住院心脏康复ppt课件.ppt

CardiacRehabilitationPhase1 Dr Andishmand 1 DefinitionofCardiacRehabilitation Thesumofactivitiesrequiredtoensurepatientsthebestpossiblephysical mentalandsocialconditionssothattheymayresumeandmaintainasnormalaplaceaspossibleinthecommunity WorldHealthOrganisation 2 Goalofrehabilitation ReturntoindependentlivingsituationNursinghomepatientsgenerallyreturntothatenvironment 3 Rehabilitationingeneral ComprehensiveMultidisciplinaryLongtermMedicalevaluationPrescribedexerciseRiskfactormodificationCounseling Education 4 Cardiacrehaboutcomes Improvedpsychosocialwell beingMortalityreductionofapproximately25 atthreeyears similartoB blockersandACEIRx Noincreaseinmorbidityormortality 5 Cardiacrehaboutcomes ImprovedexercisetoleranceforCADandCHFDecreasedsymptomsinCADandCHFMulti factorialinterventionsimprovelipidsMulti factorialrehabreducescigarettesmoking 16 26 willquit 6 CardiacRehabilitationSavesLives Notreatmentincardiacdiseasehasstrongerscientificevidenceorasignificantlygreaterimpactonsurvival Thescientificevidencehasbeenreviewedbymanyscientificandexpertbodiesoverthelast30years Everyreviewhascometothesameconclusionthatcardiacrehabilitationisanessentialtreatment CRisonlyformofchronicdiseasemanagementwithanevidencebase 7 Comprehensivehelpwithlifestylemodificationinvolvingeducationandpsychologicalinputaswellasexercisetrainingcanreducemortalityby20 25 over3years Oldridgeetal1988 O Connoretal1989 TheEvidence 8 CostofCardiacRehabilitation Theaveragecostperpatientin2006 7was 413SingledayinaCCUcosts 1 400Angioplasty doesnotreducemortality costs 3 000Bypasssurgerycosts 8 000 9 WhoMakesUpTheCardiacRehabilitationTeam PhysicianPhysicalTherapistThenurseTheoccupationalTherapistPsychologistTheDieticianorNutritionistTheExercisePhysiologist 10 Whoshouldbeinvolved Patient Pharmacist Nurse Consultant GP Physiotherapy Dietician Exerciseinstructor Smokingcessationadvisor SocialServices Psychologist DistrictNurses Practicenurses HealthVisitor Secondarycare 11 TargetGroups Coronaryheartdisease CHD Exertionalangina ACS unstableanginaorNSTEMIorSTEMI followingmedical surgicalmanagement RevascularisationStableheartfailureandcardiomyopathyThoseathighriskofdevelopingCVD totalCVDrisk 20 over10yearsordiabetesmellitus 12 Contraindicationstotherapeuticrehabilitation Unstableangina leftmaincoronarydzEndstageCHForsystemicdiseaseUnstablearrhythmiasMalignanthypertensionExpandingaorticaneurysm 13 Contraindicationstotherapeuticrehabilitation CerebralaneurysmorintracranialbleedRecenteyesurgeryorretinalhemorrhageAcute unstablemusculoskeletalinjuryAcutesystemicillness pneumonia pyelo Severedementia behavioraldisturbance 14 StructureofCardiacRehabilitation Phase1 In patient 1stcontact Phase2 ImmediatepostdischargePhase3 2 4weekspostdischargePhase4 Long term on going 15 PhaseICardiacRehabilitation Whatdowedowiththeseverysickpeople 16 Phase1 UnderstandingofconditionInformation educationRiskfactorassessmentPersonalisedhealthplanPsychologicalassessment supportReferralDrugtherapy 17 Outcomes 18 Functionaldeclineduringhospitalization Function Time Norehabilitation Hospitaladmission PostRecovery A B Rehabilitation ThresholdofIndependence 19 Etiologyofdeconditioning 20 Consequencesofdeconditioning 21 StrengthandFunctionalStatus Function Strength Poor Normal Low High HealthyAdults FrailAdults NearFrail THRESHOLD EstablishedPopulationsforEpidemiologicStudiesoftheElderly EPESE JGerontology 1994 49 3 M109 15y 1994 49 3 M109 15 22 ObjectivesofPhaseICardiacRehabilitationI Patient