Page 879 - Cardiac Nursing

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C HAPTER 37 / Exercise and Activity 855
Patient Education in Outpatient suitable period. The period of time required before patients move
Cardiac Rehabilitation to a maintenance program can vary considerably, depending on
reimbursement, the patient’s stability, exercise capacity, and the
The education component in an outpatient rehabilitation program individual patient’s needs, but it rarely exceeds 12 weeks. The
usually focuses on modifying risk factors for heart disease. purpose of this phase is to maintain training adaptations, to pre-
Chapter 32 address risk factor modification in detail. Exercise, as vent recurrence of events or symptoms, and to maintain progress.
mentioned previously, is usually the main focus of cardiac rehabil- An important concept to instill in patients at this point in time is
itation. However, exercise affects other alterable risk factors such as that continued maintenance of their exercise capacity and a phys-
hypertension, abnormal lipids, obesity, smoking, and diabetes. ically active lifestyle is one of the most important determinants of
During exercise, opportunities arise to teach informally about risk future health outcomes. 2,5,32,43–45,55,56,62 It is important that pa-
factor modification in all these areas. Teaching the patient about tients understand how to monitor their exercise intensity, under-
exercise is often performed formally through group presentations stand how to recognize symptoms, and have a basic knowledge of
and informally as each patient progresses with their exercise ses- their particular disease and medications.
sions and as the home program evolves. Other issues can be ad- When making occupational activity recommendations for pa-
dressed in formal classroom sessions, in short sessions after the ex- tients, it can be helpful to know the estimated energy require-
ercise training periods, or by distributing educational materials. ments of various activities (see Display 37-7). With this knowl-
The home exercise prescription should be given to the patient soon edge, appropriate recommendations can be made, balancing
after starting outpatient cardiac rehabilitation. Patients should be patients’ functional limitations with their need to return to work,
asked to exercise at home on the days they do not come to cardiac desire to continue recreational activities, or both.
rehabilitation. The aim is to gradually have them exercising most It is useful to perform an exercise test before the maintenance
days of the week for 30 or more minutes each time, as recom- program to provide an outgoing exercise prescription, confirm the
mended by the AHA, Surgeon General Report, and ACSM guide- safety of exercise for a given patient, and assess risk for future car-
lines. If they attempt to exercise every day, they will be most likely diac events. Funding for this phase must often be borne by the pa-
to achieve the recommended three to five times per week. When tient because most types of health insurance do not cover it; how-
patients walk for exercise, they can be encouraged to gradually in- ever, mechanisms for follow-up should be in place. In recent years,
crease the duration to 60 minutes. Walking is the most common programs have been developed in the Young Men’s Christian As-
home exercise, but if the patient has access to other forms of exer- sociation (YMCA), gyms, and other community facilities that
cise, then prescriptions should be given for these modes. Excellent make it less expensive and more accessible for patients in need of
references for home exercise include the ACSM Fitness Book, 72 maintenance programs.
73
Take a Load off the Heart, and numerous other patient education
t
t
materials that are available on the AHA and ACSM Web sites.
Rehabilitation in Patients with CHF
Until the late 1980s, CHF was considered by many authorities to
Safety of Exercise Training in be a contraindication to participation in an exercise program. To-
Outpatient Cardiac Rehabilitation day it is known that most patients with CHF derive considerable
benefits from cardiac rehabilitation. 66 With improvements in
The safety of outpatient cardiac rehabilitation has been well docu- therapy (i.e., thrombolysis, angiotensin-converting enzyme in-
mented in both the United States and Europe. In 1986, Van Camp hibitors, -blockers, implantable cardioverter defibrillators), sur-
and Peterson sent questionnaires to 167 randomly selected cardiac vival of patients with CHF has improved considerably, and more
rehabilitation centers. 74 Data were gathered on more than 51,000 of these patients are candidates for rehabilitation. The incidence
patients who exercised more than 2 million hours from January of CHF is increasing; it is currently approximately 500,000 per
1980 to December 1984. During this time, there were only 21 car- year in the United States. The numerous randomized trials per-
diac resuscitations (three of which failed) and eight MIs. This formed during the 1990s in the United States and Europe indi-
amounts to 8.9 cardiac arrests, 3.4 infarctions, and 1.3 fatalities per cated that the major physiologic benefit from training in CHF
one million hours of patient exercise. Surprisingly, ECG monitor- occurs in the skeletal muscle rather than in the heart itself.
ing had little influence on complications, which suggests that the The clinical approach to the patient with CHF who is consid-
additional expense of telemetry may not be necessary. ered for a rehabilitation program is similar to that for the post-MI
In a 16-year follow-up from William Beaumont Hospital in patient described earlier, although several important differences
Michigan, 292,254 patient-exercise-hours were recorded in phase are worth noting. While sudden cardiac events during exercise are
75
II and III programs. During this period, a total of five major car- extremely rare in all patients, the risk is higher in patients with
diovascular complications occurred; the complication rate was one CHF than in patients with normal left ventricular function. This
per 58,451 patient-exercise-hours. Over the last three decades, nu- is the population in whom serious arrhythmias occur most often.
merous other studies have confirmed the fact that exercise training There are more medications to be considered that can influence
is extremely safe in patients with cardiovascular disease. Despite exercise responses, including vasoactive, antiarrhythmic, in-
the scarcity of serious events during exercise, appropriate medical otropic, and -blocking agents. Exercise capacity tends to be sig-
personnel must be available to respond should an event occur.
nificantly lower than that in the typical patient with coronary
disease.
Maintenance Program Numerous hemodynamic abnormalities underlie the reduced
exercise capacity commonly observed in CHF, including impaired
Progression to an out-of-hospital maintenance program is desir- HR responses, inability to distribute cardiac output normally, ab-
able after patients have participated in a supervised program for a normal arterial vasodilatory capacity, abnormal cellular metabolism