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Cardiac Rehabilitation
Cardiac Rehabilitation
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Cardiac Rehabilitation
Introduction
“Cardiac Rehabilitation is the process by which patients with cardiac
disease, in partnership with a multidisciplinary team of health
professionals are encouraged to support and achieve and maintain optimal
physical and psychosocial health. The involvement of partners, other
family members and carers is also important” [1]
Description
[5]
Indication
Cardiac rehabilitation should be offered to all cardiac patients who would
benefit.[2] CR is mainly prescribed to patients with ischemic heart disease,
with myocardial infarction, after coronary angioplasty, after coronaro-
aortic by-pass graft surgery and to patients with chronic heart failure. CR
begins as soon as possible in intensive care units, only if the patient is in
stable medical condition. Intensity of rehabilitation depends on patient´s
condition and complications in acute phase of disease. [6]
Improve Cardiac Function Return to work if appropriate To restore self confidence To quit
and/or previous level of smokin
functional capacity
Reduce the risk of sudden To promote independence in Relieve anxiety and To mak
death and re-infarcation ADLs for those who are depression in pt.s and their dietary
compromised careers
Prevent progression of
underlying atherosclerotic
process
[4]
Risk factors should be evaluated using validated measures which take into
account other co-morbidities.
RISK FACTORS
Gender Dyslipedemia
Anxiety/Depression
Hostility
Stress
[1][3][7]
Family Support
Social History
Occupation
Inclusion Exclusion
Insertion of Cardiac Pacemaker (with one or more other inclusion Acute systemic illness
criteria)
Thromobophlebitis
Uncontrolled diabetes
[4][8]
Phases of Cardiac Rehabilitation
Cardiac rehabilitation typically comprises of four phases. The term phase is
used to describe the varying time frames following a cardiac event. The
secondary prevention component of CR requires delivery of exercise
training, education and counseling, risk factor intervention and follow up. [9]
2-5 days
Member of Cardiac Rehab team (CRT) should visit the patient to;
Give support and information to them and their families re: heart disease
Assist the patient to identify personal CV risk factors
Discuss lifestyle modifications of personal risk factors and help provide an
individual plan to support these lifestyle changes
Gain support from family members to assist the patient in maintaining the
necessary progress
Plan a personal discharge activity programme and encourage the patient to
adhere to this and commence daily walks
Inform patients regarding phase II and phase III programs if available and
encourage their attendance
The use of educational materials such as the heart manual and leaflets from
the Irish Heart Foundation should be considered.
Patient should be provided with an individual plan for self care and
lifestyle changes based on their clinical assessment and identified risk
factors. A discharge plan including exercise instructions should also be
formulated.
Patient should also have some form of psychosocial assessment either via
interview or use of a self reporting questionnaire such as HADS, Health
Realted QoL.
Referrals to other members of the MDT and follow up visits should also be
made during this time. [4]
Goals:
Home visits
Phone calls
Outpatient reviews
Could also look into establishing links with GP, practice nurses, primary
care team and chest pain services.
Gradual activity and low level exercise regime may commence once stable.
Intensity will increase over a varying period of time depending on
diagnosis and procedure and is done under guidance of the cardiologist
ACSM suggest 4-6 weeks post MI and post sternotomy unless otherwise
directed by cardiologist/cardiothoracic surgeon [11][12]
Exercise class will consist of warm up, exercise class, cool down – may also
include resistance training with active recovery stations where
appropriate.[8]
Phase III compromises of all the following;
o Benefits of PA
Purpose: Prepare the body for exercise by raising the pulse rate in a
graduated and safe way
Effects:
NB: should try to keep feet moving at all times to maintain HR and body
temp and avoid pooling.
Main Class:
Separate stations are set out and participants spend a fixed amount of time
at each aerobic station (30secs-2mins) before moving onto the next station
which may be rest or active recovery in the form of resistance work
targeted at specific muscle groups.
Resistance work as set out by ACSM 2006 – 10-15 reps to moderate fatigue
of 8-10 exercises.[13][14]
Cool Down:
Options:
Educational sessions
Support groups
Telephone follow up
Review in clinics
Outreach programmes
Phase IV exercise programme organised by qualified phase IV gym
instructor
Links with GP and primary health care team
Ongoing involvement of partners/spouses/family [4]
6MWT
shuttle walk test
chester step test
A patient having a stress test. Electrodes are attached to the patient's chest and connected to an EKG
machine. The EKG records the heart's electrical activity. A blood pressure cuff is used to record the
patient's blood pressure while he walks on a treadmill. [16]
Marked drop in systolic BP >20mmHG – indicates poor LV fxn or severe coronary disease
Serious arrhythmias – ventricular tachycardia
Patient fatigue and/or excessive breathlessness at low workloads – poor fxnl capacity or more serious
[14]
Completion of a workload equivalent to the second stage of the Bruce protocol (7 Inappropriate
METs) workload.