FamilyEducationII PreventDeleteriousEffectsOfBedrestIII ProvideASafeDischargeToHome 23 ObjectivesofPhaseICardiacRehabilitation I Patient FamilyEducationModificationofriskfactorprofiletreatmentofhyperlipidemiasmokingcessationtreatmentofhypertensioncontrolofdiabetesregularexercisedietarychanges 24 Education 25 ChallengesforthePtandFamily Frightening lifethreateningevent MI majorsurgery Achronicillness reducedlifeexpectancy symptomsAlteredidentity aninvalid walkingtimebombFearsforfamilyandpartnerbeingleftaloneThreattoemploymentandfinancialstatusMedicationsideeffects lethargy impotence BeingtreateddifferentlybyotherpeopleNeurologicalimpairement esp cardiacarrestpats Makinglifestylechanges smoking diet activity 26 Education CHDasadiseaseTreatmentincludingmedicationRecoveryprocessCHDriskfactorsSymptommanagementLivingwithCHD 27 ObjectivesofPhaseICardiacRehabilitation Behaviormodificationstressmanagementathomestressmanagementatworkcreationofhobbies timeoutconflictresolutionskills 28 PsychosocialCare ReducefearandanxietyAssistwithadjustmentPromotepositiveattitudeFacilitatebehaviourchangeIdentifyneedforfurthersupport 29 InvolvethechildrenTheydon thavepathologyyetbuttheyhaveallofthesamestressesTheyalsoshouldknowhowtohelpathome ObjectivesofPhaseICardiacRehabilitation 30 II PreventDeleteriousEffectsOfBedrest MobilizethepatientsoonPreventmuscleatrophyPreventbloodclotformationPreventpneumoniaPreventlethargy ObjectivesofPhaseICardiacRehabilitation 31 III ProvideASafeDischargeToHome ProvideenoughphysicalstaminatogohomeandperformADL sReducefear ObjectivesofPhaseICardiacRehabilitation 32 PhaseIismeanttobepreventativeTohavethepatientoperatewithinsafelimits nottoolittleexerciseandnottoomuchThepatientmustknowwhatactivitiesaresafeandokay III ProvideASafeDischargeToHome 33 PhaseIisalsodiagnosticHowlargewastheinfarct Whendosymptomscomeon PatientsshouldhavehadaLLGXTbeforedischarge III ProvideASafeDischargeToHome 34 PatientAssessment 35 PatientAssessment InorderforapatienttoenterPhaseICardiacRehab theymustbemedicallystable 36 WhoShouldBeEnrolledInPhaseICardiacRehab StablemyocardialinfarctsCABGpatientsPatientswhohavehadangioplastyPatientswhohavehadcardiactransplantationPatientwithOthercardiacpatientsPatientwithnoncardiacdiseasesandhaveseveralriskfactors PatientAssessment 37 WhoShouldNotDoPhaseI PatientswithunstableanginaPatientswithacuteCHFPatient swithuncontrolledrhythmsPatientswithasystolicBP 200mmHg PatientAssessment 38 WhoShouldNotDoPhaseI PatientswithacutepericarditisPatientswithrecentemboliorclotsPatientswithseverecardiomyopathiesPatientswithuncontrolledDMPatintswithsevereASPatientwiththirddegreeAVBlock PatientAssessment 39 Evaluation 40 GoalsOfTheEvaluation Clearthepatientforanymusculoskeletalproblems lossofROM pectusexcavatum pectuscarinatum scoliosis jointpain swelling musclestrength 41 GoalsOfTheEvaluation Clearthepatientofanypulmonaryproblems auscultatethelungsPFTresultsobservebreathingpatternslookforscars restrictionsinthoracicmovement 42 Returnthepatienthome preparedtogobacktowork nohome boundinvalids Helpthepatienttoknowtheupperlimitsofphysicalcapabilities GoalsOfTheEvaluation 43 Increasethepatient sphysicalworkcapacityHelpthepatienttofeelinchargeofmodifyingcoronaryriskprofile GoalsOfTheEvaluation 44 Givehelpfulinformationbacktothecardiacrehabteam theMD nurse exercisephysiologist psychologist dietician GoalsOfTheEvaluation 45 ProcessofEvaluation MedicalChartReviewPatient FamilyInterviewPatientExaminationPatient sToleranceForExercise 46 MedicalChartReview