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Cardiac Rehabilitation

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					Cardiac Rehabilitation
              Introduction
 Heart failure is estimated to affect 4 to 5
  million Americans, with 550,000 new cases
  reported annually. In the past 3 decades, both
  the incidence and prevalence of heart failure
  have increased.
 Factors that have contributed to this increase
  are the aging US population and improved
  survival rates in patients with cardiovascular
  disease due to advancements in diagnostic
  techniques and medical and surgical therapies.
   Background on Heart Disease!
• Cardiovascular disease is the number one killer
  among all diseases in the United States of
  America.
• Family genetics can be a predisposing factor.
• Males have more risk for heart disease
• Women after menopause lose cardiac protection
  due to non production estrogen .
• African Americans, American Indians, Mexican
  Americans are at higher risk.
      What is Cardiac Rehabilitation?
• It is defined as, “all measures used to help cardiac
  patients return to an active and satisfying life and
  to prevent re-ocurrence of cardiac events”.
• Cardiac Rehabilitation includes exercise,
  education, and social and emotional support.
• Rehabilitation can be hospital or home based.
     Barriers to Rehabilitation
 Lack of Knowledge
 Poor Motivation
 Insufficient understanding
 Lower perceived self-efficacy
 Forgetfulness,
 Decrease support from family and other care
  givers
 Cost
 Poor Patient referral by Nurses and Doctors
 Time conflict between work and rehabilitation
  program.
Rehabilitation Outcome and Quality of Life
  • The benefits include psychological well being,
    reduction in mortality, improvement in quality of
    life, and lowering of hospital re-admission rates,
    with the prevention of reoccurrence of future cardiac
    events
  • Cardiac rehabilitation lowers the risk of death in
    survivors by 20-25%
  • Cardiac rehab also decreases the need for medication
  • Improves exercise tolerance, coronary risk factors,
    physiological well being and health related quality of
    life, as well as reducing long term mortality
        Complication due to Non-
            Rehabilitation
• Reoccurrence of cardiac events
• Re-hospitalization due to re-occurrence of cardiac
  event with high cost of treatment
• Decreased quality of life
• Increased need for medication
• Increased risk of death
• Increased risk for co-morbidity
• Predisposition to blood clotting from stasis
          Standard Interventions

• Cardiac rehab staff nurse will meet patient prior to
  discharge from hospital and address the
  rehabilitation program protocol.
• In accordance with the American College of Sports
  Medicine guidelines for exercise prescription for
  rehabilitation ; rehabilitation consists of forty
  exercise sessions; 24 sessions (3/per week)
  endurance training on a cycle ergometer ( with 5
  minute warm up) 20 min training with constant
  workload, 5 minute cool down, and 5 min post
  exercise monitoring. In addition 16, (2/per week) 1
  hour sessions of stretching and flexibility exercises.
   Standard Interventions (Con’t)
At discharge, patients receive risk factor management
   counseling, instructions on session procedures, and
   cardiovascular risk factor management during
   exercise. Patients also receive exercise prescriptions
   both home and hospital based, physical therapists are
   assigned for home visits to patients every other week.
Information is also given to those patients who are in
   need of advice for smoking cessation, weigh loss in
   the overweight or obese, adequate physical activity,
   and lower dietary fat intake, in order to obtain optimal
   health benefits from engaging in positive health
   behavior.
         Goals for Rehabilitation
 Focus on 4 aspects of activities of daily living:
    i) Somatic goals – Teaching individuals to
       learn one’s optimal exercise limits
    ii) Social goals – helping individuals to
       reintegrate into family life with optimal
        reintegration regarding working,
      household, hobbies and leisure activities.
  Goals for Rehabilitation (Con’t)


