Page 639 - Cardiac Nursing

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C HAPTER 2 5 / Cardiac Surgery 615

■ Figure 25-9 Sample differences in response to exercise
between an innervated and denervated heart. (From
McKelvey, S. A. [1985]. Effects of denervation in the cardiac
transplant recipient. In M. K. Douglas & J. A. Shinn [Eds.],
Advances in cardiovascular nursing [p. 201]. Rockville, MD:
Aspen Systems.)

by the calcineurin inhibitors that are known to cause chronic patients are able to cycle for 20 minutes without resistance and for
nephropathy; in addition, cyclosporine is implicated in the acti- 5 minutes with resistance. With cardiac denervation, heart rate
vation of the sympathetic nervous system, resulting in hyperten- response to exercise is abnormal.
sion. 87 Patients are managed on one, two, or three agents because The ability to perform any exercise beyond mild in intensity
of the tenacity of the hypertension. depends on circulating catecholamines to increase heart rate, con-
tractility, and cardiac output. The normal, immediate increase in
Transplant Vasculopathy heart rate induced by exercise is absent in the denervated heart,
CAV is an accelerated and diffuse form of CHD unique to the and several minutes are required before heart rate can increase.
transplanted heart. It is the major cause of death in the long-term Warm-up exercise is necessary before vigorous activity, and its du-
61
heart transplant patient. CAV is a peculiar kind of vasculopathy ration should be approximately 5 minutes. Deceleration of heart
characterized by diffuse and concentric vascular inflammation and rate after exercise is prolonged. The patient’s heart rate may not
smooth muscle proliferation. It results in coronary lumen loss, is- return to resting levels for up to 20 minutes after cessation of the ac-
chemia, silent MI, and graft loss, which can present as a sudden tivity. Prolonged cool-down periods are also necessary. Figure 25-9
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death. Treatment of CAV is limited because of the diffuse nature illustrates a typical response to exercise.
of the disease, and it is not typically amenable to usual palliative Patients need to understand how their response to exercise is
interventions such as angioplasty, atherectomy, or coronary artery different after transplantation. Self-monitoring techniques are
bypass. Retransplantation is the only definitive treatment, and it taught before discharge, and continued regular exercise is encour-
is fraught with high morbidity and mortality rates, and brings aged. Patients are taught to use dyspnea as a guide for activity in-
fourth the debate regarding the use of limited donor supply. tensity rather than heart rate. The dyspnea index is presented in
Table 25-6. Patients are coached not to exceed a dyspnea index
Sexual Dysfunction greater than level 2. The rating of perceived exertion is a widely
Sexual dysfunction is a prevalent problem in cardiac transplanta- used self-monitoring tool for transplant recipient. The Borg scale
tion recipients. Impotence is not uncommon, and much of it can is a rating of perceived exertion that is scaled from 6 (very, very
be attributed to the requirement for antihypertensive therapy. Pa-
tients would benefit from knowing that these occurrences are not
uncommon. They need to feel comfortable voicing concerns and
reporting future problems so that appropriate counseling or other Table 25-6 ■ CARDIAC TRANSPLANT RECIPIENTS’
assistance can be provided. DYSPNEA INDEX FOR EXERCISE TRAINING
Level 0 No shortness of breath
Conditioning and Exercise Training Can count to 15 without taking a breath
Level 1 Mild shortness of breath
Physical rehabilitation is a necessary part of the posttransplanta- Counts to 15 and requires one breath in the sequence:
tion patient recovery program. Physical therapy is needed to ame- continue at this intensity
liorate the deconditioning of the pretransplantation, heart failure Level 2 Moderate shortness of breath counts to 15 and requires two
breaths in the same sequence; this is the desired level of
state and to decrease the sequelae of the immunosuppressants and intensity
surgical procedure. 89 Low-level exercise is begun with extremity Level 3 Definite shortness of breath
and shoulder flexion, extension, and abduction exercises. The in- Must take three breaths in the sequence of counting to 15;
tensity and duration are progressed to the patient’s tolerance. 90 reduce the intensity of exercise
These low-level exercises serve as warm-up for more intensive ex- Level 4 Severe shortness of breath
Unable to count or speak; cease activity
ercises once the patient can complete the low-level program with-
out undue fatigue or balance loss. Bicycle ergometry is usually in-
Adapted with permission from Sadowsky, H. S., Rohrkemper, K. F., & Quon, S.
troduced within 3 days. Intensity and duration are gradually
(1986). Rehabilitation of cardiac and cardiopulmonary recipients, appendix 1. Stanford,
progressed according to patient response. By discharge, most CA: Stanford University Hospital.