NB: when carrying out the test patients HR, BP and 12 lead ECG must be
constantly assessed. Once test has terminated recovery monitoring must be
continues for a minimum of 6 secs or until the ECG returns to its pretest
appearance.[14]
Risk Stratification
Low Risk (all characteristics listed Moderate Risk (any one or a High R
must be present to remain @ lowest combination of these findings)
risk)
[8]
Automated Blood Pressure Recording Machine e.g. Bicycle Multigym weights system
Dinamap ergometer dumb bells
[4]
Staffing Levels
ACPICR 2009 – minimum staff to patient ratio should be 1:5 but this will
vary depending on the risk stratification profile of the class. For higher risk
patients will have increased staff ratio eg) 1:3
SIGN 2002 guidelines: Staff should have basic life support training and
the ability to use a defribillator required for low-moderate risk patients [1]
Resources
Irish Heart Foundation
BACPR
European Society of Cardiology
SIGN Guidelines
References
1. ↑ Jump up to:1.0 1.1 1.2 1.3 1.4 1.5 1.6 Scottish Intercollegiate Guidelines Network
(SIGN) Cardiac rehabilitation: a national clinical guideline, 2002
2. ↑ Jump up to:2.0 2.1 Pryor JA, Prasad SA. Physiotherapy for Respiratory and Cardiac
Problems. Philadelphia: Elsevier Ltd, 4th Edition, 2008: 14 (470 - 494).
3. ↑ Jump up to:3.0 3.1 American Association of Cardiovascular and Pulmonary
Rehabilitation Robertson, L (Ed.) (2006) Cardiac Rehabilitation Resource
Manual. Champaign: Human Kinetics.
4. ↑ Jump up to:4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Irish Association of Cardiac
Rehabilitation Guidelines 2013
5. Jump up↑ Cardiac Rehabilitation Program. Available
from: http://www.youtube.com/watch?v=famkb_dtAF0 (accessed 20 Oct
2013).
6. Jump up↑ Cardiac rehabilitation. Available
from: http://www.pnmedycznych.pl/spnm.php?ktory=369 (accessed
22.12.2013)
7. Jump up↑ British Association of Cardiac Rehabilitation. “Risk Factors” in
Brodie, D. ed. (2006) Cardiac Rehabilitation: An Educational resource.
Buckinghamshire: Colourways Ltd.
8. ↑ Jump up to:8.0 8.1 8.2 8.3 American Association of Cardiovascular and Pulmonary
Rehabiliation: Guidelines for Cardiac Rehabilitation and secondary
prevention programs 2004
9. Jump up↑ American Association of Cardiovascular and Pulmonary
Rehabilitation Williams, M.A. (Ed.) (2004) Guidelines for Cardiac
Rehabilitation and secondary Prevention programs. Champaign: Human
Kinetics.
10. ↑ Jump up to:10.0 10.1 British Association for Cardiovascular Prevention and
Rehabilitation. (2012) The BACPR standards and core components for
cardiovascular disease prevention and rehabilitation 2012. 2nd Edition.
London: British Cardiovascular Society.
11. ↑ Jump up to:11.0 11.1 11.2 11.3 Association of Chartered Physiotherapists in Cardiac
rehabilitation (2009) Standards for Physical Activity & Exercise in the
Cardiac Population.
12. Jump up↑ American College of Sports Medicine. ACSM's Guidelines for
Exercise Testing and Prescription. Philadelphia :Lippincott Williams &
Wilkins, 2000
13. Jump up↑ Bjarnason-Wehrens, B. Mayer-Berger, W. Meister, E.R. Baum, K.
Hambrecht, R. And Gilen, S. (2004) ‘Recommendations for resistance
exercise in cardiac rehabilitation. Recommendations of the German
Federation for Cardiovascular Prevention and Rehabiliation’. European
Journal of Cardiovascular Prevention and Rehabilitation, 11(4):352-61.
14. ↑ Jump up to:14.0 14.1 14.2 14.3 American College of Sports Medicine (2006) Guidelines
for Exercise Testing and Prescription. 7th Edition. Baltimore, Maryland:
Lippincott Williams & Wilkins.
15. Jump up↑ American Diabetes Association (2013) ‘Standards of Medical Care
in Diabetes—2013’, Diabetes Care, 36: S11-S66.
