cardiovascular system

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cardiovascular system
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2015-08-10 15:05:02
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  1. cardiovascular system
    functions to deliver oxygen to organs and tissues; removes CO2 and other bi-products from the body; assists in regulation of the core body temp.
  2. Heart and circulation
    • Heart tissue
    • 1. pericardium- fibrous protective sac enclosing the heart
    • 2. epicardium- inner layer of pericardium
    • 3. myocardium- heart muscle, major portion of the heart
    • 4. endocardium- smooth lining of the inner surface and cavities of the heart

    • heart chambers  ((deoxygenated) RA -->RV -->Lungs for oxygenation--> LA --> LV --> exits via aorta to body))
    • 1. Right atrium (RA): receives blood from systemic circulation (suprior and inferioir cavae); during systole (contraction) blood is sent to the (RA)
    • 2. Right ventricle: pumps blood via pulmonary artery to lungs for oxygenation
    • 3. Left atrium: recieves oxygenated blood from the lungs; during systole blood is sent into the left ventricle
    • 4. Left ventricle: pumps blood via the aorta throughout the entire systemic circulation; walls of the L are thicker  and stronger than the R; forms most of the apex of the heart.


    valves ensure unidirectional flow of the blood through the heart
  3. Valves
    • Atriventricular valves: prevent backflow into atria during ventricular systole
    • tricuspid valve- right heart valve
    • bicuspid- left heart valve

    semilunar valves- prevent backflow of blood from aorta (L) and pulmonary(R) arteries
  4. cardiac cycle
    • Systole: ventricular contraction
    • diastole: ventricular relaxation and period of filling of blood
    • Atrial contraction occurs during the last third of diastole and completes ventricular filling
  5. Coronary Circulation
    Right Coronary Artery: supplies RA and most of RV, and in most individuals the inferior wall of LV, AV node, and bundle of His; 60% of the time supplies the SA node.

    • Left coronary Artery: supplies most of the LV
    • Left anterier descending: supplies theanterior wall of the LV
    • circumflex: supplies the lateral and inferior walls of the LV and portions of the LV; supplies SA node 40% of the time.
  6. Conduction
    specialized tissue allows for rapid transmission of the electrical impulses in the myocardium

    • Sinoatrial node: pacemaker of the heart; has sympathetic and parasympathetic innervation affecting both hear rate and strength of contraction
    • atrioventricular node: has sympathetic and parasympathetic innervation; merges with bundle of His.
    • Purkinjie tissue: specialized conducting tissue of the ventricles

    Impulses originate in the SA node and spreads through both atria which contract together; impulse stimulates AV node, is transmitted down the Bundle of His to the Purkinjie fibers; impulse spreads throughout the ventricles to contract together
  7. Hemodynamics
    Cardiac output- amount of blood ejected from the heart per minute; dependent upon heart rate and stroke volume.

    stroke volume- average amount of blood ejected per heart beat

    Ejection fraction- percentage of blood emptied from the ventricle during systole; clinical useful measurement of the LV function
  8. Peripheral circulation
    Arteries- transport oxygenated blood away from the heart (high to low pressure); maintained by heart pump

    capillaries: minute blood vessels connecting ends of arteries (aterioles) to start of veins (venules); function for the exchange of nutrients and fluids between blood and tissues

    veins- transport unoxygenated blood from tissues back to the heart (larger capacity, thinner walls than arteries); one-way valve to prevent back flow

    • Lymphatic system:includes lymphatics, lymph fluid, lymph tissues, and organs (lymph nodes, tonsils, spleen, thymus, and throacic duct)
    • drains lymph from bodily tissues and returns it to venous circulation

    • Lymphatic contraction occurs by: parasympathetic, sympathetic and sensory stimulation; contraction of adjacent muscles,abdominal and thoracic cavity pressure changes during normal breathing; mechanical stimulation of dermal tissues; volume changes within each lymphatic vessel
    • major lymph nodes are submandibular, cervical, axillary, mesenteric, illiac,  inguinal, popliteal, and cubital

    Lymph system contributes to: immune system function; lymph nodes collect celluar debris and bacteria; remove excess fluid, blood waste and protein molecules; produce antibodies.
  9. Neurohumoral influences
    neural control of heart rate and blood vessels

