise results from the exercise physiologist.
Clinical Decisions for Aerobic Exercise.
As Ellie is currently at a normal weight according to ACSM criteria, maintaining her
weight will be important. Throughout cardiac rehabilitation patients complete at least 45 minutes
of supervised aerobic exercise. However, this duration is too much for Ellie currently due to her
POTS condition. Therefore modification aerobic guidelines will need to be made and defined. As
Ellie began aerobic exercise at six minutes, therefore it will be a gradual increase starting at her
six minutes of aerobic exercise.
The ACSM recommends the intensity based upon the individual patients rate of perceived
exertion (RPE) due that most individuals in outpatient cardiac rehabilitation are on beta-blockers,
leaving heart rates blunted (American College of Sports Medicine, 2014). If a patient had
baseline exercise test data, 40-80% of exercise capacity using heart rate reserve (HRR), oxygen
uptake reserve or peak oxygen uptake methods. Ellie however, did not have a baseline exercise
test performed; therefore an RPE of 11-16/20, which is of moderate intensity, will be used.
According to the ACSM, there are specific recommendations for exercise duration which
include a 5-10 minute warm up with an RPE of <11/20. The goal duration of the aerobic
10
Level: 1
Mets: 1.0
Steps/min: 50
11-13/20
Nustep
Week 2
MWR
Level: 1
Mets: 1.2
Steps/min: 52
11-13/20
Nustep
Week 3
MWR
Level: 1
Mets: 1.4
Steps/min: 55
12-13/20
10 minutes:
Rest for 2 minutes
half way
Nustep
Speed: 1.5mph
Grade: 0%
Mets: 1.5
11-13/20
5 minutes: rest at
2.5 minutes
Treadmill
Level: 1
Mets: 1.4
Steps/min: 55
12-13/20
12 minutes: Rest
for 2 minutes half
way
Nustep
12-13/20
Treadmill
Week
Intensity
RPE
Duration
Equipment
Week 5
Level: 1
12-13/20
14 minutes: rest
Nustep
Week 4
MWR
11
Week 6
MWR
Week 7
MWR
Week 8
MWR
Mets: 1.6
Steps/min: 60
Speed: 1.8mph
Grade: 0%
Mets: 1.9
12-13/20
10 minutes: rest
for 2 minutes half
way
Treadmill
Level: 1
Mets: 1.5
11-13/20
Recumbent Bike
Level: 2
Mets: 2.0
Steps/min: 60
12-14/20
15 minutes: rest
for 2 minutes half
way
Nustep
Speed: 2.0
Grade: 0%
Mets: 2.2
12-14/20
12 minutes: rest
for 2 minutes half
way
Treadmill
Level: 1.2
Mets: 1.8
12-13/20
Recumbent Bike
Level: 2
Mets 2.2
Steps/min: 65
12-14/20
15 minutes: rest
half way for 2
minutes if needed
Nustep
Speed: 2.0mph
Grade: 0.5%
Mets: 2.5
12-14/20
Level: 1.4
Mets: 2.0
12-14/20
Level: 3
Mets: 2.6
Steps/min: 65
12-16/20
12-16/20
Level: 1.6
Mets: 2.4
12-16/20
12
15 minutes: Rest
half way for 2
minutes if needed
8 minutes: Rest
half way for 2
minutes if needed
15 minutes: rest
half way for 2
minutes if needed
15 minutes: rest
half way for 2
minutes if needed
10 minutes: rest
half way for 2
minutes if needed
Treadmill
Recumbent Bike
Nustep
Treadmill
Recumbent Bike
Resistance Testing. As the current facility does not participate in resistance exercise
testing prior to entrance of cardiac rehabilitation, current standards of practice would discuss a
10-RM as Ellie has POTS and is highly deconditioned. Resistance training is also an important
component to incorporate into Ellies physical activity regimen. Resistance training can help
improve completing activities of daily living and can assist in reducing the amount of peripheral
muscle wasting she is experiencing. It is recommended that Ellie complete a 10-RM, to better
determine which areas could use improvement to assist in completing activities of daily living.
10-RM. The 10-repetition maximum test is recommended for Maria to participate in as
the results can be used to determine the intensity of specific exercises. The 10-repetition
maximum test allows for a decrease in stress being placed on the heart when compared to the
one-repetition maximum test. In a study by Abdul-Hameed, Rangra, Shareef and Hussain (2012),
the reliability of the 1-RM in assessing strength of the upper and lower body in untrained middleaged individuals was performed. In this study, individuals participated in the supine bench press,
leg press, lateral pull, leg extension and seated biceps curls. 1-RM was estimated for all
individuals using the Brzyeki 1-RM predication equation. The test was performed one week later
to measure test-retest reliability. As Ellie suffers from deconditioning it will be recommended
that she participate in a 10-RM. Also, if she has no previous resistance training experience, the
10-RM will be better suited for Maria than the 1-RM. She will perform the 10-RM supine bench
press to determine her upper body 1-RM and the 10-RM leg extension to determine the 1-RM of
her lower body.
