OTH 5430–Exam 3: Cardiopulmonary

What is ischemic heart disease?

-part of heart is temporarily deprived of sufficient O2 to meet demand

-poor blood supply to the heart muscle via the coronary arteries

-common cause: atherosclerosis (coronary artery disease)

What is coronary artery disease (CAD)?

-a disease caused by the buildup of plaque resulting in the arteries to become hardened and narrowed (atherosclorosis)

-platelets gather on arterial wall, clogging arteries and increasing risk of blood clots

-develops over time without symptoms ("silent killer")

What happens if a patient experiences a partial blockage of coronary artery?

patient may be free of symptoms at rest but have angina with

-eating

-exercise

-exertion

-exposure to cold

What is angina?

Chest pain due to reduced blood flow to the heart

Angina varies from person to person, but the most common symptoms include ___________. How are the symptoms relieved?

squeezing

tightness

fullness

pressure

sharp pain in chest

pain that may radiate back to arm, neck, jaw

can be confused with indigestion

relieved by rest and/or medications (nitroglycerin)

Chest pain (angina) that is not relieved by rest or nitroglycerin likely indicates a ___________.

myocardial infarction (heart attack)

a medical emergency! although some patients likely to delay seeking care bc they attribute the symptoms to anxiety

What is a myocardial infarction (MI)?

-blockage of one or more coronary arteries

-heart muscles deprived of blood begin to die

if a substantial section of the heart is damaged, it will stop pumping AKA cardiac arrest

What is prescribed for the first 6 weeks post MI? Why?

activity restrictions are prescribed to decrease the risk of re-injury

-this includes a delicate balance between rest and activity with no excessive exertion/fatigue

(newly damaged heart muscle is easily re-injured)

What happens 6 weeks after an MI? What can be prescribed?

-scar tissue forms and the risk of re-injury decreases

-scarred heart tissue does NOT contract with each heartbeat (no longer elastic)

-heart efficiency is compromised

graded exercise program can be prescribed (cardiac rehab)

CAD can lead to ____________.

congestive heart failure (CHF)

What is congestive heart failure?

-when the heart muscle is overworked due to stress, high blood pressure, arteriosclerosis, and fluids begin to collect in the body tissues, esp. the lungs

-heart is unable to pump effectively enough and becomes progressively weaker

-the fluid buildup causes SOB

no cure

There are 4 functional classifications of heart disease. At what stages can an OT be most beneficial in providing treatment and interventions?

stages 3 and 4

There are 4 functional classifications of heart disease. At what stages can an OT provide preventative programs?

stages 1 and 2

What is atrial fibrillation?

-valvular disease that results in irregular, ineffective heartbeat/contractions in both atria due to damage by disease or infection

-increases the risk of stroke

volume overload results when fluid accumulates in lungs causing SOB and this overload increases the risk for AFib

What are non-modifiable cardiac risk factors?

hereditary

male gender

age

What are modifiable cardiac risk factors?

high BP

cigarette smoking

cholesterol levels

inactive lifestyle

What are contributing cardiac risk factors?

diabetes

stress

obesity

T or F: There is a bidirectional link between depression and CAD.

true

ppl with CAD more likely to develop depression and ppl with depression are more likely to develop CAD

What surgical procedures can correct CAD?

percutaneous transluminal coronary angioplasty (PTCA)

coronary artery bypass grafting (CABG)

cardiac ablation

What is a percutaneous transluminal coronary angioplasty (PTCA)?

-also known as balloon angioplasty (sx procedure)

-a catheter is inserted through femoral artery and guided to the coronary arteries

-balloon is inflated at lesion site to push plaque against arterial wall

-circulation improves after balloon deflates and catheter is removed

stent may be implanted to keep artery open

What is a coronary artery bypass grafting (CABG)?

-diseased section of coronary arteries is bypassed with healthy blood vessels to improve coronary circulation (sx procedure)

-performed when lesion is too loose or if an artery reoccludes after PTCA

a sternotomy is performed to access the heart for a CABG (leads to sternal precautions post-sx)

What is cardiac ablation?