    Parasympathetic: (cholinergice)- cardioinhibitory center; slows rate and force of heart muslce contraction and myocardial metabolism; causes corontarty artery  vasoconstriction

    Sympathetic control (adrenergic)- cadioaccelertory center; causes an increase in the rate and the forceof myocardial contraction and metabolism; causes coronary artery vasodilation

    baroreceptors: mechanism controlling heart rate; respond to changes in BP

    chemoreceptors: sesnsitve to changes in blood chemicals

    body temp- heart rate changes analagously with temp changes
  10. Ion concentrations
    • hyperkalemia: increased potassium ions; decreases the rate and force of contraction and leads to EKG changes
    • hypokalemia: decreased potassium ions leading to EKG changes, arrhythmias, may progress to ventricular fibrillation
    • hypercalcemia- increased calcium increases HR
    • hypocalcemia- decreased calcium depresses heart action

    peripheral resistance: increased resisteance increases arterial blood volume and pressure; decreased resisteance decreases arterial blood volume and pressure; influenced by arterial blood volume:viscosity of blood and diameter of arterioles and capillaries.
  11. Coronary Artery Disease (CAD)
    arterosclerotic disease process that narrows the lumen of the coronary arteries resulting in ischemia to the myocardium; characterized by thickening of the blood vessel wall from accumulation of lipids, plateleyes, monocytes, plaque, and other debris

    prevalence: increases with age and presence of risk factors

    • non-modifiable risk factors-age, sex, race, family history of CAD
    • modifiable risk factors: smoking, high BP, elevated cholesteral, emotional stress
    • contribuatory risk factors-diabetes, obesity, sedentary lifestyle
    • 2+ risk factors increase the chances of CAD
  12. symptoms of CAD
    • characteristics range from angina to infarction to cardiac death
    • imbalance of myocarial o2 supply resulting in chest pain
    • symptoms present when lumen is 70% occluded.

    angina pectoris: clinical manifestation of ischemia characterized by mild to moderatate substernal chest pain in the chest and left arm mostly; usually lasts less than 20 minutes due to transient ischemia; represents imbalance between myocardial oxygen supply and demand.

    • Myocardial Infarction (MI): prolonged ischemia,injury and death of an area of the myocardium caused by occlusion of one+ arteries; results in necrosis of the heart tissue
    • symptomology- severe substernal pain for 20+ minutes (pain can radiate to neck, jaw, arm and epigastric area); dyspenea, rapid respiration, shortness of breath; indigestion, nausea, vomitting; pain may be misinterpreted as indigestion

    results of impaired ventricular function include decreased stroke volume, cardiac output and ejection fraction; electrical instability, arrythmias, present ininjured and ischemia areas.

    • Heart Failure (HF)- clinical syndrome in which the heart is unable to maintain adequate circulation of the blood to meet metabolic needs of the body
    • etiology-may be caused by CAD, congential heart disease, hypertension, infections, valvular disease
  13. types of HF
    Left sided HF (congestive HF)- blood is not adequately pumped into systemic circulation; characterized by pulmonary congestion,and low cardiac output from LV to LA and lungs;occurs with insult to the LV from myocardial disease;excessive workload of the heart; cardiac arrythmias, or heart damage.

    Right heart failure: blood is not adequately returned from the systemic circulation to the heart; increased pressure load on RB with higher pulmonary vascular pressures.

    Left ventricular failure: (pulmonary congestion) dyspnea, dry cough, orthopnea, pulmonary wheezing; (low cardiac output) hypotension, tachycardia, lightheadedness, dizziness, cerebral hypoxia, fatigue, weakness, poor exercise tolerance, enlarged heart. murmurs

    • Right Ventricular failure
    • dependent edema, weight gain, acsicte, liver enforfment, anorexia, nauseau, bloating, cyanosis, R upper quadrant pain, jugular vein distension
  14. Classification of HF
    • New York Heart Association (NYHA) Functional Classification; relates symptoms to everyday activities
    • Class I: patients with cardiac disease but resulting in no limitation of physical activity
    • Class II: patients with cardiac disease resulting in slight limitation of physical activity.Ordinary physical activity results in fatigue, palpitation, dyspnea, or angina pain.
    • Class III: Patients with cardiac disease resulting in marked limitation of physical activity. Comfortable at rest;  less than ordinary activity causes fatigue, palpitation, dyspnea, or angina pain
    • Class IV: patients with cardiac disease resulting in inabiltiy to carry on any physical activity without discomfort; symptoms of heart failure or angina pain may be present even at rest. discomfort increases with physical activity.

