Page 873 - Cardiac Nursing

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C HAPTER 37 / Exercise and Activity 849
differ. In addition, nearly all patients will have one or more co-
DISPLAY 37-5 Characteristics that Classify an MI as morbidities, and any of these may require different clinical con-
Being Complicated
siderations and may also have a different psychosocial impact. For
• Congestive heart failure example, an increasing percentage of patients today will have obe-
• Cardiogenic shock sity, diabetes, or both, and many will have musculoskeletal prob-
• Large MI—as determined by creatine phosphokinase, lems or other metabolic disorders. Triaging or management of
troponin, and/or ECG these comorbidities often is within the purview of the cardiac
•Pericarditis rehabilitation team.
• Dangerous arrhythmias, including conduction problems.
• Concurrent illnesses Education of the Patient
• Pulmonary embolus
• Continued ischemia Education should be initiated before physical activities are begun;
• Stroke or transient ischemic attack the patient may lack self-confidence and need affirmation that the
activities are safe. Patient education during the acute phase usually
consists of an explanation of the coronary care unit, the cardiac
rehabilitation program, and the delivery of routine diagnostic and
therapeutic modalities. The patient should be educated about the
among those with uncomplicated MIs. The most important clin- limitations imposed by the disease, the potential for improve-
ical predictors of complicated infarctions have been previous MI ment, and precautions to be observed. The program should be
and the presence of CHF and/or cardiogenic shock. It is possible individualized for the patient depending on his or her clinical
to assess risk at different temporal points, from presentation in the and psychosocial status. The medical status is determined largely
emergency department through the coronary care unit, as well as by the severity of the MI, but the medical history must also be
before discharge and during later follow-up. This is important be- considered.
cause the clinical picture can change over time; a low-risk patient The activity and exercise component of inpatient education
can become a high-risk patient and vice versa. These changes in should involve teaching patients about activities they can do, as
risk are partially caused by the vicissitudes of the atherosclerosis well as those they should be more cautious in doing, during the
process, reformation of thrombus, interventions, and disease–host first few weeks of their rehabilitation. This differs somewhat be-
interactions. For instance, a patient may present with premature tween patients having cardiac surgery versus those with MI. The
ventricular contractions that can then disappear or worsen, chest activity limitations after cardiac surgery involve sternal precau-
pain may come and go, the ECG may change, or the enzymes tions and psychological adjustment to a major surgery. Those ac-
may have a late peak. This makes it difficult to classify a patient tivities that put stress on the sternal incision are listed in Display
strictly as high- or low-risk; risk stratification often requires good 37-6. It is advisable for cardiac surgery patients to wait at least 4
judgment by the patient’s physician, along with that of the nurs- to 6 weeks before driving a vehicle, partly because the sternal in-
ing staff. In addition, indicators signifying progress or regression cision would be at risk in an impact. There is also some cognitive
of the patient’s condition can change quickly during hospitaliza- adjustment that needs to take place after a major surgery before
tion. Importantly, any change in clinical status must be consid- the patient’s reflexes are fully intact. Patients with MI have slightly
ered before initiating physical activity. The pace of rehabilitative different reasons for activity limitations. It may be necessary to re-
steps must often be adjusted for a particular patient. turn to activities gradually because of the added work placed on
the healing myocardium. As mentioned, early mobilization of the
Psychosocial Considerations patient with acute MI is now well accepted; however, there are im-
Hospital admission for an acute MI is a stressful experience with portant reasons to avoid sudden increases in myocardial oxygen
a powerful impact. However, hospital discharge can be equally demand during the first few weeks of rehabilitation. In addition,
stressful after the patient has relied on the highly protective hos- those patients who have undergone PTCA and stent placement
pital support systems. Discharge into an uncertain future and into are often cautioned to refrain from strenuous activity for a some-
a home and work setting in which the patient may be considered what longer period, for example, approximately 6 weeks. A maxi-
a helpless invalid can be as damaging to the patient’s self-esteem mal exercise test is usually postponed until that time as well.
as the acute event itself. The nurse is faced with the difficult tasks Patients should understand that the conditioning program for
of not only supervising the physical recovery of the patient but patients after MI and surgery should be gradual. Those in a walk-
also maintaining morale, providing education, helping the family ing program are usually instructed to continue the walking they
cope, providing support, and facilitating the return to a gratifying have been doing in the hospital. In addition, the energy cost of
lifestyle. Studies have shown that psychosocial interventions, in-
cluding such things as counseling, group therapy, behavior modi-
fication, stress management, and relaxation techniques, are effec-
tive in improving psychological well-being, reducing stress, and
reducing type A behavior scores. 11,65 DISPLAY 37-6 Sternal Precautions and Activity Guidelines
It is also important to consider that a small percentage of pa- (for at least 6 weeks after Cardiac Surgery)
tients will have no difficulty exercising on their own and might Do not lift more than 10 lb.
not need a formal exercise program. However, all patients can Do not push up as if getting out of bed or out as if pushing
benefit from education and secondary risk reduction. Some pa- a cart.
tients benefit from exercising with a group, whereas others fare No pulling.
better by themselves. The approach to each patient must be indi- No arm activities above the level of the heart.
vidualized because patients’ reactions to problems and their needs