Cardio Flashcards
(135 cards)
1
Q
Physiological Instability
A
PT must see response at rest and with movement.
2
Q
Physiological instability requries
A
Constant re-eval of symptomatic and hemodynamic tolerance
3
Q
Specific goals of lines:
A
- Rapidly deliver important medications
- Obtain real-time measurements of physiological
function - Collect bodily fluids
- Facilitate tissue healing
- Minimize secondary infections from lines/tubes
4
Q
Arterial Catheter/Line
A
Indwelling catheter that provides measurements of systolic, diastolic, and mean arterial pressures continuously
5
Q
Arterial line Precautions with PT
A
- High pressure system, if
dislodged –> hemorrhage
– Transducer-height sensitive
6
Q
Central Venous Catheter or central line
A
Useful for more immediate
delivery of medications or
fluids and more immediate
venous blood sampling
7
Q
Central Line before mobilization
A
must secure the patient
8
Q
Central Venous Pressure
A
Measures the blood
pressure in the vena cava
just proximal to right
atrium and reflect amount of venous return to the heart
9
Q
Normal CVP
A
2-6 mmHg
10
Q
CVC and PT complications
A
occur with insertion/removal
11
Q
CVC and PT considerations
A
– Limit repeated shoulder flexion/abduction > 90 with
subclavian vein insertion to prevent vascular
injury/compromise of CVC
– Good oral hygiene/secretion hygiene with jugular vein
insertion to reduce infection risk
– Consider length of tubing/line traction with
mobilization
12
Q
Peripherally Inserted Central Catheter
A
Intravenous access that can be used for a longer period of time
Catheter is inserted peripherally and the tip is advanced to the superior vena cava
13
Q
PIIC Inserted
A
Basilic, cephalic, brachial veins
14
Q
PA Catheter (Swan Ganz)
A
Purpose is to detect heart failure, pulmonary HTN, or sepsis, monitor changes in preload, and evaluate the effects of drugs
Allows direct, simultaneous
measurement of pressures in
the right atrium, right
ventricle, pulmonary artery,
and the filling pressure
("wedge" pressure) of the left
atrium
15
Q
Normal PA pressures
A
Systolic (PASP) 15 - 30 mmHg
Diastolic (PADP) 8 - 15 mmHg
16
Q
PA catheter Precautions
A
- Hemodynamic instability
– Dysrhythmias
– Shoulder/cervical ROM
– Generally: patients are stable for PT, but you should ensure
this with the medical team
– Needs to be physically secured based on your institution’s
policies prior to mobilization
17
Q
Cardiac output
A
Normal CO = 4.0 - 8.0 L/min
18
Q
Cardiac index
A
cardiac output per square meter
of body surface area
19
Q
Normal Cardiac index
A
2.5-4.0 L/min/min
20
Q
Cardiac ouput
A
SV x HR
21
Q
Mixed venous oxygen saturation
A
Amount of oxygen returning to the heart
– Direct measure of venous oxygen reserve, indirect
measure of peripheral tissue O2 uptake
22
Q
Normal SvO2
A
60-80%
23
Q
Cerebral perfusion pressure
A
pressure at which brain is perfused
24
Q
Intracranial pressure
A
pressure around the brain
25
Normal CPP
60-80 mmHg
26
Normal ICP
5-15 mmHg
27
EVD: monitor ICP indications
```
Hydrocephalus, SAH, TBI,
stroke with hemorrhagic
conversion, tumor, postop,
vascular/ventricular
malformations
```
28
Hemodialysis
Artificially performs the normal function of the kidneys
29
Dialyzer
Blood crosses a semi-permeable membrane
30
Dialysate
metabolic waste products to diffuse into
| correction fluid
31
HD can:
- Correct fluid or electrolyte abnormalities
– Remove toxic materials
– Maintain acid-base balance
32
HD arterio-venous fistula
An artificially created
communication between
an artery in the arm and
an adjoining vein
33
HD Arterio-venous grafts
Uses an interposed
synthetic graft
– Less durable than an A-V
fistula
34
Continuous Renal Replacement Therapy
Consists of nonstop veno-venous or arterio-venous
HD
Extracorporeal blood circulation through a smallvolume,
low resistance filter to provide continuous
removal of solutes and fluid
35
Dialysis and PT
Mobilization typically contraindicated during
hemodialysis and during the inflow/outflow of the
dialysate during peritoneal dialysis
36
Patients with Dialysis you expect