    • Objective assessment:based onmeasurements such and EKG,stress tests, xrays, Electrocardiograms, and radiological images
    • Class A- noobjective evidence of cardiovascular disease;no symptoms and no limitations in ordinary physical activity
    • Class B- objective evidence of minimal cardiovascular disease; mild symptoms  and slight limitation during ordinary activity. comfortable at rest.
    • Class C- objective evidence of moderarely severe cardiovascular disease; marked limitation in activity due to sx,even during less-than ordinary activity; comfortable only at rest.
    • Class D- objective evidence of severe cardiovascular disease. Severe limitations. Experiences sx even while at rest.
  15. diagnostic procesdures
    • chest xray- evaluates for congestion in lungs, heart chamber, hypertrophy, and structural abnormalities
    • electrocardiogram (ECG)- identifies cardia arrythmias, determines adeqauncey of oxygenation of myocardium
    • holter monitor-records ECG singals over 24 hr perio while person engages in normal daily routine to determine heart function during various activities
    • echocardiogram- ultrasound useed to recodrd sir and stcutruore and motion ofthe heart and vessels
    • cardiac stress test- records cardiac activites during grade exercise; used to determine the exten to which cardiac disease affects functional capacity.
    • cardiac catheterization- invasive procedure used to visualize coronary circulatuion to determine the degree of CAD
    • pulmonary function test:used to determine the cause of dyspnea, degress of lung disease.
  16. medical interventions
    • dietary interventions: low salt, low cholesteral
    • medical therapy: medications
    • surgical interventions: angioplasty, stents, revasculariztion surgery, transplantation,Ventricular assistive devices (accessory pump improves tissue perfusion; bridge to transplantation).
  17. Peripheral Vascular disease (PVD)
    Arterial Disease
    occlusive peripheral arterial disease (PAD); chronic occlusive arterial disease of medium and large sized vessels; associated with hypertension and hyperlipidemia; patients may also have CAD, diabetes, cerebrovascular disease, metabolic syndrome, and history of smoking; diminished blood supply to affected extremitieswith pulses decreased or absent.

    early stages patients exhibit intermittent claudication/Pain is described as a burning. searing, aching, tightness, or cramping, occurs regularly andpredictably with walking and is relieved by rest.

    late stage-patients exhibit rest pain, muscle atrophy, trophic changes (hair loss, skin/nail changes)

    affects primarily LEs.

    Thromboangitis obliterans (Buerger's disease): chronic inflammatory vascular disease of small arteries and also veins; most common in young males who smoke; begins distally and progresses proixmally in both U/LEs; symptoms include pain, paresthesias, cold extremities, diminished temp sensation, fatigue; risk of ulceration and gangrene.

    diabetic angipathy: inappropriate elevationofblood glucose levels and acceleratied atherosclerosis; neuropathies are a major problem; ulcers may lead to gangrene and amputation.

    raynauds phenomenon: episodic spasm of small arteries and arterioles abnormal vasoconstriction reflex exacerbated by exposure to cold or emotional stress; tips of fingers develop pallor, cyanosis,numbness, and tingling; affects largely females.
  18. PVD
    Venous Disease
    Varicose veins- distended, swollen superficial veins; torturous in appearance, may lead to varicose ulcers

    superficial vein thrombophelebitis: clot formation and acute inflammation in a superfical vein; localized pain and acute inflammation in a superficial vein

    Deep Vein thrombosis(DVT): inflammation of a vein in association with the formation of a thrombus; usually occurs in LEs; associated with venous stasis (bed rest, lack of leg exercise), hyperactivity of blood coagulation, and vascular trauma. ***Early mobility out of bed after surgery helps to eliminate venous stasis; may be a contributing factor to or acomplication of CVA; signs and symptoms- may be asymptomatic early; progressive inflammation with tenderness to palpation; change in LE temperature, color,curcumperesnce, appearance, or tenderness/pain. Requires immediate medical attention.