Determinethepatient sdiagnosis MI CABG PTCA Wasthepatientdefribillated WhatdoestheEKGreportsay UseofTPAorStreptokinase 47 MedicalChartReview WhatdothecardiacenzymessayabouttheMI 48 49 MedicalChartReview Lookatlipidpanels HDL TGs LDL VLDL CholesterolLookatECHOreportwallmotion hypokinesisejectionfractionwallthickness 50 MedicalChartReview Catheterizationlabreport whatpercentageofvesselsblockedReadthePFTreport 51 Patient smedications betablockerscalciumchannelblockersnitratesantiarrhythmicsdiuretics MedicalChartReview 52 Patient FamilyInterview Doesthepatientunderstandwhathashappenedtothem 53 Patient FamilyInterview Didtheyhavechestpressureorpainoranginalequivalents Didthepatienthaveanypredisposingriskfactors DM HTN PVD hyperlipidemia familyhx 54 Patient FamilyInterview Didthepatientsmoke Howlongagodidtheystopsmoking theemergencyroom sdoorsor10yrs ago 55 Patient FamilyInterview Isthisthefirstadmission Isthereasupportivefamilynetwork Isthepatientwillingtoreturntowork 56 Patient FamilyInterview Willthepatientneedtobevocationallyretrained Doesthepatienthavehobbies 57 Patient FamilyInterview Isthepatientindenialastowhathashappenedtothem Doesthepatientneedpsychiatrichelp 58 ThePatientEvaluationPhysicalExamination ROMeval passive activeGrossmusclestrengthSkin normalcolor Pulsecheckpedal femoral popliteal carotid 59 Surgicalsites Tenderpointsonpalpationofthorax Breathingpatterns dotheribsflare doesthethoraxriseappropriately ThePatientEvaluationPhysicalExamination 60 AuscultatethelungsBloodpressureonright leftarmsinsupine sitting standing bilaterallyequal ObservetheEKGmonitorwhensittingandstanding ThePatientEvaluationPhysicalExamination 61 Canthepatientdothefollowingthingsfirstinsupine nextinsittingandfinallyinstanding ThroughatotalarmandlegROMactivelyandpassively positionalperturbations SelfCareEvaluation 62 SelfCareEvaluation combhair brushteeth shave performalimitedbedbath washtheunderarmsandgenitalregions washtheanklesandfeet etc canthepatientdress pants shirt socks 63 SelfCareEvaluation Canthepatientdoallofthesethingswhilebeingmonitoredonthetelemetryunitinthecriticalcareunitfor BP EKGchanges HR Whataboutthepatient ssubjectivesymptoms 64 Next MoveOutOfBed WhilemonitoringthepatientforEKGchanges BP HR cometooob cometostandingcanthepatientsupporttheirownbodyweightwithoutassist canthepatientwalkinplace 65 Next MoveOutOfBed CanthepatientdoaSPTintoabedsidechairorcommode Canthepatientwalkinplaceorintheroom Canthepatientsit15 30minutesatatime 66 Next MoveOutOfTheRoom WhilethepatientisbeingmonitoredcontinuouslybyEKGtelemetry forBP HR walk25feet rest doitagainprogressovertimeasablewithEKG BP HRunremarkable 67 Metabolicequivalentofenergyexpenditureforvaryinglevelsofactivity 68 Detailesandstagesofmobilizationofthepatientshouldbedocumented 69 Detailesofpatienteducationshouldbedocumentedinthepatientmedicalrecords 70 Graduation UncomplicatedMI sgohomein5 10daysGraduatefromPhaseICardiacRehabhavingeither LowLevelGXTFullGXTlater 71 Graduation Ifthepatientdoesn tgetaLLGXTinthehospitalbeforedischarge thenusuallytheygototheirphysician soffice1 2weekslaterforamodifiedBruceprotocol 72 ModifiedBruceExerciseTestProtocole 73 DischargePlan Discharge follow upplanthatreflectsprogresstowardgoalsandguideslong termsecondarypreventionplans Interactively communicatethetreatmentandfollow upplanswiththepatientandappropriatefamilymembers domesticpartnersincollaborationwiththeprimaryhealthcareprovider 74 DischargePlan Documenteddischargeplansummarizinglong