Transcript Problem Scenarios

Cardiac Rehabilitation
Objectives
To gain an understanding of:
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Aims and benefits of cardiac rehabilitation
Cardiac rehabilitation pathway
Assessment
Risk stratification
Exercise session
Monitoring
Safety
Transfer to Phase IV
Principle of Cardiac Rehabilitation
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Enable the patient to regain full
physical, psychological and social
status
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Promote secondary prevention to
optimise long term prognosis
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Comprehensive cardiac rehabilitation
Patient groups
 Acute cardiac event
 Awaiting or post revascularisation
 Stable angina
 Stable heart failure
 Post valve surgery
 Post heart transplantation
 Post ICD insertion
Benefits of Cardiac Rehabilitation
 ↓ angina
 ↓ blood pressure
 ↓ anxiety and
depression
 ↓ hospital
admissions
 ↑ lipid profile
 ↑ functional capacity
 ↑ compliance with
lifestyle modification
 ↑ confidence
 ↑ return to work
 ↑ return to leisure
activities
↓ mortality by 31% (Taylor et al,2004)
Cardiac Rehabilitation Team
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Multi-professional
Overall coordinator
Interdisciplinary working
Multi tasking / skill extension
Rehabilitation services should be available from people
trained in:
 Cardiology
 Exercise
 Lifestyle intervention
 Psychological treatments
SIGN 2002
Phases of CR
Phase I
In-patient stay
Phase II
Post discharge at home
(2 – 6 weeks)
Phase III
Out-patient care
Hospital or community
Delivered by health care services
(6 -12 weeks)
Phase IV
Long term maintenance
Delivered by leisure services
Pre Phase 1
 Pre operative sessions for patients/spouse.
 Invited along to local CR site.
 Provide with information regarding surgery, hospital
stay, and planned follow up.
 Very well received and demonstrating positive
outcomes.
Phase I
 Education about cardiac
event / condition
 Risk factor modification
 Symptom management
 Counselling & support
 Early mobilisation
 Referral to and contact
details for Phases II and III
Phase II
Under care of GP
• assessment of cardiac risk
• assessment of physical, psychological and
social needs for cardiac rehabilitation
• provision of lifestyle advice and psychological
interventions
• Community nurse involvement
Often a neglected phase – patients can feel isolated
Phase II
Delivered by:
Home visit
Telephone contact
Telephone help line
Heart manual
Problems at this stage
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Symptoms
Medication titration
Conflicting advice
Inequity of cover throughout Grampian
Phase III
 Timeframe
2 – 6 weeks post event
 Venue
hospital / community
 Duration
8 weeks
twice week
Assessment at Phase III
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Current clinical / cardiac status
Investigations / results
Risk stratification
Medication
Psychological status
Functional capacity assessment
Calculation of THR
Physical limitations
Personal goals
Habitual activity
Functional capacity tests
 Sub maximal Bruce / Modified Bruce Protocol
 Shuttle Walk test
 6 minute walk test
 Cycle ergometer
 Chester step test
Risk Stratification
Risk Stratification:
 The process of determining the level of risk of a
patient having a further cardiac event whilst
exercising
Criteria used:
 cardiac history
 current cardiac status
Risk Stratification Criteria
Risks associated with exercise:
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Extensive myocardial damage
Poor LV pumping capacity
Residual ischaemia
Ventricular arrhythmias
Criteria checklist and AACVPR Stratification to risk stratify
Risk stratification determines
 Exercise prescription
• Exercise intensity
 Level of monitoring & supervision
Contraindications to Phase III
exercise component
 unresolved unstable angina
 resting BP 200 / 110mmhg
 significant unexplained drop in blood
pressure during exercise
 resting tachycardia > 100 bpm
 uncontrolled atrial or ventricular arrhythmias
 unstable heart failure
 unstable / uncontrolled diabetes
 fever (febrile illness)
Screening and Induction
Checklist prior to each session:
 Changes in symptoms/ medication
 Heart rate and BP measurements
 Home activity
 Problems / concerns
Induction should include an explanation of:
 the aims of the programme
 the exercises and equipment to be used and any exercise
adaptations
 pulse monitoring/safe target heart rate ranges
 the use of ratings of perceived exertion (RPE)
 reporting abnormal symptoms
Conditioning Component
 FITT principle
 Both circuit or gym designs used
 Monitoring
 Progression
 Safety
Home programme
 To support the phase III exercise sessions
 Walking
 Activities similar to those performed under
supervision
 Home exercise record
Education Component
Heart disease, investigations and
procedures
Risk factors for CHD
Effects and benefits of exercise
Healthy eating
Medication
Relaxation / stress management
Psychological Component
Screening:
Quality of life tools
Anxiety and depression
Intervention:
Motivational Interviewing
Cognitive Behavioural Therapy
Counselling
Relaxation / Stress management
Health Beliefs
Health beliefs are central to a person’s
management of their CHD.