    Chronic venous insufficiency: chronic leg edema, skin pigmentation changes, scaly appearance, itchy.
  19. PVD- Lymphedema
    chronic disorder with excessive accumulation of fluid due to obstruction of lymphatics; causes swelling in the soft tissues in thearms and legs; results from mechanical insufficiency of the lymphatic system.

    primary lymphedema: congenital condition with abnormal lymph node or lymph vessel formation

    secondary lymphedema: acquired,due to injury of one or more parts of the lymphatic system. Causes could include: surgery (radical mastectomy, lymph node removal), tumors, trauma, or infection affecting the lymph nodes, radiatoino therapy with fibrosis of tissues, chronic venous insufficiency


    • initiation factors:
    • inactivity and changes in cabin pressure during air flight; fluctuationin weight gain and fluid volumes; heperemia, hypoproteimia.

    • Stages of lymphedema (progessive disease)
    • Stage 1- reversible lymphedema: limb is soft and pitting, swelling may increase overnight
    • Stage 2- sponstaneously irreversible, swelling with increase in fibrotic tissue; risk for infection
    • Stage 3 lymphostatce elephantiasis- extreme increase in swelling skin changes (fibrosis, sclerosis, papillomas).
  20. Pulmonary system
    function-respiration,delivers oxygen to the cardiovascular system; removes CO2 and other bi-products from body.

    • Anat and phys
    • bony thorax- anterior border is the sternum, lateral border in the rib cage, posterior border is the vetebral column; shld girdle can affect the motion of the thorax

    • Airways
    • upper airways- nose, pharynx, and larynx
    • lower airways- conducting airways; trachea to terminal bronchioles and the respiratory unit

    • Lungs
    • Pleura

    • Musclesof ventilation
    • Primary muscles of inspiration- diaphragm and intercostals
    • Accessory muscles of inspiration- used when a more rapid or deep inhalation is required or in disease; include sternocleidomatoid, scalenes, levator costarum, serratus, trapezius, and pectorals

    • Expiratory muscles
    • resting expiration- done by passive relaxation of inspiratory muscles and elastic recoil tendency of the lungs; used when quicker, fuller expiration is desired or in disease; include quadratus lumborum, intercostals, rectus abdominis, trangulis sterni

    Mechanics of breathing-forces acting upon the rib cage include elastic recoil of lungs, bony thorax muscles

    ventilation and perfusion- the movement of gas in and out of the pulmonary system; measurements include volumes, capacties, flow rates; optimal respiration occurs when ventilation and perfusion (blood flow to lungs) are matched; body position/gravity affects distribution of ventilation and perfusion.

    respiration- diffusion of gas accross the alveolocapillary membrane

    • control of ventilation-
    • receptors-barroreceptors, chemoreceptors,irritant receptors, stretch receptors
    • Central control centers- brain and autonomic nervous systems
    • ventilatory muscles
  21. Pulmonary dysfunction- Acute diseases
    bacterial pneumonia: inta-alveolar bacterial infection; gram positive bacteria usually acquired in the community (streptococcal is the most common); gram negative usually develop in host who has underlying chronic condition, acute illness, recent antibiotic therapy; usually results in early tissue necrosis and abscess formation

    viral pneumonia: an inerstitial or interaveolar inflammatory process cause by viral agents

    aspiration pneumonia: aspirated material causes an acute inflammatory reaction within the lungs; usually found with patients with impaired swallowing abilties (dysphagia).

    Pneumocystis pneumonia: pulmonary infection caused by a fungus in immunocomprised hosts; most often found in patients following transplantation, neonates, and those with HIV.

    SARS (Severe acute respiratory syndrome): atypical respiratory illness cause by a coronavirus. Initial outbreak in southern mainland China with woldwide spread.
  22. Tuberculosis (TB)
    an airborne infection caused by a bacterium

    risk factors- can be passed by sneezing or coughing; people most at risk for infection are those who are in close contact with an infected individual; people who have a weakend immune system ( HIV/AIDS, substance abuse, diabetes, scoliosis, cancer of the head or neck,  lukemia, severe kidney disease, low body weight, certain medical conditions (organ recipients, steroid users);babies, young children and elderly have a higer risk, along with intravenous drug users.

    People can breath in TB and fight off the infection;this is called TB infection as the cells are inactive but remain in the body. Those with TB infection are asymptomatic, do not feel ill and are not contagious, but they can develop full-blown TB later if they are not treated for the TB infection.