  iii). Psychosocial goals – empowering
individuals by evaluating anxiety levels and
concerns towards cardiac exertion during
exercise, that may lead to negative emotions.
  iv). Secondary prevention goals – helping
      individuals to modify risk behavior &
      reinforce compliance to therapy regimen
      Guidelines for Rehabilitation
 Being discharge Nurse ( Provide 1 on 1 consultation
  for patients)
 When discharging patients – Nurse will
   meet with patients (experimental group).
 Make sure patients are enrolled into an
   exercise program. Also contact rehab
    unit each day of exercise for patients’ performance
  update. Nurse will call patient twice before each
  exercise session to reassure and provide anticipatory
  guidance.
  Guidelines for Rehab (Con’t)
 Consider the age of the patient, and register
  patients in particular peer age group suitable for
  rehab ability & regimen thus increasing patients
  self esteem.
 Discharged Nurse Call patient 2 days before
  scheduled rehab ( to discuss with patients’ about
  their goals & outcomes reassurance, and to
  answer any questions or clear doubt)
    Guidelines for Rehab (Con’t)
 Give “advanced anticipatory guidelines”
       towards expectations including advantages,
       outcomes, side effects, possible
       complications, how to monitor their own
       pulse rates and maximum heart rates, and
       how to recognize symptoms of over-exertion
      (ex: muscle cramps, short of breath).
   Assess patient’s stress level, emotional status,
      and functional status every time the nurse calls
      (pre/post rehab sessions).
        Outcome measuring tools
• Establish a baseline evaluation for cardiac rehabilitation.
• vital signs, pulse ox
• EKG
•  BMI
•  pulse ox with activities to monitor the need for oxygen.
• Re-hospitalization do to reoccurrence of a cardiac event.
• Establish daily patient journal to monitor patient
  impression of daily improvement and level of
  performance of ADL.
• Pre, intra, post –echocardiogram to evaluate ejection
  fraction.
            Research Finding
• Mortality rate caused by cardiovascular disease
  is 8.2% for patients who participate in cardiac
  rehabilitation program and patients not
  participating (control group) is 15.3%
  (Hedback, Perk, Hornblad, Ohlsson, 2001).
• Percentage of patients who had a recurrent
  cardiac events was 18.4% in experimental
  group compared to 34.7% in the control group.
  (Hedback, Perk, Hornblad, Ohlsson, 2001).
      Research Finding (Con’t)
• Only less than 25% of approximately 1 million
  myocardial patients each year actually enroll in
  cardiac rehabilitation program (Thomas, Miller,
  Lamendola, Berra, Hedback, Durstine, Haskell,
  1996).
• 12.7 % of patient are more likely to be referred
  to a cardiac rehabilitation program when seen by
  a cardiologist verses 6.2% of patient who are see
  by their primary physician (Barber, Stommel,
  Kroll, Holmes-Rovner, McIntosh, 2001).
                 Conclusion
 Ensuring patients enrollment into cardiac
  rehabilitation program post myocardial event and
  ensuring participation in a rehab program by
  providing anticipatory guidance, monitoring
  improvement using measuring tools weekly for the
  first 6 weeks then monthly for one year, to show
  improvement in quality of life through increased
  endurance, return to work, increased self-esteem,
  and increase social and emotional integration into
  family life will be an area of research.
                           References
• Marchionni, N., Fattirolli, F., Fumagalli, S., Oldridge, N., Del Lungo, F.,
  Morosi, L., Burgisser, C., & Masotti, G. (2003). Improved exercise
  tolerance and quality of with cardiac rehabilitation of older patients after
  myocardial infarction: Result of a random control trial. Journal of the
  American Heart Association, 107; 2201-2206.
• Thomas, R. J., Miller, N. H., Lamendola, C., Berra, K., Hedback, B., &
  Durstine, J. L. (1996). National survey on gender differences in cardiac
