Cardiac Rehabilitation
NP06L012
Study Guide
References: Timby, B. & Smith, N. Introductory Medical-Surgical Nursing, 8th
Edition.
And Linton et.al Inroductory Nursing care of Adults 2nd Ed. page 594
Student Study Assignment: This study guide
Terminal Learning Objective:
Given a patient requiring cardiac rehabilitation, provide safe and effective
care IAW Timby.
Enabling Learning Objective:
1. Define the four phases of cardiac rehabilitation
2. Describe the role of the 91WM6 in the care of the cardiac rehabilitation
patient
Discuss the four phases of cardiac rehabilitation
1.
2.
3.
4.
What is the role of the cardiac rehabilitation team
Cardiac Rehabilitation
NP06L012
Study Guide
Review the following:
Metabolic equivalents (METs) used for cardiac patients to identify level of activity
able to perform.(Lemone & Burke, Medical Surgical Nursing 2nd Ed. 2000)
(1) Activity is progressive and limitation may be quantified by the number of
METs allowed
(2) Mets reflect the amount of oxygen consumed per unit of body weight during
the resting state
(a) As cardiac workload increases so does the metabolic rate and the oxygen
demand
(b) Manifestations of over exertion include:
1) Pulse greater than 120
2) Chest pain
3) Shortness of breath
4) lightheadedness
5) Dizziness
(c) Typical exercise (in ascending METs)
1) 1 MET: Lower extremity/upper extremity active range of motion
2) 2 METs: Sit in chair (20 minutes), ADLs at bedside, walk 50 ft
4) 3 METs: Sitting shower, Walking 250 ft
5) 4 METs: Independent ADLs, standing shower, walking 1000 ft, one
flight of stairs
Discuss patient teaching for the patient in cardiac rehabilitation
Cardiac Rehabilitation
NP06L012
Study Guide
What is the primary role of the 91WM6 when caring for a cardiac rehabilitation
patient
a. Overview
(1) Most commonly initiated at the time of a cardiac event:
(a) Acute MI
(b) Coronary Artery Bypass Graft surgery (CABG)
(c) PTCA or atherectomy
(d) Stent placement
(e) CAD verification via cardiac catheterization
(2) Common goal for all of these patients is achieving a better quality, and
hopefully quantity of life through a healthier lifestyle
(a) Minimize risk of repetition of adverse cardiac event
(b) Attain the highest level of wellness and workability
(c) The program is individualized to the patient
(d) Carried out by a multi-disciplinary team to include physician, nurse,
physical therapist, occupational therapist, dietitian, etc.
(3) Activities and educational activities include the following:
(a) Gradual exercise that increases according to the patient's tolerance
(b) Establishment of physical limitations
(c) Sign, symptoms and management of depression
(d) Medication regimen
(e) Stop smoking
(f) When and how to resume sexual activity
1) Check with physician
2) Avoid sex with anyone other than your usual partner
Cardiac Rehabilitation
NP06L012
Study Guide
3) Adequate rest before intercourse
4) Avoid positions that require supporting your own weight
5) Wait 2-3 hours after a big meal or consuming alcohol
6) A short-acting nitrate may be prescribed
7) Begin with moderate foreplay
8) Medium water temperature when bathing or showing before and after
sexual activity
(g) Diet modification
(h) Pulse and blood pressure monitoring
(i) Signs and symptoms of complications
(j) Stress reduction
(k) Importance of continued medical supervision
(4) Exercise and risk factor improvements are the basis of these programs
(a) Benefits of exercise training
1) Decrease in blood pressure
2) Increase in HDLs (good cholesterol)
3) Augmented weight loss efforts
4) Psychological effects
a) Less depression
b) Reduced anxiety
5) Improved glucose tolerance
(5) Activities
(a) Must be specific and measurable
Cardiac Rehabilitation
NP06L012
Study Guide
(b) Must be flexible in activities per phase, as the focus is to maximize
patient activity without causing complications.
b. Metabolic equivalents (METs) used for cardiac patients to identify level of
activity able to perform.(Lemone & Burke, Medical Surgical Nursing 2nd Ed.
2000)
(1) Activity is progressive and limitation may be quantified by the number of
METs allowed
(2) Mets reflect the amount of oxygen consumed per unit of body weight during
the resting state
(a) As cardiac workload increases so does the metabolic rate and the oxygen
demand
(b) Manifestations of over exertion include:
1) Pulse greater than 120
2) Chest pain
3) Shortness of breath
4) Lightheadedness
5) Dizziness
(c) Typical exercise (in ascending METs)
1) 1 MET: Lower extremity/upper extremity active range of motion
2) 2 METs: Sit in chair (20 minutes), ADLs at bedside, walk 50 ft
4) 3 METs: Sitting shower, Walking 250 ft
5) 4 METs: Independent ADLs, standing shower, walking 1000 ft, one
flight of stairs
c. Cardiac rehabilitation has historically been divided into four phases
(1) Phase I- Inpatient stay
(a) The objectives are:
Cardiac Rehabilitation
NP06L012
Study Guide
1) Educate the patient and family regarding the cardiac event and
diagnostic tests and prepare them for the stages of cardiac rehabilitation and
returning home
2) Offset the negative physiologic and psychological effects of bedrest
3) Activities are gradually increased and the patient's response is
monitored and documented.