    Signs /Symptoms of TB: bad cough for 2+ weeks, chet pain, blood tinged sputum or phlegm, weakness or fatigue, weight loss, loss of appetite, chills/fever, night sweats

    • prevention, detection and early intervention: avoid high rsk situation, get checked frequently ever 1-2 yrs
    • medical treatment/drug therapy: used to treat TB infetion or prevention after exposure; durges should be takien for 6 months- if a person stops takingthem the drugs may become ineffective and the TB could become multidrug resistant.

    There can be alot of side effects of the drugs--> no appetite, nasuea/vomitting, jaundice, prolonged fever, abdominal pain, tingling in fingers/toes, easy brusing, blurred vision, tinnitus, hearing loss

    • seqelae of TB
    • infection into lungs and can then spread to other parts of the body, kidney dysfunction, spine (roods disease) vertebral collapse due to compression of the spinal cord, cervical and thoracic lesions.
  23. Chronic obstructive diseases
    • COPD- disorder characterized by poor expiratory flow rates
    • peripheral airways disease- inflammation of the distal conduction airways (Associated with smoking)
    • Chonical bronchitis- chronic inflammation of the trachobronchial tree with cough and sputum production lasting at least three monst for 2 consecutive years
    • emphysema- permanent abnormal enlargement and destruction of air spaces, distal to terminal bronchioles, may result in destrcution of acini, the functional units for gas exchange in the lungs.


    • Signs/symptoms
    • primary complaint of dyspnea on exertion
    • diminished breath sounds, wheezing (typically associated with exertion), prolonged expiratory phase,  pursed lip breathing, physcial presentation may include enlarged anterior/posterior dimensions of the ches wall, hypertrophied accessory muscles for breathing, forward leaning posture, presence of chronic cough and sputum, diease advancement may result in patient becoming emacieted, signs of R HF due to secondary pulmonary hypertension..

    • inerventions
    • smoking cessation, bronchiodilators, medications, vaccination angain influenza and pneumococcus, oygen, surgeries

    prognosis-varies depending upon degree of obstruction, presence of hypercapnia (increased levels of CO2), recurrence of infections, and development of RHF
  24. Chronic obstructive diseases
    • asthma
    • increased reactivity of the trachea and bronchi to various stimuli

    etiology-unknown, factors associate with development include maternal smoking, early infention, and genetics

    risk factors- childhood asthma, family history, maternal smoking, occupational exposures, exposure to secondhand smoke

    manifests by widespread narrowing of the airways due to inflammation, smooth muscle constriction, and increased secretions

    • signs/symptoms
    • wheezing, dyspnea, chest pain, facial distress, non-productive cough ***symptoms in adults may include paroxysmal nocturnal dyspnea, morning chest pain, and increased sx with exposure to cold.

    • intervention
    • prevetion, smoking cessation and minimizing secondhand exposre, annual flu shot, avoidance of stimulates that lead to episode, short/long acting dilators, establishment of a routine exercise program
    • **reversible in nature.
  25. Chronic restrictive diseases
    • etiologies will vary
    • diseases are all chategorized by difficulty expanding the lungs causing a reduction in lung volumes.
    • restrictive disease due to alterations in lung parenchyma and pleura (fibrotic changes with the lung)
    • restrictive disease to alteration in the chest wall- restricted motion of the bony thorax (diseases such as ankylosing spondylitis, arthritis, scoliosis, arthrogryposis)
    • restrictive disease due to alteration in the nuero muscluar apparatus- decrease muscular strength results in an inability to expand rib cage, seein in MS, muscular dystrophy, Parkinson's, SCI, or CVA
  26. Other pulmonary conditions
    Pulmonary edema: ecessive seepage of fluid from the pulmonary vascular system into the interstitial space; may lead to alveolar edema

    pulomonary emobli (PE): thrombus from the peripheral venous circulation becomes embolic and lodges in the pulmonary circulation; small emboli do not necessarily cause infarction

    pleural effusion: excessive fluid between the visceral and parietal pleura, cause mainly by increased permeability of protroens

