Page 881 - Cardiac Nursing

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C HAPTER 37 / Exercise and Activity 857
DISPLAY 37-10 Core Components for Cardiac Rehabilitation/Secondary Prevention Programs
Lipid Management • Short-term: Continued assessment and modification of in-
terventions until progressive weight loss is achieved.
• Short-term: Assessment and modification of interventions Have patient participate in on-site weight loss program or
until LDL 100 mg/dL. provide referral to specialized nutrition weight loss pro-
• Long-term: LDL 100 mg/dL. Secondary goals include grams such that weight goals are achieved.
HDL 40 mg/dL and triglycerides 200 mg/dL.
• Long-term: adherence to diet and exercise program aimed
toward attainment of established weight goal.
Hypertension Management
• Short-term: Assessment and modification of interventions Diabetes Management
until BP is 140 mm Hg systolic and 90 mm Hg • In patients with diabetes:
diastolic; in patients with heart failure, diabetes, and re- – Short-term: Develop a regimen of dietary adherence and
nal failure, BP 130 mm Hg systolic and 85 mm Hg dias- weight control which includes: exercise, oral
tolic. hypoglycemic agents, insulin therapy, and optimal
• Long-term: BP 140 mm Hg systolic and 90 mm Hg di- control of other risk factors. Drug therapy should be
astolic; in patients with heart failure, diabetes, and renal provided and/or monitored in concert with primary
failure, BP 130 mm Hg systolic and 85 mm Hg healthcare provider.
diastolic. – Long-term: Normalization of fasting plasma glucose
(80–110 mg/dL or HbA1C 7.0), minimization of
Smoking Cessation diabetic complications, control of associated obesity,
hypertension ( 130/85 mm Hg) and hyperlipidemia.
•Short-term: patient will demonstrate readiness to change • Refer patients without known diabetes whose fasting glu-
by initially expressing decision to quit (contemplation) cose is 110 mg/dL to their primary healthcare provider
and selecting a quit date (preparation). Subsequently the for further evaluation and treatment.
patient will quit smoking and use of all tobacco products
(action); adhere to pharmacotherapy, if prescribed; prac- Physical Activity Counseling
tice strategies as recommended; and resume cessation
plan as quickly as possible when relapse occurs. • Increased physical activity, which includes 20 to 30 min-
• Long-term: complete abstinence from smoking and use of utes per day of moderate physical activity on 5 or more
all tobacco products at 12 months from quit date. days per week, and increased activity in usual routines;
for example, parking farther away from entrances, walking
Weight Management two or more flights of stairs, walking 15 minutes during
lunch break.
2
• In patients with BMI 25 kg/m and/or waist 40 in. in • Increased participation in domestic, occupational, and
men (102 cm) and 35 in. (88 cm) in women. recreational activities.
• Establish reasonable short-term and long-term weight • Improved psychosocial well-being, reduction in stress,
goals individualized to patient and associated risk factors facilitation of functional independence, prevention of dis-
(e.g., reduce body weight by at least 10% at a rate of 1–2 ability, and enhancement of opportunities for independ-
lb/week over a period of time up to 6 months). ent self-care to achieve recommended goals.
LDL, low-density lipoprotein; HDL, high-density lipoprotein, BP, blood pressure; BMI, body mass index; HBA1C, glycosylated hemoglobin.
From the AHA and AACVPR. (2007). Scientific statement on core components of cardiac rehabilitation secondary prevention programs: 2007 update. Journal of Cardiopulmonary
7
7
Rehabilitation, 27, 121–129.
with acute MI in Northern California. Patients were randomized close adherence to appropriate use of aspirin, -blockers,
either to special risk reduction intervention by a nurse case man- angiotensin-converting enzyme inhibitors, and lipid-lowering
ager or to usual care. The intervention patients received education agents, combined with outpatient exercise, nutrition, and smok-
and counseling regarding smoking cessation, regular physical ac- ing cessation counseling. After the study period, there was greater use
tivity, and nutrition. Medical management, such as lipid-lowering of appropriate medications, an increase in the percentage of patients
therapy, was instituted as indicated for risk factors not controlled achieving a low-density lipoprotein-C level less than 100 mg/dL, a
by lifestyle change. Much of the intervention was mediated by reduction in recurrent MI, and a lower 1-year mortality.
phone and mail contact. The intervention group showed greater At Stanford, a randomized controlled trial funded by the Na-
improvement at 6 months and 1 year in functional capacity, rate tional Institutes of Health (NIH) was performed to evaluate the
of smoking cessation, and changes in low-density lipoprotein-C efficacy of case-managed, physician-directed multi-risk factor in-
compared with the usual care group, and subsequent analyses have tervention (the Stanford Coronary Risk Intervention Project
92
shown MULTIFIT to be cost-effective. 95 [SCRIP]). Case managers coordinated care along with a team of
The Cardiac Hospital Atherosclerosis Management Program nutritionists, psychologists, and physicians to provide clinical and
(CHAMP) 94 compared outcomes among 302 patients enrolled lifestyle interventions, attempting to achieve nationally recog-
in a case-managed risk reduction intervention and compared nized goals for risk factor reduction. Three hundred subjects were
them to 256 control patients. All were discharged from UCLA randomized to intervention or usual care groups. After the 4-year
Medical Center with a diagnosis of coronary artery disease or study period, the intervention group demonstrated an increase in
other vascular disease. The case-managed approach emphasized exercise participation, reductions in dietary fat and cholesterol