They are formed from a variety of
sources and influence perception of
their illness and how to cope with it.
What are Health Beliefs?
When people have a diagnosis, illness or injury they
generate beliefs in these 5 areas to help them to
understand and respond to their health event:
 Identity
 Cause
 Consequence
 Time line
 Cure / control
Leventhal el al., (1997)
Identity
 Diagnostic label
 Symptoms
 Type of people who have the same condition
Typical beliefs may include:
‘I only had a heart attack.’
‘It’s only men that get heart problems.’
‘I’m like my Dad, he had problems with
his heart and veins.’
Cause
 The patients perception as to why they have CHD
may include:
• Family history
• Stress
• Smoking
• Bad luck
 Accurate identification of risk factors are crucial
 Research shows misconceptions about causes of
CHD.
Consequences
This is the patient’s perception of the longer term impact
and implications of their CHD on their lifestyle, family
and friends.
 Beliefs may include:
• ‘My heart is weak and damaged, I’ll never be the
same again.’
• ‘If I manage my risk factors, I can reduce the
chances that I have if I have another heart attack.’
Timeline
The length of time patients expect their illness to last
will have an effect on their other health beliefs and
how much that may do to modify their lifestyle
positively.
• Beliefs that may be held could include:
‘I have only had a heart attack, once I have finished my
rehabilitation I will be fine.’
 ‘CHD is for life, I must change my lifestyle to manage my
condition.’
Cure / Control
Patients who believe that their condition is
manageable/controllable are more likely to make a
better physical and recovery:
• ‘If I give up smoking and take up exercise I can reduce my
chances of problems in the future.’
Patients who wrongly perceive that their condition is
cured or uncontrollable may not address their risk
factors:
• ‘I have had a bypass operation and now I am cured.’
• It runs in the family, it was bound to happen, that’s life!’
Implications for Long Term
 Beliefs are strongly held
 Consider patient’s beliefs & experiences
 Can promote a good recovery and facilitate effective
management of patient’s recovery.
 Can also hinder recovery and prevent an individual
adjusting and managing condition.
Transfer to Phase IV
 Ensure medically and psychologically stable
 Criteria required for transfer from Phase III to IV
Ensure individual can:
• exercise independently and safely
• self-monitor effectively
• recognise warning signs and symptoms
• identify goals for lifestyle change & risk factor reduction
• identify psychological goals
• demonstrate knowledge of their cardiac condition
• demonstrate compliance to home-based activities
 Fast track protocols
Long term management plan
 Risk factor monitoring & management
 Local exercise opportunities / resources
 Details of medical follow up
 Long-term exercise advice
 Support services for behaviour change
maintenance
 Local support group information
 Phase III CR team contact details
Summary
 Principle and benefits
 Phases
 MDT Team
 Exercise component of Phase III
 Psychological component
 Discharge and Transfer to phase IV
 Risk Stratification