    atelectasis- collapsed or airless alveolar unit, caused by hypoventilation secondary to pain during the ventilator cycle
  27. OT cardiopulmonary assessment
    • review medical record
    • interview patient and/or family/caregiver
    • Note symptoms: pain/agina (note location, severity, type-- see intermittent claudication rating scale p 231 where 0 is no pain and 4 is max pain cannot continue), dyspnea (shortness of breath- note severity, position or times in which discomfort is experienced---see 5 grade dyspnea scale 0-no dyspnea, 4 is severe difficulty), fatigue (note severity, time of occurrence, association with activities), palpitations(note persons awareness of heart rhythm abnormalities-- pounding, fluttering, racing, skipped beats), dizziness (note time of occuernce and association with postural changes), edema (note location, measurements, time of day when edema is most prominent, resolution with activity

    Past medical history (onset of incidence, other diagnoses and chronic conditions, diagnoses and prognoses; current medications)

    dianostic tests (review results to determine implications for OT intervention including activity restrictions, vital sign parameters, and prognosis)

    social history-information used to determin implications for OT intervention includeing activity selection, educational/learningneeds, social supports, discharge needs

    discharge envirionment and anticipated level of activity.
  28. vital signs
    important and reliable indicator of activity tolerance/response to evaluation and treatment

    • heart rate    Adult 60-Infant 120bpm
    • blood pressure <120/80       75/50
    • respiratory rate  12-20br/min  40br/min

    • Pulse/heart rate: rhythmical throbbing of arterial wall as a result of each heartbeat;influenced by force of contraction, volume and viscosity of blood, diameter and elasticity of vessels, emotions, exercise, blood temp, hormones
    • Assessment-done by palpatation of peripheral pulses with normal thythm palpate 30 seconds; with irregular palpate 1-2 minutes; taken prior to ax, during and post ax.

    palpation sites- radial (most common), temporal- superior and lateral to eye, carotid- on either side of anterior neck, brachial- medial aspect of the antecubital fossa, femoral, poplieal, pedal


    • normal HR is 70bpm (range is 60-100)
    • tachycardia is >100bpm
    • brachcardia is < 60 bpm
    • irregular:force and frequency vary; may be due to arrythmia or myocarditis

    bruit- abnormal sound or murmur associated with atherosclerosis.

    Auscultation of heart: done with stehoscope to assess heart sounds (note any abnormal heart sounds such as crackles, rattling, bubbling, wheezes/whistling)

    • BP -monitor at rest, during activity, post activity
    • normal is <120/80
    • increased BP could be related to stress, pain, hypoxia, drugs and disease
    • decreased BP could be related to bed rest, drugs, arrythmias, blood loss/shock, and myocardial infarction
    • hypertension is >120/80.
  29. Condition of Extremities
    Diaphoresis- excessive sweating associated

    pulses- decreased pulse or absent associaeted with PVD-- see 8-6 grading scale for peripheral pulse p. 232

    • skin color and vascular status:
    • cyanosis- bluish color related to decreased cardiac output or cold, especially lips, fingertips, nailbeds
    • pallor: absence of rosy color in light skinned individuals associated with decreased peripheral blood flow (PVD)
    • rubor:dependent redness with PVD
    • Temperature
    • skin changes: clubbing of fingernails, pale, shine, dry, abnormal pigmentation, ulcerationm dermatisit, gangrene
    • intermittent caudication- pain, cramping, fatigue occuring wih exercise relived by rest, pain is typially in calf and associated with PVD
    • Edema.
  30. Mobility assessment
    • bed mobility
    • transfers
    • wheelchair mobility
    • ambulation status
  31. Cognition
    provides a baseline of persons ability to understand, process, retain and apply information taught during rehabiliation

    Look at orientation, memory, concentration, judgement
  32. ADL
    • self care, household management, lesuire, community activities
    • note level of function and type of assistance required

    note levels of dyspnea, and angina reported during activities.
  33. activity tolerance
    graded exercise test done by exerrcisephsyiolofist

    observation of activities with monitoring of vital signs, monitoring of dyspnea, angina, exertion

    Metabolic equivalent levels (METS)-use of METs must be taken into consideration when planning interventions.
  34. Psychosocial assessment
    overt signs/symptoms of depression, anxiety, and/or stress and the observed effects on the  individuals capacity to complete/engage in activities

    stress management/coping styles and psychosocial,family/caregiver spiritual supports
  35. environmental assessment
    accessibility issues related to safety, risk for falls, and environmental barriers in the discharge environment; physcial demands of the discharge environment; presences of stairs and airborne irritants.
  36. METS
    Refer to pages 234-235
  37. OT Cardiopulmonary Rehab- Phase I Inpatient Rehabilitation/Hospitalization Stage (ACUTE)
    Phase I

    • begins when a pt is determined to bet medically stable following a cardiac or pulmonary event (MI,CABG, angioplasty,valve repair, CHF,etc.)
    • Typically 24 hours post or after pt is stable for 24 hours.

