Examination

• BP = cardiac output x total peripheral resistance

  • measure of force exerted against the arterial walls during systole and diastole
• SBP should increase with exercise, DBP typically stays the same or slightly decrease
• Systolic = maximal amount of pressure exerted against the arterial walls when the heart contracts
• Diastolic = amount of pressure exerted against the arterial walls while the heart is at rest

  • time between beats while the heart is refilling
• Causes of Hypotension

  • arrhythmias
  • Structural diseases
  • Hypovolemia***
  • Systemic vasodilation
  • Obstructive
• Heart rate reserve = difference between resting HR and Max HR
• an increased resting HR is associated with increased all cause mortality
• Karvonen‘s Formula

  • Target HR = ([HRmax-HRrest] x [% of target intensity]) + HRrest
• Apnea is lack of airflow to the lungs for >15 seconds
• Bradypnea is RR < 12 bpm
• Tachypnea RR >20 bpm
• RR >45 = use caution while exercising
• Exercise is contraindicated = RR >50
• SpO2 = perioherally measured O2 saturation via pulse ox
• Signs of poor oxygenation

  • SOB
  • Dizziness
  • Cyanosis
  • HA
  • Tachycardia
  • Tachypnea
  • Confusion
• Pulse amplitude classification

  0 absent pulse

  1+ diminished pulse = reduced stroke volume and EF, increased vascular resistance
• Pulse amplitude Classification

  2+ normal

  3+ full pulse = slightly increased stroke volume and EF

  4+ bounding pulse = increased stroke volume and EF
• Edema scale

  1+ = barely detectable impression when a finger is pressed

  2+ = slight indentation, 15 sec to rebound

  3+ = deeper indentation, 30 seconds to rebound

  4+ = >30 seconds to rebound
• Bell for lower pitched sounds such as heart murmurs
• Diaphragm used for higher pitched sounds such as normal heart sounds
• Normal heart sounds = S1-S2

  Abnormal heart sounds = S3-4
• Low risk

  • LV EF >50%
  • no resting or exercise induced complex dysrhythmias
  • uncomplicated MI, CABG, angioplasty, artherectomy, or stent
  • Maximal functional capacity of at least 7 METs
  • asymptomatic with exercise or in recovery without angina
• Moderate risk

  • LV EF 40-50%
  • signs and symptoms including angina at moderate levels of exercise
  • mild to moderate silent ischemia seen on EKG with exercise or in recovery
• High risk

  • LV EF <40%
  • survivor of cardiac arrest
  • complex ventricular dysrhythmias at rest or with exercise
  • MI or cardiac surgery complicated by cardiogenic shock, CHF
  • Abnormal hemodynamics with exercise, decreasing systolic BP
  • Maximal functional capacity <5 METs
  • signs and symptoms including angina pectoris, dizziness, lightheaded, dyspnea at low levels of exercise
• orthopnea is a condition in which the breathing is affected by the position of the body such as sleeping
• trepopnea is difficulty breathing when on one side
• paroxysmal nocturnal dyspnea is a condition where the patient has difficulty breathing during sleep
• Accessory muscles of breathing are SCM and scalenes
• Pre gait exercises = mini squats, marching in place
• when to hold activity in the hospital

  • signs of pump failure such as SOB, worsening edema, diaphoresis, decreased BP with activity
  • recurrent malignant arrhythmias
  • angina as rest
  • second or third degree heart block
  • signs of poor perfusion
• aerobic exercises

  • functional, large muscle mass
  • start with short intervals of 2-5 minutes and build up to 20-30 minutes
• Resistance training

  • avoid straining
  • weight should be 30-50% 1 RM
  • perform 8-10 reps
  • exercise large muscle groups before small ones
• when to terminate exercise

  • angina
  • decrease in SBP with activity
  • SBP >240
  • DBP >110
  • EKG changes
  • Ventricular arrhythmias of >6/min
  • dyspnea
• Systolic hypotension

  • >20 drop
• Abnormal responses to exercise

  • symptoms
  • Angina
  • undue dyspnea
  • excessive fatigue
  • confusion/dizziness
  • claudication
• abnormal responses to exercise

  • signs
  • pallor
  • cold sweats
  • ataxia
  • new murmur
  • pulmonary rales
• ECG abnormalities

  • serious arrhythmias
  • 2nd or 3rd degree heart block
  • acute ST changes
• Abnormal HR response

  • too rapid of an increase
  • failure of HR to increase
  • Decreases with exercise