potential dehydration, hypovolemia, orthostatic
| hypotension, and patient fatigue post dialysis
37
3 Chambers of Chest Tube
– Collection
– Underwater seal
– Suction
38
Chest Tubes and PT
```
• 1. Determine if you need to
keep to suction or if
“waterseal”/ “gravity seal”
is OK (should be an MD
order)
• 2. Note the quality and
quantity of the fluid
• 3. Plan your walking setup
to keep the chest tubes on
slack, but not dragging
• 4. Maintain collection
reservoir below the level of
insertion
```
39
Foley Catheter
Thin, sterile tube inserted into
| the bladder to drain urine
40
Considerations for PT with patients with Catheters
```
Need to maintain Foley
Catheters below the level
of the bladder
• Drain any urine in the
tubing before
mobilization for
prevention of backflow
```
– 1. Catheter bag needs to
be emptied
– 2. A patient is mobile
enough to use a commode
41
Feeding Tubes
• Deliver nutrition when GI obstruction, aspiration,
| or calorie supplementation is needed
42
Feeding Tubes and PT
Determine if tube is to suction or gravity
drainage, and whether tube can be disconnected
for out of bed mobility
• Determine if the tube can be disconnected prior
to and/or during therapy session
• Feeds should be temporarily suspended for all
supine/head flat positioning due to risk of
aspiration
43
If suspending PT for therapy
consider feeding schedule and insulin doing
44
Pacemakers
To initiate myocardial contractions when intrinsic
| electrical impulses are insufficient
45
Automatic Implantible Cardiac
| Defibrillators (AICD)
ICD provides an electrical shock to temporarily
depolarize an irregularly beating heart
allowing normal electrical and coordinated
contractile activity to resume
46
Left Ventricular Assistive Device (LVAD)
Treatment for end stage heart failure
47
Pulse Oximetry
Non-invasive means of measuring pulse rate and
| blood oxygenation/hemoglobin saturation (SpO2)
48
Normal SpO2
> 92%
49
Therapy needed for pulse ox
< 88-90%
50
Pulse Oximetry and PT
Inaccurate readings can occur related to nail polish,
motion artifact, poor circulation, dark complexion,
dysrhythmias/irregular pulses, etc.
51
Indications for Mechanical Ventilation
```
Acute Lung Injury/Acute Respiratory Failure
– Hypoxic/hypoxemic
– Hypercarbic
• Impending Respiratory Failure
• Respiratory muscle weakness/paralysis
• Reduced myocardial oxygen consumption
– i.e. myocardial infarction, heart failure
• Prevent or reverse atelectasis
• Stabilize the chest wall after trauma
• Airway Protection
– i.e. angioedema, CNS injury or LOC
• Provide sedation/paralysis for a procedure
```
52
Pressure Control:
preset PIP amounts, – Limits potential for barotrauma, but may result in variable
tidal volumes and minute ventilation
53
Volume Control:
preset tidal volume and minute
ventilation
– May increase the risk of ventilator-induced lung injury due
to barotrauma
54
Pressure Support
The difference between PEEP and
PIP
– Vent augments spontaneous breaths to reach a preset PIP
– Patient-initiated
– Facilitates larger tidal volumes, minimizes barotrauma
55
CPAP:
applies constant pressure throughout the
breathing cycle to increase functional residual
capacity (FRC)
56
BiPAP:
cycled bilevel ventilation between Inspiratory
Positive Airway Pressure (IPAP) and Expiratory
Positive Airway Pressure (EPAP)
57
Intubation
The insertion of a flexible plastic tube into the trachea to
| maintain an open airway
58
Assist Control (AC)
Delivers a set TV, rate, and inspiratory flow
• Between the set rate of machine-delivered breaths,
the patient may initiate their own breath
59
Synchronized Intermittent Mandatory
| Ventilation (SIMV)
• Combination of spontaneous mode and AC
• Delivers a set number of mandatory breaths at a
preset TV
• Between the set rate of machine-delivered breaths,
the patient may breathe on their own, at their own
TV
60
Pressure Support (PS)
• Delivers every breath at a preset pressure and
inspiratory time
• Allows the patient to control the rate and the
minute ventilation
• Benefits: pressure is
61
The Risks of Ventilation
