Cardiac Rehabilitation

• Cardiac rehabilitation


  Interdisciplinary team approach to patients with functional limitations secondary to heart disease

  
• Focus of cardiac rehabilitation


  • Restoring patients to their optimal medical, physical, mental, psychologic, social, emotional, sexual, vocational, and economic status compatible with the severity of their heart disease
• Primary prevention


  Screening clients to identify and treat risk factors before illnesses develop
• Secondary prevention


  Improving risk factors or heart disease risk factors and limiting further morbidity and mortality when the condition is already present
• Multidisciplinary team members


  • Physical therapist
  • Occupational therapist
  • Psychologist
  • Nutritionist
  • Rehabilitation nurse
  • Physiatrist
• Physical therapist roles


  • FIM scoring
  • Treatment of physical comorbidities
  • Balance, gait, and stair training
  • Supervision of aerobic training sessions
  • Chest physical therapy
  • Home equipment recommendations
• Occupational therapist roles

  • FIM scoring
  • Treatment of physical comorbidities
  • Cognitive and safety evaluation
  • ECT and pacing education
  • Use of assistive devices
  • SMRT education
  • Home equipment recommendations
• Psychologist roles


  • Cognitive and psychosocial evaluation and therapy
  • Behavioral modification and smoking cessation
• Nutritionist roles


  • Dietary evaluation, education, and counseling
• Rehabilitation nurse roles


  • Wound and skin care
  • Pain management
  • Safety education
  • Medication education
  • Risk factor education
• Physiatrist roles


  • Prescription of CR program
  • CR program modification
  • Coordination of medical care
  • Patient education
• Modifiable risk factors for coronary artery disease

  • Physical inactivity
  • Hypertension
  • Smoking
  • Dyslipidemia
  • Overweight or obesity
  • Diabetes
• Non-modifiable risk factors for coronary artery disease

  • Increasing age
  • Gender: male > female
  • Prior history: cardiac, peripheral vascular, or cerebrovascular disease
  • Family history: genetics
  • Cultural or socioeconomic
• Lifestyle modification without medication

  Recommended in stage 1 hypertension
• Medications


  Recommended for stage 2 hypertension, or when lifestyle modification does not normalize blood pressure
• Signs and symptoms of cardiac distress

  • Angina
  • Dyspnea
  • Orthopnea
  • Diaphoresis
  • Fatigue
  • Orthostatic hypotension
  • Nausea/Emesis

  
• Borg Rate of Perceived Exertion Scale

  Allows clients to rate their exertion during activity, combining all sensations and feelings of physical stress and fatigue
• Specific Activity Scale classes

  • Class I: Can perform activities requiring < 7 METs
  • Class II: Can perform activities requiring < 5 METs but not > 7 METs
  • Class III: Can perform activities requiring < 2 METs but not > 5 METs
  • Class IV: Cannot perform activities requiring > 2 METs
• Basal Metabolic Equivalent Table of Self-Care and Homemaking Tasks helps identify appropriate activities for clients
• Canadian Cardiovascular Society Functional Classification

  • Class I: Ordinary physical activity does not cause angina
  • Class II: Ordinary activity is somewhat limited
  • Class III: Ordinary physical activity is significantly limited
• CLASS III


  Clients with cardiac diseases resulting in marked limitations in physical activities. Client cannot do more than 50% of the activities he or she does.
• CLASS IV


  This category includes patients with cardiac disease resulting in inability to carry out physical activities w/o discomfort.
• CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL CLASSIFICATION


  • CLASS I
  • CLASS II
  • CLASS III
  • CLASS IV
• CLASS I


  Ordinary physical activity, such as walking and climbing stairs, does not cause angina. It occurs prolong exertion or extraneous exertion during work and other recreational activities.
• CLASS II


  Ordinary activity is somewhat limited. This includes walking or climbing stairs rapidly; walking uphill; and walking or climbing stairs after meals, in cold, when under emotional stress.
• CLASS III


  Ordinary physical activity is significantly limited. This includes walking one to two blocks on level surface and climbing more than one flight in normal conditions.
• CLASS IV


  Patients are unable to carry out any physical activity without discomfort. Angina syndrome may be present at rest.
• PHASES OF CARDIAC REHABILITATION

  • PHASE I : INPATIENT CARDIAC REHABILITATION
  • PHASE II : OUTPATIENT CARDIAC REHABILITATION
  • PHASE III : COMMUNITY-BASED EXERCISE PROGRAMS
• PHASE I : INPATIENT CARDIAC REHABILITATION


  Monitored low level physical activity, including ADL. Reinforcement of cardiac and postsurgical precautions. Instruction in energy conservation and graded activity. Establishment of guidelines for appropriate activity levels at discharge.
• PHASE II : OUTPATIENT CARDIAC REHABILITATION


  Exercise can be advanced patient is closely monitored on an outpatient basis. Return to work. Stress management and relaxation techniques.
• PHASE III : COMMUNITY-BASED EXERCISE PROGRAMS

  Some individuals require treatment in their place of residence because they are not strong enough to tolerate outpatient therapy. 'maintenance phase'.
• Monitoring response to activity

  • HEART RATE (HR)
  • BLOOD PRESSURE (BP)
  • RATE-PRESSURE PRODUCT (RPP)
• HEART RATE (HR)


  Number of beats per minute; can be monitored by feeling the patient's pulse at the radial, brachial, or carotid sites.
• BLOOD PRESSURE (BP)


  Pressure that the blood exerts against the walls of any vessel as the heart beats.
• RATE-PRESSURE PRODUCT (RPP)


  Product of HR and SBP (RPP= HR x SBP). During any activity, the RPP should rise at peak and return to baseline in recovery (after 5 to 10 minutes of rest).
• Parameters are frequently written in abbreviations: "Call HO if SBP > 150 < 90; DBP > 90 < 60; HR > 120 < 60"
• Psychosocial considerations


  • Fear and anxiety develop initially as patients confront their mortality
  • Denial is common in patients with cardiac disease
  • Depression is common 3 to 6 days after MI and may last many months
• Fear and anxiety develop initially as patients confront their mortality


  Sedatives may be prescribed to reduce stress and allow rest
• Denial is common in patients with cardiac disease


  Must be closely monitored during acute phase of recovery
• Depression is common 3 to 6 days after MI and may last many months


  Psychosocial counseling – focuses on improving self health appraisal, improving social support, and establishing and effective means of coping to improve quality of life. Family should also be included since they may be the cause why client is anxious.