Page 871 - Cardiac Nursing

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C HAPTER 37 / Exercise and Activity 847
drastically altered the way in which cardiac rehabilitation is im-
DISPLAY 37-3 Physiologic Consequences of Prolonged plemented. Hospital stays are shorter, progression through the
Bed Rest
program is more rapid, and much of “cardiac rehabilitation” as
1. Loss of muscle mass, strength, and endurance it was traditionally known has changed. Reimbursement pat-
2. Decreased plasma and blood volume terns differ considerably from one state to another, and insur-
3. Decreased ventricular volume ance coverage for rehabilitation services differs widely. With
4. Increased hematocrit and hemoglobin shorter periods of time for physicians and nurses to interact with
5. Diuresis and natriuresis and monitor patients and cover educational materials ade-
6. Venous stasis quately, there is a greater need for structured outpatient pro-
7. Bone demineralization
8. Increased HR at rest and submaximal levels of activity grams in the home or community.
9. Decreased resting and maximum stroke volume Historically, typical phases that were included in rehabilitation
10. Decreased maximum cardiac output were phase I, which includes the coronary care unit and inpatient
11. Decreased maximal oxygen uptake care during the first few days after the event; phase II, which in-
12. Increased venous compliance volves convalescence, an outpatient program, or a home program;
13. Increased risk of venous thrombosis and thromboem- and phase III, which was usually a longer-term community-based
bolism or home program. The precise course of each program naturally
14. Decreased orthostatic tolerance depends on the individual’s needs and clinical status.
15. Increased risk of atelectasis, pulmonary emboli
In-Hospital Rehabilitation After a
Myocardial Event
only by reduced exercise capacity but also by reductions in mus- The purpose of beginning cardiac rehabilitation immediately af-
cle mass and strength, alterations in body fluid distribution, and ter a myocardial event is to counteract the negative effects of de-
orthostatic intolerance (Display 37-3). The importance of the ab- conditioning rather than to promote training adaptations. It also
sence of orthostatic stress on the deconditioning response has provides an ideal time to begin education and psychological sup-
been documented by studies demonstrating that exercise training port. These first 3 to 5 days after an MI or bypass surgery are crit-
during bed rest is only partially effective or fails to maintain ical for beginning these processes. The literature is replete with
.
VO 2 max.
V V 63,64 studies documenting the efficacy and safety of beginning activi-
Through much of the past century, patients were almost com- ties and education soon after a coronary event in stable patients.
pletely immobilized in bed for 6 to 8 weeks after MI. As recently Initially, it is worthwhile for the nurse, in concert with the pri-
as the 1960s, extended periods of bed rest were thought to facili- mary physician, to medically evaluate the patient, including as-
tate myocardial healing for patients recovering from MI. Today, sessing the patient’s clinical stability and the severity of the MI.
the converse is true. Carefully prescribed and supervised physical Details concerning the diagnosis and management of MI are pre-
activity is recommended as soon as 1 day after the event to coun- sented in Chapter 22. An overview of patient assessment is pro-
teract the many negative physiologic effects of bed rest. In addi- vided in the context of the patient being considered for cardiac
tion to their cardiovascular event, patients may be subjected to rehabilitation.
long periods of immobilization because of severe pain; muscu-
loskeletal or nervous system impairment, including paralysis; gen- History and Physical Examination
eralized weakness; psychosocial problems, such as severe depres- The tools for assessment begin with the history and physical ex-
sion; and infectious disease. The extensive literature available on amination. The first step in evaluating patients for cardiac reha-
the deleterious effects of immobility has been reviewed else- bilitation is to determine whether the cardiovascular disease is sta-
where. 63,64 ble. Each patient should be stratified into an appropriate risk
category using information usually available from the history and
physical examination, as well as diagnostic tests performed as part
CARDIAC REHABILITATION of the hospital course (Display 37-4). 65 Stability is determined
primarily by the presence or absence of myocardial ischemia,
Cardiac rehabilitation programs are designed to limit the physi- CHF, and dysrhythmias.
ologic and psychological effects of cardiac illness, reduce the risk The hallmark symptom of ischemia is chest pain. Most pa-
for sudden death or reinfarction, control cardiac symptoms, sta- tients have chest pain of some type, and it is frequently ignored.
bilize the atherosclerotic process, and enhance the psychosocial Once patients are told about heart disease, their routine pains can
and vocational status of selected patients. Cardiac rehabilitation become frightening. Clinically, it is important to separate nonis-
services are typically prescribed for patients who (1) have had chemic from ischemic chest pains. Chest pain that is unrelated to
MI; (2) have had coronary revascularization (bypass surgery, per- exercise or that is sharp is usually not attributable to ischemia, and
cutaneous transluminal coronary angioplasty [PTCA], or stent not all chest pains should be called angina pectoris. Angina is con-
placement); or (3) have chronic stable angina pectoris. In recent sidered unstable when it changes in pattern (i.e., occurs more fre-
years, cardiac rehabilitation has been expanded to include pa- quently, at rest, or at lower workloads). It is important to note that
tients who have CHF and those who have undergone valvular as many as 25% of patients with acute MI have an atypical chest
replacement, cardiac transplantation, or pacemaker implanta- pain pattern, and some will have no chest pain at all. Ischemia can
tion. Although the spectrum of patients who benefit from reha- cause transient CHF, and increasing symptoms of CHF should be
bilitation has widened, changes in health care economics have noted; these include sudden weight gain, edema in the lower