Mechanical ventilation is a highly effective, life-saving
| therapy, but carries a high-risk for complications
62
Methods of Weaning
Intermittent Mandatory Ventilation (IMV)
– Set machine rate reduced in steps of 1-3 breaths/min
– Gradual reduction in vent support, resulting in a
progressive workload for patient
• Timed spontaneous breathing periods using a T-piece
– T-shaped tubing connected to an ET tube
– Duration of trials gradually increases
• Pressure Support Ventilation (PSV)
– Vent augments spontaneous breaths with a fixed amount
of positive pressure
– Positive pressure is reduced for a trial duration
63
PT considerations when weaning
– Facilitate upright positioning for improved
ventilation/perfusion ratio
– May require slightly higher pressure support
settings for mobility (compared to at rest)
– Balance patient’s energy expenditure
– Airway clearance techniques
– Cough/huff strategies
– Breathing strategies
64
Lab value WBC
3.9-10.7
65
Lab value Hemoglobin
Male: 14-17Gm/dL
Female: 12-16Gm/dL
66
Lab value Lactate
0.5-1 mmol/L
67
Lab value BUN
5-25 mg/dL
68
Lab value Potassium
3.5-5.0 mEq/L
69
Lab value BNP
< 100 pg/mL
70
Lab value Troponins
<0.01 ng/mL
71
Lab value PT/PTT
Normal: 23.8-36.6 sec
Therapeutic: ~60-80 sec
72
Lab value INR
Normal: 0.9-1.1
Therapeutic: 2.0-3.0
73
Exclusion Criteria
• Immediate plans to transfer to another floor / outside hospital
• Requires significant doses of vasopressors for hemodynamic stability (to maintain
mean arterial pressure >60 mm Hg)
• MAP <60 mm Hg
• Precaution: PAP > 50 cm H20
• Mechanically ventilated patient with FiO2 >0.8 and/or PEEP >12 mm Hg, or acutely
worsening respiratory failure
• Active bleeding
• Maintained on neuromuscular paralytics
• Currently in an acute neurological event (cerebrovascular accident, subarachnoid
hemorrhage, intracranial hemorrhage) with reassessment for mobility every 24
hours
• Unresponsive to verbal stimuli, unable to follow commands
• Unstable spine or extremity fractures
• Grave prognosis, transferring to comfort care
• Open chest/open abdomen (risk for dehiscence)
74
Signs/Symptoms of Intolerance for exercise for lower intensity for ICU
```
HR increases >20-30 bpm above
resting HR
– SBP increases > 20-30 mmHg
– RR > 30
– Increased accessory muscle use
– Dizziness, nausea/vomiting
– Mild/moderate pain
– Mild agitation, nonverbal signs of
pain
```
75
Signs/Symptoms of Intolerance for exercise for terminate exercise for ICU
```
>20% decrease in resting HR
– HR <40 bpm, >130 bpm
– MAP < 65, > 110 mmHg
– Orthostatic hypotension
– Severe agitation RASS >2
– Sedation or coma RASS ≤-3
– EKG changes, chest pain,
diaphoresis
– SpO2 decreases 4%, or <88-90%,
– RR < 5 breaths/min, >40
breaths/min, intolerable dyspnea
– Patient discomfort/refusal
```
76
Signs/Symptoms of Intolerance for exercise for ventilator specific for ICU
```
Ventilator alarms for disconnect
– FiO2 ≥ 0.60, PEEP >10
– Patient-ventilator asynchrony
– Mode changed to Assist-Control
– Tenuous airway
```
77
know the alarms steps
1. determine if alarm is accurate
2. accurate and persistent
3. perform cardio screen. HELP Asap
78
Acute Respiratory Distress Syndrome
| ARDS
severity of hypoxemia, pulmonary inflitrates
79
Indications for heart transpalent
Patients who maxed out medical interventions
ejection fx <20-25%
<70 yr old
Pulmonary Vascular Resistance <4 wood units
Peak Oxygen Intake < 12-14 ml/kg/min
Ability to comply with medical follow-up care
80
Absolute Contraindications For Heart Transplant
Irreversible advanced renal or liver failure
Advanced irreversible pulmonary disease with FEV1 < 1L/min
Advanced pulmonary artery HTN
History of solid organ or hematolgic malignancy within last
5 years
81
Relative contraindications for heart transplant
```
Severe PAD
• Cerebrovascular disease
• Severe osteoporosis
• BMI > 35 kg/m2
• Poor wound healing, increased risk of infection, higher risk for
DVT/PE
• Acute PE
• Active infection
• >70 years old
• Psychological instability
• Recent (w/I 6 months) substance use; tobacco, alcohol, opioids, etc.
