Page 877 - Cardiac Nursing

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C HAPTER 37 / Exercise and Activity 853
reimbursement, proximity to the hospital or clinic, and personal
DISPLAY 37-9 Clinical Indications and Contraindications commitment.
for Inpatient and Outpatient Cardiac
Rehabilitation The first few exercise sessions after hospital discharge usually
emphasize warm-up and cool-down activities, with only a modest
Indications aerobic component; some programs use direct electrocardio-
graphic telemetry for the initial sessions to ensure safety. There is
• Medically stable post-MI
• Stable angina less emphasis today than in the past on the need for direct ECG
• Coronary artery bypass graft surgery monitoring (see later). A symptom-limited maximal exercise test
• PTCA is usually recommended approximately 6 weeks after the hospital-
• Compensated congestive heart failure ization to determine an appropriate exercise prescription and ac-
• Cardiomyopathy tivity limitations.
• Heart or other organ transplantation At the beginning of the outpatient program, it is advisable to
• Other cardiac surgery including valvular and pacemaker conduct a patient assessment, discuss the objectives of the pro-
insertion (including implantable cardioverter defibrillator) gram, and develop reasonable goals for the patient based on their
• Peripheral vascular disease needs, capabilities, and clinical condition. Usually the patient is
•High-risk cardiovascular disease ineligible for surgical
intervention scheduled for an initial interview, where baseline data are gathered
• Sudden cardiac death syndrome and information about the program is given to the patient. At this
• End-stage renal disease initial interview the nurse should have reviewed the inpatient
• At risk for coronary artery disease, with diagnoses of records so that the patient has been stratified into the appropriate
diabetes mellitus, hyperlipidemia, hypertension, etc. risk category. In general, the objectives of the outpatient program
• Other patients who may benefit from structured include the following:
exercise and/or patient education (based on physician
referral and consensus of the rehabilitation team) ■ Increase activity level and functional capacity
■ Increase regular exercise participation
Contraindications ■ Improve the patient’s psychosocial status, depression, or anxiety
through participation in exercise, education, or counseling
• Unstable angina
• Resting systolic blood pressure 200 mm Hg or when appropriate
diastolic 110 mm Hg Educate and support patients in other risk reduction efforts
• Blood pressure drop of 20 mm Hg with symptoms (i.e., stop smoking, control hypertension, normalize lipid values,
•Moderate to severe aortic stenosis and maintain healthy weight). The exercise prescription for out-
• Acute systemic illness or fever
• Uncontrolled atrial or ventricular arrhythmias patient rehabilitation is based on the exercise test and is described
• Uncontrolled tachycardia ( 100 bpm) in detail below. A number of fundamental considerations are im-
• Uncompensated congestive heart failure portant when initiating outpatient rehabilitation. Although the
• Third-degree heart block (without pacemaker) typical outpatient session may last approximately 45 minutes, pa-
• Active pericarditis or myocarditis tients should work up to this duration gradually. It is preferable to
• Recent embolism focus on warm-up, stretching, range of motion, and cool-down
• Thrombophlebitis exercises for the first three to six sessions and gradually increase
• Resting ST displacement ( 2 mm) the aerobic portion such that 30 to 45 minutes can be completed.
• Uncontrolled diabetes Regardless of the duration of the aerobic portion, all exercise ses-
• Orthopedic problems prohibiting exercise sions should include warm-up and cool-down periods of 5 to
• Other metabolic problems
10 minutes. A variety of exercise modalities should be used, in-
cluding those that use the upper and lower muscle groups. For ex-
From American College of Sports Medicine. (2006). Guidelines for exercise testing
and prescription (7th ed.). Philadelphia: Lippincott Williams & Wilkins. ample, patients may spend alternating periods using the treadmill,
arm ergometer, cycle ergometer, or stair climber. Resistance exer-
cise is also widely recommended today to assist the patient in
pulmonary disease. Studies show that if these contraindications restoring muscular strength, and complementing aerobic exercise
are considered, the incidence of exertion-related cardiac arrest with resistance training has been demonstrated to have favorable
in cardiac rehabilitation programs is extremely low, and because effects on cardiovascular endurance, hypertension, hyperlipi-
of the availability of rapid defibrillation, serious events rarely demia, and psychosocial well-being. 71
occur. Changes in reimbursement patterns have changed outpatient
programs more than other components of cardiac rehabilitation.
Outpatient Cardiac Rehabilitation In some circumstances, only a few exercise or educational sessions
are reimbursed. The transition from an outpatient to a home-
There have been multiple approaches to outpatient rehabilitation, based maintenance program now occurs more rapidly. Random-
and it has become necessary for programs to be more creative to ized trials have demonstrated that patients can return to work
provide outpatient rehabilitation in the current climate of reduced quickly and safely during rehabilitation and that participation in
reimbursement. Traditionally, this phase begins 1 to 2 weeks after rehabilitation facilitates this process. It is also currently appreci-
discharge from the hospital and may last from 1 to 4 months. ated that only a small percentage of patients require continuous
Most commonly, patients attend group exercise sessions three ECG monitoring during exercise. Efforts to reduce the cost of re-
times per week; however, frequency of exercise is often modified habilitation in addition to the recognition that most patients can
by the individual patient’s overall goals, functional capabilities, exercise quite safely without continuous telemetry have brought