Phase 1 Cardiac Rehabilitation - Comprehensive Notes

Phase 1 Cardiac Rehabilitation: Overview and Goals

  • Phase 1 occurs while the patient is in an intensive care, telemetry, or transitional unit setting.
  • Primary goals:
    • Assess the patient's ability to safely perform daily activities after discharge.
    • Provide education on the condition and management strategies.
    • Collaborate with the care team to support a smooth transition home or to a facility for continued rehab.
  • Physiologic monitoring is essential during Phase 1, especially when initiating early mobility (now standard of care).
  • Monitoring modalities may include:
    • Portable ECGs
    • Pulse oximetry
    • In some cases, invasive lines for continuous blood pressure readings
  • Monitoring is applied during routine activities (toileting, self-care, position changes) to gather data that informs medical decisions and optimizes the patient’s condition before discharge.
  • Activity guidelines in Phase 1 are designed to progress gradually with daily reassessments that account for changes in hemodynamics and overall function.
  • Education components:
    • Teach patients and caregivers how to monitor symptoms.
    • Modify risk factors.
    • Emphasize the value of continuing formal cardiac rehabilitation after discharge.
  • By the end of Phase 1:
    • Patient and family should have a strong understanding of safely managing the condition.
    • They should feel confident taking the next steps in recovery, preparing for structured outpatient rehab focused on long-term conditioning, sustainable lifestyle changes, and reducing risk of future cardiac events.

Evaluation in Phase 1: Key Steps for Physical Therapist

  • Evaluation begins with thorough chart review:
    • Primary diagnosis (e.g., myocardial infarction).
    • Secondary diagnoses (e.g., diabetes, chronic kidney disease) that influence activity safety.
    • Initial and ongoing symptoms suggesting cardiovascular or systemic dysfunction (angina, shortness of breath, fatigue, dizziness).
    • Documentation of symptoms by nurses, therapists, or other care team members.
    • Review medications and their effects on heart rate, blood pressure, and movement response.
    • Review lab and diagnostic results: cardiac enzymes (e.g., troponins), basic blood panels, imaging (chest X-ray, echocardiograms) to gauge cardiopulmonary status and guide safe activity levels.
    • Synthesize data (diagnoses, symptoms, medications, test results) to develop an individualized assessment plan before entering the patient’s room.
  • Surgical history and precautions:
    • CABG or PCI procedures, understanding surgical approach and graft locations.
    • Facility-specific precautions and potential complications (e.g., perioperative myocardial infarction) and pacemaker placements.
    • These details influence precautions, activity limitations, and progression speed.
  • Monitoring throughout inpatient care:
    • Track trends in heart rate, blood pressure, and oxygen saturation to assess stability and guide progression.
    • Evaluate hemodynamic stability as activity increases; signs like hypotension or arrhythmias may require plan adjustment.
  • Continuous ECG/telemetry monitoring support:
    • Use 3-lead or 5-lead systems to watch for arrhythmias, ischemic changes, and other events affecting safety during activity.
  • Medication review:
    • Understand current cardiac meds (e.g., beta blockers, antiarrhythmics, vasodilators) because they affect exercise tolerance and vital sign responses.
    • Example: beta blockers blunt heart rate response, so RPE may be favored to monitor intensity.
    • Diuretics can increase risk of orthostatic hypotension or electrolyte imbalances; factor this into exercise planning.
  • Supplemental oxygen considerations:
    • Assess oxygen needs; respiratory orders provide initial flow/usage parameters, but clinicians monitor oxygen levels during therapy and adjust as needed to maintain stable saturation.
    • If dyspnea or fatigue arises, modify exercise by adding rest breaks or reducing intensity.
  • After chart review and relevant consultations, move to patient interview to gain subjective insight.

Patient Interview: Building Rapport and Gaining Insight

  • Purpose: gain insights into symptoms, experiences, health understanding, home environment, and personal recovery goals.
  • Interview principles:
    • Use open-ended questions to allow patient stories without medical jargon.
    • Practice active listening to understand perceptions and emotional responses.
  • Example areas and questions:
    • Current complaint: "What brought you to the hospital? How did this issue start?"
    • Medical history: "Have you had any past health issues?"
    • Current symptoms: "What symptoms are you currently experiencing?"
    • Risk factors: family history or lifestyle factors.
    • Home and social support: "Who supports you at home?"
    • Education readiness: "What do you think is causing your symptoms? How ready are you to learn about managing your condition?"
    • Goals for recovery: "What are your goals for recovery?"
  • The interview informs discharge planning and helps tailor education and rehabilitation planning.
  • The interview also includes a review of systems, bridging subjective reports to the physical examination that follows.

Systems Review: Focus on Cardiovascular, Pulmonary, and Musculoskeletal

  • Purpose: identify symptoms and signs that could impact safety for mobility and exercise; detect red flags early.
  • Cardiovascular system: inquire about angina, palpitations, shortness of breath, dizziness, edema; symptoms may indicate ongoing ischemia, heart failure, or arrhythmias requiring adjustments to mobility plans.
  • Pulmonary system: inquire about cough, wheeze, dyspnea at rest or with activity; possible pulmonary edema or reduced respiratory capacity; influences activity tolerance and may necessitate pacing or supplemental oxygen.
  • Musculoskeletal system: assess pain, stiffness, weakness due to bed rest, surgery, or compensatory patterns; sternotomy may cause shoulder pain or ROM limitations that affect safe/effective therapy.
  • Review of systems integration: links subjective patient reports with objective findings to guide the physical examination.