-medical procedure that destroys all small areas of the heart that are emitting dangerous signals causing abnormal contractions

-small catheters are threaded through a vein to the heart

-the dysfunctional cardiac tissue is reached and an electrical impulse is sent to the site, destroying the abnormal tissue

When the heart's pumping ability has become too compromised by CHF or cardiomyopathy, a _____________ may be considered.

heart transplant or heart-lung transplant

Cardiac medications produce various side effects. Why is this important for an OT to know?

because different side effects can have an impact on rehab and performing occupations

ex: blood thinners – increased risk of bleeding (opt for electric razor rather than blade)

ex: diuretics – increased urination

Common psychosocial considerations in cardiac rehab include _________. How can OT help?

depression

anger

anxiety disorders

social isolation

OT can help by educating on importance of coping mechanisms, returning to activities, finding social support (groups, family)

How many days after an MI is the patient's medical condition usually stabilized?

1-3 days (the acute phase)

acute phase is followed by period of early mobilization

How many phases are there in cardiac rehab? What are they?

3 phases

phase 1 - inpatient cardiac rehab

phase 2 - outpatient cardiac rehab

phase 3 - community-based exercise programs

Phase 1 - inpatient cardiac rehab

-monitored low-level physical activity

-participation in self-care

-reinforcement of cardiac and post-sx precautions

-instruction in energy conservation and graded activity

-establishment of guidelines for appropriate activity levels at DC

-education on S&S of cardiac distress

What are the signs and symptoms of cardiac distress?

angina

dyspnea

orthopnea

nausea/emesis

diaphoresis

fatigue

orthostatic hypotension

What is dyspnea?

shortness of breath with activity or at rest

What is orthopnea?

difficulty breathing when supine

What is emesis?

vomiting

What is diaphoresis?

excessive sweating (cold, clammy)

Phase 2 - outpatient cardiac rehab

-usually begins at DC from inpatient cardiac rehab

-exercise intensity is advanced (and closely monitored)

-may be delivered in person's home initially to build tolerance for intervention in the clinic

-instruction in a sustainable program for optimal physical conditioning

Phase 3 - community-based exercise programs

-individualized recommendations for maintenance

-group fitness classes

What are sternal precautions?

precautions to prevent trauma to new graft sites, incisions, and sternum; generally last 8 weeks (vary amongst dr.'s and hospitals - controversial)

do not push or pull with arms when getting in/out of bed/chair

do not bring elbows above shoulders (keep shldr height)

avoid twisting and deep bending

hug a pillow when coughing or sneezing

no driving until cleared

report clicking or popping noises to surgeon

What vital signs do we monitor throughout activity?

HR

BP

O2Sat

arterial blood gas (ABG)

arterial pressure line

T or F: Heart rate should increase with physical activity.

true

OT's and patients should note whether HR is regular or irregular

A heart rate can be described as regular or irregular. How can an irregular heart rate be described?

1) regularly irregular - consistent irregular pattern

2) irregularly irregular - no pattern to the premature or skipped heart beat

T or F: When giving exercises to a client, the OT should always take a baseline of the client's heart rate to compare to throughout the exercise.

true

always check for irregularities or a drop in HR (HR should increase with exercise, not drop, but should also not exceed past 20 bpm of RHR)

Normal adult HR at rest

60-100 bpm

T or F: Physicians usually indicate treatment parameters for the HR and BP of patients in medical facilities. HR and BP will fluctuate in response to activity, and cardiac output is affected by both HR and BP.

true

What is rate pressure product?

-serves as an estimate of myocardial oxygen demand

-product of HR and systolic BP (RPP = HR × SBP)

-5 digit # but drop last 2 to report as 3 digit #

-during any activity, the RPP should rise at peak and return to baseline in recovery (after 5 to 10 minutes of rest)

ex: HR 100 × SBP 120 = 12,000 = RPP 120

Normal adult BP

≤ 120/80

Normal O2Sat range

92-100%

What do we do when O2Sat is less than 88% (<88%)?