    Program focus-patient/family education about the disease process and recovery; increase knowledge of energy conservation and work simplification

    improve ability to carry out low level functional and self care activities

    decrease anxiety

    • promote risk factor modification
    • discharge to home


    • Evaluation/intervention:
    • initated at bedside with a monitored, functional assessment of self care and mobility

    if no pain, no arrhythmia, and has a regular pulse of 100 or less an activity program is initiated.


    intsnse monitoring during activitiy espeicallyin CCU

    Being activitesat MET 1-2 (bed mobility, static standing, treanfer from bed to chair/bedside commode, bed bath, feeding,grooming at sink in sitting, AROM/warm-up exercises,wheelchair mobility/ambulation in room)

    all activites use energy conservation techniques (pace oneself, monitor body position, organize daily activities and work areas, delegate responsibilties)

    • breathing exercises
    • abdominal diaphragmatic breahing- sterngthens diaphragm, decreased need to use shoulder and neck muscles
    • pursed lip breathing-controls respiratory rate, helps remove trapped air
    • **techniques are done during all exercises and activities.

    monitor vital signs before during and immediately and 4-5 minutes post activity

    adhere to activity guidelines (MET)

    • observe any contraindications/precautions per doctors orders:
    • observe for SOB, chest pain, nausea, vomitting, dizziness or fatigue
    • observe facial expressions/facial changes
    • monitor HR, BP, O2 saturation

    **avoid isometric muscles work, straining, breath holding (valsalva), overhead exercises or holding UEs overhead for extensive periods of time, avoide lateral arm movements and exervises that stretch/pull incision

    • Clincal signs/symptoms that therapy should be stopped or is contraindicated:
    • uncontrollable atrial/ventricualar arrythmia
    • recent embolism/thrombophlebitis
    • dissecting anneurysm
    • sevoere aortic stenosis
    • aute ststemic illness
    • acute MU
    • diogoxin toxicity
    • acupte hypoglycemia or metabolic disorder
    • thirdt degree heart block
    • unstable angina

    Absoute contraindications of inpt. and outpt. cardiac rehab: acute MI (within 2 days), unstable angine, uncontrolled cardiac arrhythmia, Acute PE, acute myocarditis, acute aortic dissection)

    pateitns are genrally dischared to phase 2 when able to carry out activities at MET level 3.5

    LOS 5-14 days in hospital.
  38. Phase 2:  Outpatient Rehabilitation/Convalescnese Stage (Subacute)
    Begins as early as 24 hours after d/c from hospital; frequecy of the visits depends on the pts needs.

    • program focus:
    • educate pt on importance of continued exercise
    • build up activity tolerance
    • improve ability to carryout IADL and community tasks
    • improve ability to perform work activities
    • support persons effort in lifestyle changes prn

    • evaluation/intervention
    • home evaluation
    • consumer and family education
    • graded exercise program with slow and gradual increase of wt.
    • begin activities at a MET level of 405 and gradually increase as pt tolerance improves
    • practice functional actvities in the d/c environment.
    • use energy conservation techniques in faily tasks
    • community tasks
    • work site eval if applicable

    length of otpatient program is depenent on several factors
  39. Phase 3:Maintenance/Training Stage (Community Exercise Programs)
    patients generally attend sessions 1x/week following completion of phase 2

    groups may be integrated into individual exercise programs

    OTintervention is provided as necessary for IADL, leisure pursuits, and work

    wt training for strength in U and LB, and cardio to maintain cardiopulmonary health.
  40. Guidelines for lymphatic disease
    Phase I (management): edema secondary to lymphatic dysfunction

    • short stretch comprssion banagaesworn 24 hours/day
    • manual lymph drainage (MLD)with complete decongestive therapy; massage and PROM to assist drainage; emphasis on decongesting proximal segments first (trunk quadrant) then etremities

    • functional activiites
    • ADL, adaptation of IADL, work and leisure
    • energy conservation to minimize exacerbation of swelling.

    patient and family education for skin care, doning/doffing compression garments, environmental changes to improve mobility and function

    adress psychosocial issues.