16. Jump up↑ https://www.nhlbi.nih.gov/health/health-
topics/topics/stress/during
https://www.crnbc.ca/Standards/CertifiedPractice/Documents/RemotePractice/780AdultCardioRes
pAssessDST.pdf
https://physiotherapyguide.blogspot.com/2010/06/general-cardio-respiratory-assessment.html
GENERAL CARDIO-RESPIRATORY
ASSESSMENT
Adult Cardio-Respiratory Assessment
ASSESSMENT
General
• Location - radiation
• Associated Symptoms
• Relieving factors
• Effects on ADLs
Cough
• Severity
Sputum
• Colour
• Consistency
Hemoptysis
• Amount of blood
Shortness of Breath
• Exercise tolerance (number of stairs client can climb or distance client can walk)
• Relation to posture
Cyanosis
• Observation of blue colour of the lips or fingers (under what circumstances, when first
noted, recent change in this characteristic)
Wheeze
• Explore the pain carefully. Include quality, radiation, severity, timing, quality.
Fainting or Syncope
Extremities
• Edema:
• Tingling
• Leg cramps or pain at rest
• Fever
• Malaise
• Fatigue
• Night sweats
• Weight loss
• Palpitations
• GI Reflux
• Allergies
• Medications currently used (prescription and over the counter [e.g., angiotensin-
converting enzyme (ACE) inhibitors, ß-blockers, ASA, steroids, nasal sprays and inhaled
medications (puffers, antihistamines, estrogen, progesterone, diuretics, antacids,
steroids, digoxin)]
• Herbal/traditional preparations
• Disorders:
• Seasonal allergies
• Blood transfusion
• Allergies, atopy
• Diabetes mellitus
• Substance use – alcohol, caffeine, street drugs, including injection drugs, cocaine,
steroids
• Exposure to pets
• Alcohol use
• HIV risks
• Mold
• Obesity
PHYSICAL ASSESSMENT
Vital Signs
• Temperature
• Pulse
• Respiratory rate
• Blood pressure
• Sp02
General Appearance
• Diaphoresis
Inspection
• Intercostal indrawing
• Evidence of trauma
• Color of conjunctiva
• Extremeties
- Hands - edema, cyanosis, clubbing, nicotine stains, cap refill (<3 seconds)
- Feet and legs - changes in foot colour with changes in leg position (i.e., blanching with
elevation, rubor with dependency), ulcers, varicose veins, edema (check sacrum if client
is bedridden), colour (pigmentation, discoloration), distribution of hair
Palpation
• Respiratory Excursion
• Tactile fremitus
• Spinal abnormality
• Masses
• Subcutaneous emphysema
• Apical beat:
- Assess quality and intensity of apical beat – normal, diffuse, weak, forceful, heave
• Identify and assess pulsations and thrills (palpable murmur that feels like a purr) in
aortic, pulmonic, mitral and tricuspid areas, along left and right sternal borders, in
epigastrium and along left anterior axillary line
• Peripheral pulses
- Check for presence, rate, rhythm, amplitude and equivalence of peripheral pulses,
(radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis)
• Edema: pitting (rated 0 to 4) and level (how far up the feet and legs the edema
extends); sacral edema
• Resonance
• Listen for sounds of normal air entry before trying to identify abnormal sounds
• Adventitious Sounds:
- Wheezes (aka rhonchi): continuous sounds, ranging from a low-pitched snoring quality
to a high-pitched musical quality, may be inspiratory or expiratory, or both, may clear
with coughing, may be present only on forced expiration.
- Crackles (aka rales): discrete, crackling sounds heard on inspiration, may clear with
coughing. May be fine (high-pitched, short popping sounds) or coarse (low-pitched,
bubbling and gurgling sounds). Diffuse in severe pneumonia, bronchiolitis, CHF.
Localized in bronchiectasis and pneumonia.
- Pleural rub: a coarse, creaking sound from pleural irritation, heard on inspiration or
expiration
Auscultation of heart
• Listen to normal heart sounds before trying to identify murmurs. Use diaphragm of
stethoscope first, then bell of stethoscope, when listening to the heart
• Auscultate at aortic, pulmonic, Erb’s point, tricuspid, and mitral. Attempt to identify:
• Auscultate carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral
arteries for bruits
Grade Characteristics
I
Very quiet, barely audible
II
Quiet but audible
III
Easily heard
IV
Thrill can be felt, murmur is easily heard
V
Thrill can be felt and loud murmur can be heard with stethoscope placed lightly on chest
VI
Thrill can be felt and very loud murmur can be heard with stethoscope held close to chest
wall
Associated Systems
The first step is to differentiate between acute respiratory distress and respiratory
conditions that can be managed safely by certified practice nurses.
The following signs and symptoms require immediate referral to a physician or nurse
practitioner:
• Severe dyspnea
• Tracheal shift
• Unrelieved chest pain
• Cyanosis (central cyanosis is not detectable until SaO2 is less than 85%)
• Intercostal indrawing
• Pulsus paradoxus
• Recent MI
DIAGNOSTIC TESTS:
• The certified practice nurse may consider the following diagnostic tests in the
examination of the cardio-respiratory system to support clinical decision making:
- ECG
- Hemoglobin
- Cardiac troponins