Cardiorespiratory and Supported Exam: Auscultation and Breath Sounds

  • Auscultation of heart/lungs is a key skill for PTs in acute or chronic cardiorespiratory impairment settings.
  • Heart sounds:
    • S1 (lub): closure of mitral and tricuspid valves; marks ventricular systole; best heard at the tricuspid and mitral areas.
    • S2 (dub): closure of aortic and pulmonic valves; marks start of ventricular diastole; best heard at the aortic and pulmonic areas.
  • Abnormal heart sounds to recognize (S3, S4, murmurs) and their clinical significance; interpretation improves with practice.
  • S3 (ventricular gallop): associated with heart failure and increased ventricular filling pressures; best heard at the mitral area.
  • S4 (atrial gallop): indicates stiffened ventricles from hypertension or aortic stenosis; reduced ventricular compliance.
  • Murmurs:
    • Caused by turbulent blood flow due to valve dysfunction or high flow.
    • Types include forward flow through stenotic valves or backward flow through regurgitant valves.
    • Graded on a scale from 1 to 6; 1 is barely audible, 6 is very loud.
    • Entry-level PTs should recognize clearly abnormal sounds and know when to refer for further evaluation; detailed auscultation skill develops with experience.
  • Lung auscultation and signs of edema:
    • Crackles/rales indicate fluid accumulation from congestive processes; early inspiration crackles are typical.
    • Wheezes may indicate bronchial constriction due to interstitial edema and airway narrowing.
    • Left-sided heart failure can cause pulmonary edema, manifesting as crackles/wheezes depending on the scenario.
  • The role of auscultation in guiding PT decisions: identify complications and determine appropriateness of interventions.

Peripheral Edema and Vascular Assessment

  • Peripheral edema is common when the heart cannot pump effectively (acute MI or chronic heart failure).
  • Mechanism: reduced effective circulating volume triggers renal fluid retention to maintain perfusion, leading to edema in dependent regions (ankles, feet, pretibial areas).
  • Edema monitoring is essential for safe mobility progression and for identifying when medical interventions (e.g., diuretics) or therapy adjustments are needed.
  • Outpatient education emphasis: daily weight tracking to monitor fluid shifts and treatment effectiveness.
  • In Phase 1, edema assessment before mobilization is critical due to impact on mobility, comfort, joint range, and balance.
  • Edema assessment method:
    • Pitting edema test by applying firm pressure to the pretibial region for roughly 10–20 seconds.
    • Indentation persistence is graded on a scale: 0 (no edema) to 4+ (skin rebound >30 seconds).
    • Typical scale (as described):
    • 1+: barely perceptible depression
    • 2+: easily identified depression with rebound within 15 seconds
    • 3+: rebound within 15–30 seconds
    • 4+: rebound after more than 30 seconds
  • Tracking edema trends helps guide safe mobility, inform need for medical intervention, and adjust therapy accordingly.
  • Edema is not specific to cardiac dysfunction and can occur with other conditions, but in cardiac disease its presence aids in identifying fluid balance challenges and treatment response.

Multisystem Assessment: Vascular, Musculoskeletal, Integumentary, and Neurologic Systems

  • Vascular: assess arterial disease or reduced cardiac output leading to poor peripheral perfusion; evaluate pulses, extremity temperature, skin color; signs include cool limbs and delayed capillary refill; poor perfusion can cause fatigue, delayed healing, and cramps, potentially limiting weight-bearing and ambulation.
  • Musculoskeletal: bed rest and systemic inflammation can cause weakness, joint stiffness, and pain; use manual muscle testing (MMT) and ROM assessments to identify deficits; plan interventions (strengthening, joint mobilization) to restore function.
  • Integumentary: examine wounds/incisions for infection; protect skin integrity and monitor healing progress; adjust positioning and activity to prevent pressure injuries after surgery or prolonged immobility.
  • Neurologic: screen for cognitive deficits, assess sensation, evaluate balance; reduced cerebral perfusion or peripheral neuropathy can affect safety, communication, and motor performance during rehab.
  • Rationale: addressing multi-system impairments early optimizes outcomes and reduces risk of setbacks during recovery.