• Diabetes with end organ damage
• Lack of support
```
82
Ventricular Assist Devices (VAD) indications
Bridge to transplant
• VAD to stabilize patient and to prevent organ damage from HF
• Bridge to candidacy
• Same as above, but gives MDs time to examine if patient meets criteria
for txp
• Destination
• Bridge to recovery
• Has a reversible condition. VAD used temporarily and then
disconnected.
83
Types of VADs: pulsatile
Have systolic and diastolic phase
84
Types of VADs: Non pulsatile
Internal VAD
• Driveline exits through abdomen
• Blood is moved via centrigugal force
• Will not feel pulse (no diastolic phase)
• Blood pressure with doppler estimates MAP
• Pulse ox may not read appropriately
• Pump sometimes hemolyzes blood – Anemia and ex
tolerance
85
PT and LVAD hold PT if
new onset orthostasis, SOB, SBP < 80mmHg, neurological changes
86
Heart Transplant post op medications
* (+) Inotrope medications
* Dobutamine, Milranone, Dopamine
* Anti-hypertensive medications
* Medications to control fluid load
* Diuretics
87
Hall mark for Heart failure
Exercise intolerance
88
Heart failure central changes
. Decreased cardiac output with activity
Diminished ejection during systole
Architectural changes in LV
Heightened sympathetic activation
Elevated resting HR
Decreased HRR
Angiotensin – Aldosterone system activation
* Increased vasoconstriction
* Increased plasma volume
* Increased or decreased blood pressure
89
Heart failure Peripheral changes
Abnormal distribution of blood to working muscles
• Diminished mitochondrial density
• Loss of Type I fibers
• Increased anaerobic enzymes
• Decreased ability to vasodilate in response to metabolic needs
90
Non pharmacological management of strategies for Heart failure
Check weight daily and report gains of more than 2 lbs in a 2 to 3 day period.
Limit sodium to < 1500 mg daily.
Limit alcohol consumption completely (preferred) or to
less than one drink per day.
For stable heart failure patients, exercise training may improve survival and quality of life.
91
Strength training for heart transplant
* Sternal Precautions
* Borg 12-14/20
* muscle endurance training
92
Heart transplant Considerations
Long warm up and cool down
Use RPE
Incorporate strength training
endurance training
93
Heart block 1st degree
PR interval prolonged
94
Heart block 2nd degree type 1
progressive prolongation of PR interval until one QRS is dropped
95
Heart block 2nd degree type 2
PR interval is normal however one dropped QRS
96
Heart block 3rd degree
P waves have no relationship to QRS
97
maximal graded exercise test limitations
➢A lot of motivation needed
➢Potential to perform at a high workload needed
➢Equipment needed
➢Qualified and trained medical staff needed with emergency procedures in
place
➢Expensive
98
Ventilatory threshold
Measurements of oxygen consumption, carbon
| dioxide production, respiratory rate and volume
99
Lactate threshold
measured by blood samples to determine when lactate
| clearance is falling behind lactate production
100
To improve aerobic conditioning must apply
OVERLOAD
101
Training zone: low intensity
40-60%
102
Training zone: moderate intensity
50-70%
103
Training zone: high intensity
70-85%
104
Training zone: for cardiac patients
40-70%
105
Hyperglycemia if BG is 300
do not exericse
106
Primary prevention of exercise rehab
• Risk factor management to prevent cardiopulmonary
& vascular diseases
• “Client”
107
secondary prevention of exercise rehab
People with known CV or P disease
Reducing symptoms
Slow progression of disease
108
Chronotropic Incompetence
blunted adrenergic response
109
Left ventricle for aging and cardiac rehab
wall thicken - increased collagen, calcification
prolonged time is systole
prolonged late diastole
110
Structural and Physiological Changes
| with Aging: Impact on Exercise
* Lower Cardiac Reserve
* Higher blood lactate levels during sub-max ex
* HR, peripheral vasodilation have a blunted response
111
AHA class A level 1
Children, adolescents, Men<45, women< 55 with no symptoms or presence
of heart disease or major risk factors
112
AHA class A level 2
Men > 45 and women >55 with no symptoms/presence of HD with < 2 major
CV risk factors
113
AHA class A Level 3
Men > 45 and women > 55 with no symptoms/presence of HD and with >2 risk
factors
114
AHA Class A Guidelines
* No activity restrictions
* 45-85% HRR (Karvonen)
* 12-16 BORG
* No medical clearance required
* ECG not required
* No supervision necessary
115
Class A Level 2 and 3 for high intensity
need medical supervision
116
NYHA Class 1 PA
No limitation of physical activity. Ordinary
physical activity does not cause undue fatigue,
palpitation, or dyspnea
117
NYHA Class 2 PA
Slight limitation of physical activity.