termgoalsandstrategiesforsuccess 75 WithThanks 76 Evaluation MedicalHistory Reviewcurrentandpriorcardiovascularmedicalandsurgicaldiagnosesandprocedures includingassessmentofleftventricularfunction comorbidities includingperipheralarterialdisease cerebralvasculardisease pulmonarydisease kidneydisease diabetesmellitus musculoskeletalandneuromusculardisorders depression andotherpertinentdiseases symptomsofcardiovasculardisease medications includingdose frequency andcompliance dateofmostrecentinfluenzavaccination cardiovascularriskprofile andeducationalbarriersandpreferences Refertoeachcorecomponentofcareforrelevantassessmentmeasures 77 Evaluation PhysicalExamination Assescardiopulmonarysystems includingpulserateandregularity bloodpressure auscultationofheartandlungs palpationandinspectionoflowerextremitiesforedemaandpresenceofarterialpulses post cardiovascularprocedurewoundsites orthopedicandneuromuscularstatus andcognitivefunction Refertoeachcorecomponentforrespectiveadditionalphysicalmeasures 78 Evaluation Testing Obtainresting12 leadECG assesspatient sperceivedhealth relatedqualityoflifeorhealthstatus Refertoeachcorecomponentforadditionalspecifiedtests 79 Interventions Documentthepatientassessmentinformationthatreflectsthepatient scurrentstatusandguidesthedevelopmentandimplementationof 1 apatienttreatmentplanthatprioritizesgoalsandoutlinesinterventionstrategiesforriskreduction and 2 adischarge follow upplanthatreflectsprogresstowardgoalsandguideslong termsecondarypreventionplans 80 Interventions Interactively communicatethetreatmentandfollow upplanswiththepatientandappropriatefamilymembers domesticpartnersincollaborationwiththeprimaryhealthcareprovider 81 Interventions Inconcertwiththeprimarycareproviderand orcardiologist ensurethatthepatientistakingappropriatedosesofaspirin clopidogrel blockers lipid loweringagents andACEinhibitorsorangiotensinreceptorblockersaspertheACC AHA andthatthepatienthashadanannualinfluenzavaccination 82 ExpectedOutcomes PatientTreatmentPlan Documentedevidenceofpatientassessmentandpriorityshort term ie weeks months goalswithinthecorecomponentsofcarethatguideinterventionstrategies Discussionandprovisionoftheinitialandfollow upplanstothepatientincollaborationwiththeprimaryhealthcareprovider 83 ExpectedOutcomes OutcomeReport Documentedevidenceofpatientoutcomeswithinthecorecomponentsofcarethatreflectsprogresstowardgoals includingwhetherthepatientistakingappropriatedosesofaspirin clopidogrel blockers andACEinhibitorsorangiotensinreceptorblockersaspertheACC AHA andwhetherthepatienthashadanannualinfluenzavaccination andifnot documentedevidenceforwhynot andidentifiesspecificareasthatrequirefurtherinterventionandmonitoring 84 NutritionalCounseling 85 Evaluation Obtainestimatesoftotaldailycaloricintakeanddietarycontentofsaturatedfat transfat cholesterol sodium andnutrients 86 Evaluation Assesseatinghabits includingfruitandvegetable wholegrain andfishconsumption numberofmealsandsnacks frequencyofdiningout andalcoholconsumption 87 Evaluation Determinetargetareasfornutritioninterventionasoutlinedinthecorecomponentsofweight hypertension diabetes aswellasheartfailure kidneydisease andothercomorbidities 88 Interventions PrescribespecificdietarymodificationsaimingtoatleastattainthesaturatedfatandcholesterolcontentlimitsoftheTherapeuticLifestyleChangediet Individualizedietplanaccordingtospecifictargetareasaswellasheartfailureandothercomorbidities Recommendationsshouldbesensitiveandrelevanttoculturalpreferences 89 Interventions Educateandcou