As Ellie does not currently participate in strength training exercises, resistance training
will be beneficial for her to participate in. Through strengthening her body she will further be
able to perform her activities of daily living. Resistance training may also assist Ellie to become
stronger to aid in the process of her return to work goal. It will be important for Ellie not to
overdo the amount of resistance training, as she will experience delayed onset of muscle
soreness. Having POTS will also exaggerate these symptoms of soreness.
As there is not much information on POTS and resistance training, the studies used in the
above section of aerobic exercise also discusses resistance training. Shibata et al. (2012), discuss
that resistance training using weight lifting was incorporated. Resistance training began once per
week for 15-20 minutes per exercise session and built up to twice per week for 30-40 min per
session. Through the performance of resistance training as well as aerobic training, participants
were able to increase overall muscle and strength (Shibata et al., 2012). A comparison a study
performed by Fu et al. (2011), resistance training began once per week for 15-20 minutes per
session and was increased to twice per week for 30-40 minutes each session.
According to Dysautonomia International (2012) patients can benefit from overall
increase in tone and strength. The stronger our muscles are, the more efficiently the use oxygen,
the better will be able to tolerate orthostatic stress. Dysautonomia International (2012), discusses
emphasizes can be place on strengthening leg and core muscles. It is recommended to begin with
light weights, and use them in a reclined or seated position. It will also be important to not have
individuals with POTS lifting their arms over their head as this can cause patients to become
extra symptomatic (Dysautonomia International, 2012).
Resistance training. Based on the current standards of St. Josephs hospital and research,
patients participating in cardiac rehabilitation programs do participate in resistance training. For
Ellie it will be important to find exercises that do not allow for her to lift her arms above her
head. It is also important to begin with lightweights and few exercises. The resitance exercises
13
TABLE 8. Resistance training program. *All exercises are done seated, except squats*
Week
Exercise
Intensity
RPE
Important Tips
Modifications
14
Week 1
MWF
Bicep Curl
Lateral Raise
Tricep Kickback
Squats
Weight: 1 lb
Sets: 1
Reps: 8
11-14/20
Do not hold
breath!
Bicep Curl: keep
elbows to sides.
Lateral Raise: only
bring arms up to
should height.
Squat: keep knees
behind toes. Keep
a straight back.
Week 2
MWF
Bicep Curl
Lateral Raise
Tricep Kickback
Squats
Weight: 1 lb
Sets: 2
Reps: 8
11-14/20
Do not hold
breath!
Bicep Curl: keep
elbows to sides.
Lateral Raise: only
bring arms up to
should height.
Squat: keep knees
behind toes. Keep
a straight back.
Week
Exercise
Intensity
RPE
15
Important
Tips
Modifications
are based
upon how the
individual is
progressing. If
should hurt or
are too sore,
only perform
exercises until
point of
discomfort,
not pain.
Modifications
are based
upon how the
individual is
progressing. If
should hurt or
are too sore,
only perform
exercises until
point of
discomfort,
not pain.
Modifications
Week 3
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Squats
Weight: 2 lb
Set: 1
Reps: 8-10
11-14/20
Do not hold
breath!
Week 4
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Squats
Weight: 2 lb
Set: 2
Reps: 8-10
11-14/20
Do not hold
breath!
Week
Exercise
Intensity
RPE
Important
Tips
16
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Modifications
Week 5
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Squats
Weight: 3 lb
Set: 1
Reps: 8
11-14/20
Do not hold
breath!
Week 6
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Squats
Weight: 3 lb
Set: 2
Reps 8-10
11-14/20
Do not hold
breath!
Week
Exercise
Intensity
RPE
Important
Tips
17
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Modifications
are based upon
how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back
Modifications
Week 7
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Full Squats
Weight: 4 lb
Set: 2
Reps: 8-10
11-14/20
Do not hold
breath!
Modifications
are based
upon how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back
Week 8
MWF
Bicep Curl
Lateral Raise
Tricep
Kickback
Full Squats
Weight: 4-5lb
Sets: 2
Reps: 8-10
11-14/20
Do not hold
breath!
Modifications
are based
upon how the
Bicep Curl:
individual is
keep elbows
progressing. If
to sides.
should hurt or
are too sore,
Lateral Raise: only perform
only bring
exercises until
arms up to
point of
should height. discomfort,
not pain.
Squat: keep
knees behind
toes. Keep a
straight back.
Patient Education
As Ellie continues with cardiac rehabilitation, education will be an important part of her
recovery process. Topic of education would include: Blood lipid management, medication
compliance and stress management and continuation of increasing the amount of exercise she
participates in outside as well as after completion of the cardiac rehabilitation program. These
topics of education are important factors that contribute to cardiovascular disease. Addressing
each of these will be important.
