Page 875 - Cardiac Nursing

LWBK340-c37_p842-860.qxd 29/06/2009 09:40 PM Page 851 Aptara

C HAP TE R 37 / Exercise and Activity 851

■ To offset the deleterious physiologic and psychological effects of
DISPLAY 37-8 General Guidelines and Precautions for bed rest
Cardiovascular Exercise
■ To return the patient to ADLs
1. Exercise only when feeling well. Wait 2 days until after ■ To provide additional medical surveillance for the patient
a cold or flu. Never exercise when you have a fever. ■ To introduce the patient to behavior modification with the goal
2. Do not exercise vigorously soon after eating. Wait at of reducing risk factors
least 2 hours.
3. Adjust exercise to the weather. Exercise in the cooler To stratify the patient’s risk for future cardiac rehabilitation
time of day on hot days. Exercise at a slower pace and (see Display 37-4). Patients experiencing MI, undergoing coro-
drink more water than usual in hot weather. nary artery bypass surgery, or undergoing PTCA are usually trans-
4. Slow down for hills. Stay at the same level of exertion ferred from the cardiac or intensive care unit to a telemetry unit
for hills. and sometimes to a general medicine or surgical unit. However,
5. Wear proper clothing and shoes. with decreased length of stays, many are discharged directly from
6. Understand personal limitations. Find out from your the telemetry or step-down unit. The nurses on each of these units
physician what limitations to exercise you have.
7. Select appropriate exercise. Aerobic exercise should are usually the ones who orient and explain to the patient the
be a major component of activities. However, flexibil- processes involved in diagnosis and treatment of the specific car-
ity and strengthening exercises should also be consid- diovascular event. Education about risk factor reduction and the
ered for a well-rounded program. important aspects of medical observation of the patient are dis-
8. Be alert for symptoms. If the following occur while ex- cussed further in Chapter 32. As mentioned, before 1970, pa-
ercising or immediately after, contact a physician be- tients were generally relegated to strict bed rest after an acute MI.
fore continuing exercise: It was thought that any physical activity could lead to complica-
a. Chest discomfort tions such as ventricular aneurysm formation, cardiac rupture,
b. Faintness CHF, dysrhythmias, reinfarction, or sudden death. 67 It has be-
c. Shortness of breath during exercise to the point of come well established that complications are not increased with
uncomfortableness
d. Discomfort in bones and joints either during or af- early ambulation. One of the important roles of inpatient cardiac
ter exercise rehabilitation is to counteract the detrimental physiologic effects
9. Watch for the following signs of overexercising: of strict bed rest. There are also data demonstrating that activity
a. Inability to finish during the in-hospital period may help to decrease anxiety and
b. Inability to converse during the activity depression, improve self-esteem, and reduce type A behavior char-
c. Faintness or nausea after exercise acteristics such as hostility and anger. 11,65
d. Chronic fatigue Traditionally, progressive stepped programs have been used to
e. Sleeplessness increase activity levels while the patient was in the hospital, in-
f. Aches and pains in the joints cluding early mobilization, range-of-motion exercises, and pro-
10. Start slowly and progress gradually. Allow time to gressive activity. A sample step program is shown in Table 37-5. It
adapt.
should be noted that in the current health care climate, the time
available for inpatient rehabilitation is far more limited. Thus, the
From American Heart Association: Exercise Guidelines.

Table 37-5 ■ EXAMPLE OF A PROTOCOL FOR PATIENT AMBULATION EARLYAFTER AN MI
Step Nursing Physical Therapy Occupational Therapy Dietary
Step 1 (bed Orient patient to cardiac care unit, Lower extremity (LE), UE, active range of motion and
rest)* 1 MET use of commode (1.5); arms active range of motion evaluation, introduction to
supported for upper extremity and evaluation sternal precautions and cardiac
(UE) activities, decrease anxiety, rehabilitation (CR) progress
advise patient of activity limitations
Step 2 survey Sit in chair for meals, and 20 minutes Walking in room, or 50 ft UE activity with shoulder flexion
(in room) at a time, three to four times per (2.0), warm-ups (WU) 45 degrees, 10 repetitions,
2 METs day, personal ADLs at bedside or and cool-downs (CD) education: activity guidelines
sink, answer patient questions as (2.5 to 3.0) and risk factor introduction
they arise
Step 3 (short Sitting shower (3.5), continue risk Walking 100 to 250 ft with Increasing abduction to 90 degrees Introduction
walking) 3 METs factor education WU and CD, instruction and 15 repetitions, continue to heart
in independent walking energy conservation and showering healthy
guidelines eating
Step 4 (long Independent in ADLs and walking Walking 250 to 1000 ft Review of ADLs at home, work, Review of
walking) 4 METs on ward, standing shower (3.7); three to four times per and leisure (postsurgery and dietary
discharge instruction: medicines, day, one flight of stairs post-MI) activity precautions follow-up
appointments, emergencies, review (12 steps) (3.5 to 4.0) (sex, driving) as needed
plans for risk factor reduction efforts Given and taught home
exercise program

*MET estimates are in parentheses.