Comfortable at rest, but ordinary physical
activity results in fatigue, palpitation, or
dyspnea.
118
Class B risk:
known stable cardiovascular disease - low risk
• NYHA classes I & II
• Exercise capacity < 6 METS (walking at 4.5mph)
• No ischemia or angina at rest or with GXT when workload
<6METs
• BP appropriately rises with exercise
• No tachycardia at rest
• Can self-monitor activity
119
Class B Guidelines
Medical Clearance PRIOR to exercise initiation
• Supervised exercise program during initial sessions
• Supervised sessions by non-medical personnel after first few sessions if
normal response to exercise and
• When person able to self-monitor then can be unsupervised
120
Class C - moderate/high risk
CAD, valve disease, congenital heart disease,
cardiomyopathy with EF<30%, dysrhythmia not
well controlled
• NYHA class 3 or 4
• Exercise capacity < 6 METS
• Angina or ischemic ST depression at workload < 6
METS
• Fall in SBP with exercise
• Non sustained ventricular tachycardia with exercise
• Previous cardiac arrest
121
Class C – Exercise Guidelines
Medical Clearance
• Exercise stress test
• Medical supervision during sessions
• ECG monitoring
122
Class D- Unstable disease with activity restriction
• Unstable ischemia, severe valve stenosis or regurgitation,
uncompensated heart failure, uncontrolled dysrhythmia
• ACTIVITY GUIDELINES
• No activity until medically cleared
123
Indications for Cardiac Rehab
```
Medically stable post-MI
• Stable angina
• CABG
• PTCA
• Compensated, controlled CHF
• Cardiomyopathy
• Heart transplant
• Valve or pacemaker surgery
• PAD
• High-risk CV disease, ineligible for surgery
• End-stage renal disease
• Heart failure (new in 2014!!)
```
124
Contraindications cardiac and aging
```
• Unstable angina
Resting SBP>180 or resting DBP > 110
Orthostatic blood pressure drop > 20mm
with symptoms
Critical AS
Acute systemic illness or fever
Uncontrolled dysrhythmias
Uncontrolled sinus tachycardia (>120 bpm)
Uncontrolled Diabetes
```
125
Contraindications cardiac and aging
```
Uncompensated CHF
• Third degree heart block without
pacemaker
• Active pericarditis or myocarditis
• Thrombophlebitis
• Resting ST displacement (>2mm) or >3mm if on Digitalis
• Orthopedic problems that would prohibit
exercise
```
126
Blood pressure normal
<120/ 80
127
Elevated BP
120-129/ <80
128
Stage 1 HTN
130-139/ 80-89
129
Stage 2 HTN
>140 or > 90
130
Decrease BP with medicine top things
```
- Weight loss
• DASH diet
• Aerobic Exercise
• Strength (you can take the average of isometric and dynamic RT)
• Alcohol consumption
```
131
Cardiac rehab - phase 1
* In-hospital rehabilitation
* Stable
* No chest pain x 8 hours
* Stable heart function
* No significant dysrhythmia
* Monitored
132
Cardiac Phase 1 goals
Assessment of post event/intervention response to activity
Prevention of DVT, Pneumonia, orthostatic hypotension
Lifestyle modification education
Activity Guidelines
Education regarding cardiopulmonary signs of overexertion
Referral for cardiac rehabilitation
133
Increase in CV risk within 2 hours of sex
1.10% in Patients vs 1% in healthy
134
Cardiac phase 2
* Medically Supervised
* Cardiologist on-site
* Cardiac Rehabilitation Specialist
* Physical Therapist
* Nurse, exercise physiologist
* Monitored
* Telemetry
* Blood pressure, HR, RPE, O2 sats, dyspnea scale
* Exercise prescription based upon GXT
* Lifestyle modification classes
135
Phase 2 Frequency and intensity
F- 2/3x a wk\ and HEP total 5-6 ...intensity based on stress test, risk stratification