  rehabilitation programs: Patient characteristics and enrollment patterns.
  Journal of Cardiac Rehabilitation, 16(2) 402-412.
• Roblin, Douglas PhD; Diseker, Robert A. III MPH; Orenstein, Diane PhD;
  Wilder, Myrtle CNP, MPH; Eley, Melanie RN. (2004). Delivery of
  Outpatient Cardiac Rehabilitation in a Managed Care Organization.
  Journal of Cardiopulmonary Rehabilitation, 24(3), 157-164.
                   References Con’t
• Caulin-Glaser, Teresa MD, FACC; Blum, Michael MD, FACC; Schmeizl,
  Renae RN, BSN, BS; Prigerson, Holly G. PhD; Zaret, Barry MD, FACC;
  Maxure, Carolyn M. PhD. (2001). Gender Differences in Referral to
  Cardiac Rehabilitation Programs after Revascularization. Journal of
  Cardiopulmonary Rehabilitation, 21(1), 24-30.
• Donker, Frank. (2000). Cardiac rehabilitation: a review of current
  developments. Clinical Psychology Review, 20 (7), 923-943.
• Goble AJ, Worcester MUC. (1999). Best practice guidelines for cardiac
  rehabilitation and secondary prevention: a synopsis. Heart Research
  Centre.
• Daoud, E. G., Dabir, R., Archambeau, M., Morady, F., & Strickberger, S. A.
  (2000).
•     Randomized, double-blind trial of simultaneous right and left atrial
  epicardial pacing for prevention of post-open heart surgery atrial
  fibrillation. Circulation. 102, 761-765.
                    References Con’t
• Barber, K., Stommel, M., Kroll, J., Holmes-Rovner, M., & McIntosh, B.
  (2001). Cardiac rehabilitation for community-based patients with
  myocardial infarction: Factors predicting discharge recommendation and
  participation. Journal of Clinical Epidemiology. 54(10), 1025-1030.
• Hasnain,. D ,Philip,H.E & John, L.C (2004) Recent development in
  secondary prevention and cardiac rehabilitation after acute myocardial
  infarction. BMJ Publishing Group. 328, 693-697.
• Kate,J.R.(2003) Home-based versus hospital-based cardiac rehabilitation
  after myocardial infarction or revascularization: design and rationale of the
  Birmingham rehabilitation uptake maximization study: a randomized
  controlled trial. BioMed Central Cardiovascular Disorders. 3 (10) p.1471-
  2261
• Evenson, K.R., Johnson, A., & Aytur, S.A. (2006). Five-year Changes in
  North Carolina          Outpatient Cardiac Rehabilitation. [Electronic
  Version]. Journal of Cardiopulmonary Rehabilitation, 26, 366-376.
                    References Con’t
• Mittag, O., China, C., Hoberg, E., Juers, E., Kolenda, K., Richardt, G.,
  Maurischat, C., &        Raspe, H. (2006). Outcomes of Cardiac
  Rehabilitiation with versus without         Follow-up Intervention Rendered
  by Telephone (Luebeck Follow-up Trial):             Overall and Gender-
  specific Effects. [Electronic Version]. International Journal          of
  Rehabilitation Research, 29, 295-302.
• Pierson, L. M., Norton, H. J., Herbert, W. G., Pierson, M. E., Ramp, W. K.,
  Kiebzak, G. M., Fedor, J. M., Cook, J. W. (2003). Recovery of self-reported
  functional capacity after coronary artery bypass surgery. Chest, 123(5),
  pp.1367-1374.
• Goodman, J. M., Pallandi, D. V., Reading, J. R.; Plyley, M. J.; Liu, P. P.,
  Kavanagh, T. (1999). Central and peripheral adaptations after 12 weeks of
  exercise training in post-coronary artery bypass surgery patients. Journal of
  Cardiopulmonary rehabilitation, 19(3), pp. 144-150.
                    References Con’t
• Evenson, K.R., Johnson, A., & Aytur, S.A. (2006). Five-year Changes in
  North Carolina Outpatient Cardiac Rehabilitation. [Electronic Version].
  Journal of    Cardiopulmonary Rehabilitation, 26, 366-376.

• Mittag, O., China, C., Hoberg, E., Juers, E., Kolenda, K., Richardt, G.,
  Maurischat, C., & Raspe, H. (2006). Outcomes of Cardiac Rehabilitiation
  with versus without     Follow-up Intervention Rendered by Telephone
  (Luebeck Follow-up Trial): Overall and Gender-specific Effects.
  [Electronic Version]. International Journal of Rehabilitation Research, 29,
  295-302.

				
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