What do we do when O2Sat is less than 84% (<84%) with COPD?

modify treatment

What is chronic lung disease?

umbrella term for chronic lung conditions such as

-sarcoidosis

-asthma

-COPD

-idiopathic pulmonary fibrosis

-cystic fibrosis

persons w/ these conditions may benefit from learning better ways to breathe and conserve their energy

What is chronic obstructive pulmonary disease (COPD)?

chronic, progressive lung disease that includes two primary medical conditions: emphysema and bronchitis

-air sacs become damaged, lose their elasticity, and become clogged with mucus

-breathing takes more effort and therefore participation in ADL and IADL decreases

-damage is irreversible – NO CURE (modify approach)

What is emphysema?

destruction of alveoli; a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness

risk factors

-smoking, air pollutants, weed smoke, manufacture particles

What is bronchitis?

-inflammation of the bronchi leading to increased mucus production, cough, and airway obstruction

-experience SOB (dyspnea) on exertion and as disease progresses, dyspnea occurs at rest

-more prone to developing URI which worsens the disease

risk factors

-smoking

Pulmonary risk factors

cigarette smoking is the leading cause of COPD

air pollution

chemical exposure

dust

stress

overly vigorous work

How is COPD medically managed?

medications:

-anti-inflammatory agents (steroids)

-bronchodilators (albuterol - opens airways)

-expectorants (loosen and clear mucus)

-O2 therapy prescribed at specific flow rate

-mechanical ventilators (prescribed for acute exacerbation caused by flu, pneumonia, CHF)

-pulmonary rehab (dr, nurse, OT, PT, resp. therapist, psych)

Signs and symptoms of respiratory distress include ___________

difficulty breathing

extreme fatigue

non-productive cough

confusion

impaired judgement

cyanosis

The most severe form of shortness of breath (dyspnea) is __________

most severe form is shortness of breath even at rest

ex: unable to utter short phrases w/o gasping for air

ex: "SOB when washing face while standing at sink"

Respiratory rate

process by which O2 and CO2 are interchanged

breaths/1 min

described as normal, rapid, slow

What is the goal of pulmonary rehab?

stabilize or reverse the disease process and return the patient's function and participation in activity/occupation to the highest capacity

What are pulmonary rehab guidelines?

-both low and high intensity exercises are beneficial (higher intensity is better if tolerable)

-arm exercises should be unsupported (active motion with no outside assistance), against gravity and without resistance

-leg exercises should be included

-supplemental O2 is helpful during rehab exercises

apply these guidelines during ADL training

Dyspnea control postures

When sitting – the patient bends forward slightly at the waist while supporting the upper body by leaning the forearms on the table or thighs

When standing – leaning forward and propping the body on a counter or shopping cart may relieve the problem

Pursed-lip breathing (PLB)

-a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping

-done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure

some ppl with COPD instinctively adopt this technique, others are taught

1) relax neck and shoulders

2) inhale slowly through nose for count of 2

3) purse lips as if to whistle

4) exhale slowly through lips for a count of 4

When should pursed-lip breathing be used?

should be used when bending, lifting, and stair climbing

Diaphragmatic breathing

-breathing pattern which calls for increased use of diaphragm to improve chest volume

-breathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate

1) have pt lie in supine

2) place a small book on base of sternum

3) instruct to inhale slowly and make the book rise

4) instruct to exhale through pursed lips and make the book come down again

Relaxation techniques

promotes relaxation using breathing techniques while thinking peaceful thoughts (passive relaxation) or while tensing and relaxing specific muscle groups (progressive relaxation)

helpful in decreasing anxiety and controlling SOB

1) When performing a clinical evaluation, clients with impairments in cardiovascular system will require monitoring of _______. 2) When should monitoring of these occur?

1) HR, RR, and S&S of respiratory distress (anxiety, SOB, confusion, difficulty comprehending, fatigue, dec. endurance, abnormal posture, reduced ability to move, etc.)