a) Breathing exercises
b) Leg exercises
c) Pulse assessment
d) Effects of medication assessment
f) Diet teaching
g) Walking exercises
(b) Assessment
1) Assess the acute response to increasing activities
2) Motivation
a) Critical assessment for all patients
b) Lack of motivation may be linked to fear and anxiety and depression
after the event
c) High motivation may cause patients to "over-do it"
d) Low motivation may cause patients to be sedentary
e) Education can assist in maintaining a healthy balance
3) Previous activity level
a) Assessment of living arrangements (number of stairs in house, where
bedroom is located, who performs household chores, etc.)
b) Critical to setting realistic goals for the patient
Cardiac Rehabilitation
NP06L012
Study Guide
4) Other health problems- anything that may influence, limit, or restrict an
activity for a patient
(c) Patients able to perform 4 METs are capable of performing ADLs without
assistance at home
(d) Education
1) Teach/assess patient understanding of activities he/she can perform
a) Often given a MET list listing activities he/she can safely perform
b) Provide the patient with target heart rate for monitoring
2) Teach/assess understanding of medications, side effects and reasons to
call physician- requires frequent reinforcement and written instructions, as
retention in the hospital setting is poor
3) Provide appointment date and time for start of outpatient cardiac
rehabilitation
4) Remind patient that participation in a cardiac rehabilitation program will
help them become active in a safe manner.
5) Stop smoking
6) Maintain or lose weight, generally patients are place on a low fat and low
sodium diet.
7) Refer patient to their local chapter of the American heart association
(2) Phase II- Immediate Outpatient Cardiac Rehabilitation begins at discharge
(usually about 12 weeks)
(a) Objectives of the outpatient program
1) Increase activity level and functional capacity
2) Increase regular exercise participation
(b) Delayed emotional responses such as anger, anxiety, and depression
may occur
1) Improve the patient's psychological status, depression, or anxiety
through participation in exercise, education and/or counseling
Cardiac Rehabilitation
NP06L012
Study Guide
(c) Educate and support patients in risk factor reduction efforts (smoking,
hypertension, weight loss, etc.)
(d) During this phase many patients are able to return to work
(e) Education is focused on modifying risk factors for heart disease
(3) Phase III- Continuation program
(a) Begins at 3-month to one year, program following the immediate
outpatient cardiac rehabilitation
(b) Patients taught to initiate and monitor their own response to exercise
(c) Stress management and modification of risk factors are emphasized
1) Diet
2) Exercise
3) Medications
(4) Phase IV- Maintenance program begins at one year and last throughout life
(a) Objectives
1) Continued exercise training
2) Therapeutic fitness outings
3) Risk factor modification
4) Health promotion activities
5) Exercise based on graded exercise testing, i.e. treadmill
6) ECG monitoring for intermediate or high-risk patients, as needed
7) Work evaluation, testing and counseling, as needed
(b) Evaluation- transition to assist patients in monitoring their own exercise
program
(c) Education
Cardiac Rehabilitation
NP06L012
Study Guide
1) Teach self-monitoring
2) Encourage patients to engage in different types of exercise
3) Encourage continued risk modification
4) Renew health goals with patient
The role of the 91WM6 in care of the cardiac rehabilitation is to provide emotional
support and patient and family member teaching
(1) Providing emotional support for the patient and family members begins
during hospitalization
(a) During hospitalization many patients who have had a myocardial
infarction or revascularization (PTCA or CABG) experience denial, depression
and anxiety
(b) Anxiety varies in intensity depending on the severity of threat perceived
by the patient and the patient’s success in coping
(c) The cardiac rehabilitation team assists the patient to learn how to cope
with the stress of initiating with a new lifestyle
b. The role of the 91WM6 in patient teaching for the patient and their family
members during cardiac rehabilitation is essential to patient recovery
(1) Education should include the resumption of sexual activity
(a) Many patients will not initiate conversation regarding sexual activity, so
the nurse must initiate the conversation
(b) The patient should discuss sexual activity with their physician
(c) Most post-coronary patients are able to resume sexual activity
(2) Participation in a cardiac rehabilitation program should be discussed before
discharge from hospital and the importance of the rehabilitation services
(a) Teach/assess patient understanding of the importance of regular ,
dynamic activity on the heart
(b) Teach/assess understanding of medications and the need to continue
taking them, even if the patient feels better
Cardiac Rehabilitation
NP06L012
Study Guide
1) Males should be instructed before discharge that beta blockers
(lopressor, etc.) can cause impotence
(c) Monitor patients for signs/symptoms of depression and instruct to call with
lingering symptoms
(d) Explain cardiac warning symptoms
(e) Teach patients to take own pulse and evaluate themselves for signs of
exercise tolerance/intolerance