Blood lipid management. According to ACSM guidelines Ellie meets dyslipidemia
criteria. This means it will be important to discuss lipid management with her. The American
Association of Cardiovascular and Pulmonary Rehabilitation (2013), discusses that research has
18
19
Outcomes
As Ellie is currently in cardiac rehabilitation for POTS, per recommendation from her
cardiologist, it will be important for her to make lifestyle changes. Each of these changes will
assist Ellie in better managing her cardiovascular risk factors. These lifestyle changes will
include: improvements in blood lipid values, increasing physical activity, and stress
management. These improvements can be achieved using dietary changes and increased physical
activity. Using the S.M.A.R.T. goal format, Ellies goal can be further specified in order for
increased program adherence to achieve positive outcomes. Ellies specific goals will be outlined
for her based upon her baseline levels and the reasoning for her lifestyle changes.
Recommendations for Ellie would be that she document her dietary and sodium intake. For Ellie,
she is not a sodium restriction as she is on sodium medication because her body does not retain
any sodium. This can be done using a computer spreadsheet or a paper notebook.
Ellie could also use an app for her iPhone such as MyFitnessPal to track her dietary
intake. This app has a scanner function that allows for a simple scan of the food label and it is
uploaded into the apps database. If only half the serving was consumed there is an option to
manually change the portion that was consumed. Ellie was open to the idea of this app and
agreed to try it. She has since stated that she likes the app and that is has been beneficial for her
to track the foods she is eating to make sure they are healthy and contain the proper nutrients that
she requires for a healthier lifestyle. A fitbit or bodymedia band will be recommended as
beneficial as these can track physical activity such as steps per day. With the use of the fitbit or
bodymedia band, steps per day will be encouraged. This goal will start out small, as Ellie is still
very deconditioned. According to the ACSM (2014), steps should be increased by 10-20% each
week. Ellies goals will be structured in a way that he will achieve smaller goals as a way to
reach her overall goal. Through focusing on the smaller goals in progression to her long-term
goals will also assist Ellie as she faces possible barrier along the way. Finally, Ellies goals will
be bound by time, creating a specific time frame in which she should work to achieve her goals.
A study performed by Fox (2013), found that one in three cell phone owners have used
their phone to look up health information and half of smartphone users have done the same. Fox
(2013), also discovered that 19% of smartphone owners have downloaded a health app for easier
tracking and documentation of health data. Lastly, Fox (2013), found that 7 in 10 U.S. adults
track a health indicator for themselves or a loved one and many have stated that this activity has
changed their overall approach to health. Therefore, Ellie may have a better chance of remaining
compliant with her exercise program as other adults have in accordance to the study that was just
discussed.
As Ellie has dyslipidemia, it will also be important for her to continue monitoring her
blood lipid values. Her blood lipid values should be monitored every eight weeks to determine if
there have been any changes in her levels that are benefiting her health. In a research study
performed by Paoli, Bianco, Grimaldi, Lodi, and Bosco (2013), observation of overweight and
obese subjects participated in the Mediterranean diet for one year. The findings of this study
displayed that with adherence to the Mediterranean diet, weight loss as well as a decrease in total
cholesterol, LDL cholesterol, and triglycerides were found. There were, however, no significant
changes in HDL cholesterol values. Therefore, if Ellie were able to adhere to the Mediterranean
diet plan, she would be able to reduce and improve her blood lipid values. These are important to
decrease and improve, as it will assist in the decrease of further risks of cardiovascular disease.
20
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References:
AbdulHameed,U.,Rangra,P.,Shareef,M.Y.,&Hussain,M.E.(2012).Reliabilityof1repetitionmaximum
estimationforupperandlowerbodymuscularstrengthmeasurementinuntrainedmiddleagedtype2diabetic
patients.AsianJournalofSportsMedicine,3(4),267273.Retrievedfrom
22
Fu, Q., VanGundy, T., Shibata, S., Auchus, R., Williams, G., & Levine, B. (2011, June 20).
Exercise Training Versus Propranolol in the Treatment of the Postural Orthostatic
Tachycardia Syndrome. Retrieved November 10, 2014, from
https://hyper.ahajournals.org/content/58/2/167.full
Hill, K., Wickerson, L. M., Woon, L. J., Abady, A. H., Overend, T. J., Goldstein, R. S., & Brooks,
D. (2011). The 6-min walk test: responses in healthy Canadians aged 45 to 85 years.
Applied Physiology, Nutrition & Metabolism, 36(5), 643-649.
Giannuzzi P, Temporelli PL, Marchioli R et al (2008) Global secondary prevention strategies to
limit event recurrence after myocardial infarction: results of the GOSPEL study, a
multicenter, randomized controlled trial from the Italian Cardiac Rehabilitation Network.
Arch Intern Med168(2): 2194-2204
Kivimki, M., Nyberg, S. T., Fransson, E. I., Heikkil, K., Alfredsson, L., Casini, A., . . . Pentti,
J. (2013). Associations of job strain and lifestyle risk factors with risk of coronary artery
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Association Journal, 185(9), 763-769. doi:10.1503/cmaj.121735
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