    • Phasee II (self-mamangement)
    • skin care, compression bandages,exercise, lymphadema bandages at night, MLD as needed, compression pumps:use with caution, limited benefits

    • education
    • skin and nail care, self bandaging, infection management, maintain exercises, home management
  41. Basic life supportn-- CPR
    • Compression first, then focus on airway and breathing (CAB)
    • 911 immediatele, push at least 2 inches foradults, about 100 compressions/minutes (30 compressions then 2 breaths)
    • handaonly CPR for untrained lay rescuers
  42. Pediatric Pulmonary disorders- CF
    • Cystic fibrosis
    • genetically inherited autosomal recessive trait; can expect to live into their 30s, 40s, +.

    diagnosis: chronic, progressive lung disease characterized by production of abnormal mucous; salt concentration in sweat; decreases release of certain enzymes by the pancreas; certain abnormalities views on x-rays; failure to grow properly

    cardiac sx are possible compications of CF along with diabetes, cirrhosism and rectal prolapse

    managed by medications

    • functional effects:
    • exercise intolerance; poor nutrition due to malabsorption

    • OT evaluation:
    • assess for developmental delays due to decreased strength and endurance and decreased attention due to pain

    assess the environment to determine adaptations for energy conservation and equipment needs

    • assess psychosocial status
    • child and family stress related to frequent hospitalizations, school absensces, social isolation and ongoing treatment; fatigue related to level of care; emotional stress related to pain and prognosis

    • OT interventions:
    • energy conservation
    • environmental adaptations
    • positioning to promote postural drainage
    • NDT to improve endurance and postural stability
    • facilitations of F/GMC, visual motor, cognitive, and psychosocial development
    • parent education (treatment protocols, advocacy skills)
    • teacher education(energy conservation, precautions during play)
    • observe medical precautions (respiratory  and cardiac conditions)
  43. Pediatric Pulmonary Disorders- Respiratory Distress Syndrome (RDS)
    etiology- premature birth, insufficient production of surfactant to keep alveoli open

    diagnosis- lungs collapse after each breath; xray of lungs reveals "ground glass" appearance

    • medical management
    • mild case: supplemental O2 alone or in combination with positive airways pressure administered through tubes in the nose

    severe case:intubation and a mizture of o2 and air provided by a ventilator under positive end expiration pressure

    • complication
    • severerisk of intracranial hemorrhage; risk for developmental and severe developmental delay

    effects on function: may include visual defects, hypotonia, and other health issues that can impact development

    • OT eval
    • assess for developmental delay
    • ssess the environment

    • OT treatment
    • monitor development; facilitate sesori-motor and cognitive development; address psychosocial issues that arise; provide parent education (positioning, handling, energy conservetions, facilition of develeopment), adapt as necessary, onserve mediacl precautions, refer to opthamologist and other services prn.
  44. Bronchiopulmonary dysplasia (BPD)
    etiology- respiratory disorder often as a result of barotrauma (high inflating pressures, infection, meconium aspiration, asphyxia);complication of prematurity

    walls of the immature lungs thicken, making the exchange of o2 and CO2 more difficult

    dignosis- infant must work harder than normal to obtain sufficient O2 for survival

    • medical management
    • months or years of O2 therapy and artificial ventilation; bronchiodilators and diuretics to keep the aiways and lungs dry

    • complications
    • greater risk ofr hypotonial and GM delays; feeding problems can occur and lead to poor nutrition

    • effect on functions
    • poor autonomic and sensory state regulation, can impact on the alert state necessary for proper feeding
    • poor exercise/activity tolerance
    • reduces ability to socialize due to long periods of poor health
    • isolation and stress on the child and family can lead to psychosocial problems
    • greater risk for attachment disorder

    • OT eeval
    • assess  for developmental delays
    • assess the environment

    • OT intervention
    • facilitate sensori-motor and cognitive development; address psychosocial issues that arise; provide parent education; parent advocacy; observe precautions

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