2) should occur during an assessment of tolerance to postural changes and during functional tasks

Heart rate - appropriate response to activity

increases with activity to no more than 20 bpm above resting HR

ex: RHR = 100 bpm ; anything surpassing 120 = bad!

Heart rate - inappropriate response to activity

HR more than 20 bpm above resting HR with activity

RHR ≥ 120

HR drops or does not rise with activity

Blood pressure - appropriate response to activity

SBP rises with activity

Blood pressure - inappropriate response to activity

SBP ≥ 220 mmHg

postural hypotension ( ≥ 10-20 drop in SBP)

decrease in SBP with activity

Signs and symptoms - appropriate response to activity

absence of adverse symptoms

Signs and symptoms - inappropriate response to activity

excessive SOB

angina

nausea

vomiting

excessive sweating

extreme fatigue (rate of perceived exertion ≥ 15)

cerebral/cognitive symptoms (confusion, etc.)

T or F: The energy costs of an activity or occupation and the factors that influence energy costs can further guide the clinician in the safe progression of activity or participation in occupation

true

Oxygen consumption suggests how hard the heart and lungs are working and is indicative of the amount of energy needed to complete a task. This is also known as ____________.

metabolic equivalent (MET)

as the activity level increases, the more O2 is needed to complete task

Resting quietly in bed requires the 1) _________ amount of O2 per kg of body weight and equates to 2) ______ basal MET.

1) lowest amount of O2

2) 1 basal MET

Why is the MET-level activity table beneficial to OTs?

helps guide OT in identifying effective progression of activity tolerance (based on the patient's response to activity or occupation, the prognosis, and goals)

progression of intensity increases as the MET level increases; duration of sustained physical activity must also be taken into consideration

What would be the next intervention up from seated sponge bath? What is the MET level?

a standing sponge bath

2-3 METs

Dressing requires ______ METs, or roughly twice the amount of energy that lying in bed requires.

dressing requires 2.5 METs

At ______ METs, sexual activity is a grave concern for patients. However, patients are frequently able to return to sexual intercourse once they can climb up and down two flights of steps in 1 minute with appropriate cardiovascular responses

sexual activity = 5 METs

Which of the following activities fall within the MET Levels 1-2 for Activities of Daily Living (ADL)?

A) Running at 5 mph

B) Gardening and light housework

C) Transferring from bed to chair

D) Swimming and jogging

C) Transferring from bed to chair

Which of the following activities fall within the MET Levels 3-4 for Activities of Daily Living (ADL)?

A) Light housework, such as dusting or folding laundry

B) Running at 5 mph

C) Bowel movement on the toilet

D) Bowel movement on a bedpan

C) Bowel movement on the toilet

Which of the following activities fall within the MET Levels 3-4 for Instrumental Activities of Daily Living, Work, Play, and Leisure?

A) Sweeping, mopping

B) Using an electric vacuum

C) Washing dishes

D) Changing bed linen

A) Sweeping, mopping

What would be the next intervention up from a seated warm shower? What is the MET level?

next would be a standing warm shower (4-5 METs)

(seated warm shower = 2-3 METs)

Energy conservation principles

-decrease rate

-decrease resistance

-decrease use of large muscles

-decrease use of trunk musculature

-lowering one's arms

-decrease isometric work (straining) – contraindication

-UE activity is more demanding of than LE activity

-standing requires more energy than seated activity

-extremes of temp, high humidity, and pollution increase demand upon cardiopulmonary system

Energy conservation: time management

-high energy demanding tasks should be interspersed with lighter tasks

-rest breaks should be scheduled throughout the day (especially after meals)

ex: laying out next days clothes the night before to make mornings easier

Lifestyle modifications include

-guided programs of increased activity and participation in occupation

-stretching, strengthening, aerobic activity

-monitoring vitals and perceived exertion

-cool down

-safety issues related to clothing and environmental factors, and warning signs

-plan for resuming exercise (if skipped)

-emergency guidelines

meal prep activities focusing on nutrition

smoking cessation programs (altering habits to support cessation)

Patient and family education include focusing on _______

disease process

symptom management

risk factors

diet

exercise

energy conservation