Understanding Stability: Absolute and Relative Indications for Mobilization

  • Information gathered from chart review, interviews, and systems review helps determine clinical stability; this information should be readily retrievable for decision-making.
  • Absolute indicators of instability (may necessitate withholding activity until stabilized):
    • Decompensated congestive heart failure (CHF): signs include extra heart sounds, worsening pulmonary crackles, increased peripheral edema, unrelieved dyspnea.
    • Arrhythmias with ischemia or hemodynamic changes (e.g., drops in blood pressure) that increase risk of sudden cardiac events.
    • Dissecting aortic aneurysm (medical emergency): exercise can cause rupture; halt treatment and seek immediate medical intervention.
  • Relative indications for action after clinical judgment and monitoring:
    • Resting tachycardia: may reflect physiologic stress (dehydration, fever) or decompensation (infection, worsening cardiac function); assess whether tachycardia is compensatory or pathologic; new or worsening tachycardia warrants closer monitoring.
    • Resting blood pressure concerns:
    • Systolic > 160 \, \text{mmHg} or Diastolic > 90 \, \text{mmHg} may indicate poorly controlled hypertension and increased cardiac workload; some individuals may tolerate higher values, but caution is needed, especially if cardiac function is impaired.
    • Systolic < 80 \, \text{mmHg} can signal hypotension, raising concerns for syncope and perfusion deficits; mean arterial pressure (MAP) < 60 \, \text{mmHg} indicates critically impaired organ perfusion.
    • MAP is defined as MAP = \frac{SBP + 2\cdot DBP}{3}
    • Recent myocardial infarction within the past two days: high risk of recurrent ischemia, arrhythmias, and sudden cardiac arrest; modify or defer PT until stabilization.
    • Uncontrolled metabolic disturbances (e.g., hypoglycemia, electrolyte imbalances) can strain the cardiovascular system or provoke arrhythmias; exercise with caution and correction of abnormalities.
    • Psychosis or unstable psychiatric conditions: may impair adherence to instructions and increase risk of falls or other incidents; modify environment or plan as needed.
  • Overall approach: decisions are contingent on careful reassessment and vigilance; these are not automatic contraindications but require tailored adjustments and monitoring.

Practical Considerations: Monitoring, Medications, and Oxygen during Phase 1

  • Monitoring guidance emphasizes safety and data-driven progression:
    • Continuous ECG/telemetry monitoring to detect arrhythmias or ischemic changes during activity.
    • Pulse oximetry to ensure adequate oxygenation during therapy; adjust oxygen as needed.
    • Blood pressure and heart rate trends to guide progression and detect instability.
  • Medication effects on exercise:
    • Beta blockers blunt heart rate response, increasing reliance on RPE for intensity regulation.
    • Antiarrhythmics and vasodilators can influence exercise tolerance and hemodynamic responses.
    • Diuretics may predispose to orthostatic hypotension or electrolyte disturbances; plan activities with attention to hydration and position changes.
  • Oxygen therapy:
    • Respiratory orders provide initial parameters; clinicians monitor oxygen saturation and adjust flow to maintain safe levels.
    • If dyspnea worsens or oxygen saturation drops, modify therapy by adding rest breaks or reducing intensity.
  • Safe progression relies on integrating data from chart review, interview, and systems review to tailor activities to the patient’s current condition.

Notes on the Plan for Outpatient Rehabilitation and Continuity of Care

  • Phase 1 emphasizes preparing the patient and family for structured outpatient rehab with a focus on long-term conditioning and sustainable lifestyle changes.
  • The continuity of care requires effective communication with nurses, physicians, and other allied health professionals to coordinate discharge planning and home or facility-based rehabilitation pathways.

Summary: Why These Steps Matter for Safety and Outcomes

  • Early mobility and continuous monitoring reduce the risk of deconditioning and support safer discharge planning.

  • A comprehensive, multi-system assessment helps identify hidden risks and tailor activity levels to individual stability.

  • Recognizing red flags (absolute and relative) and understanding when to escalate care protects patients from adverse events.

  • Patient-centered interviewing fosters engagement, adherence, and informed decision-making about recovery goals and home care.

  • The framework connects chart data, patient experience, and physical examination to produce a cohesive, safe, and effective Phase 1 rehabilitation plan.

  • Connections to practice:

    • Informs decision-making across inpatient care and transitions to outpatient rehab.
    • Supports safer early mobilization and better long-term outcomes by aligning therapy with stability indicators.

  • Ethical and practical implications:

    • Prioritize patient safety while enabling necessary activity to prevent deconditioning.
    • Balance risks and benefits through continuous assessment and collaboration with the medical team.
    • Respect patient and family goals while ensuring clinically appropriate care and timely escalation when red flags emerge.

  • Important numerical references and formulas to memorize:

    • Red flags thresholds for blood pressure:
    • Systolic > 160 \, \text{mmHg} or Diastolic > 90 \text{ mmHg} may be problematic in some patients.
    • Systolic < 80 \text{ mmHg} raises concern for syncope and poor perfusion.
    • Mean arterial pressure: MAP = \frac{SBP + 2\cdot DBP}{3} with MAP < 60 \text{ mmHg} indicating critical perfusion concerns.
    • Edema grading scale for pitting edema: 0 to 4+ (described verbally above) with indentation persistence evaluated after pressing for 10-20 \text{ seconds}.
    • Edema assessment time references for skin indentation and rebound times (e.g., 15 seconds, 15-30 seconds, >30 seconds) as described in the scale.
    • Timeframe for edema assessment and daily weight considerations are particularly emphasized for outpatient education but are relevant to inpatient management as well.