Transcript Treatment Planning for Patients with Cardiopulmonary Dysfunctions

Treatment Planning
for Patients with
Cardiopulmonary
Dysfunctions
Ms. Mary Grace M. Jordan, PTRP
PT 159: Treatment Planning
December 9, 2009
Learning Objectives…
1. Review assessment procedures for
patients with cardiopulmonary
dysfunctions and relate it to PT
concerns (impairments, activity
limitations and participation
restriction), goal-setting and treatment
planning.
2. Design an appropriate treatment plan
for patients with cardiopulmonary
dysfunctions reflecting sound clinical
decision making skills.
Learning Objectives…
3. Choose appropriate and evidencebased treatment strategies for a given
impairment or activity limitation.
4. Appreciate the value of clinical
reasoning in designing a treatment
plan.
5. For the laboratory session: Write a
coherent and cohesive physical therapy
document that reflects sound
assessment and that follows the SOAP
format
Cardiopulmonary Rehabilitation
• Designed to improve the health and
quality of life of patients with heart
and lung disease.
• It is a collaborative effort of
cardiologists, pulmonologists,
specially trained nurses, respiratory
therapists, exercise physiologists,
physical therapists and dieticians.
Cardiopulmonary rehabilitation
• Prolonging survival (cardiac rehabilitation)
• Helping patients adjust physically and
psychologically to their illness
• Improving patients' capacity for physical
exertion
• Reducing symptoms
• Reducing risk factors to help prevent
future cardiac problems or progression of
pulmonary disease
• Providing education and counseling to
improve patients' understanding of their
condition
• Providing guidance on return to work,
when applicable
Clinical Decision-making Model
1. Collect Initial Data
2. Generate a differential diagnosis
Generate client’s problem statement
3. Frame presenting problem
4. Examination – establish specific movement problem
5. Revise diagnosis/ problem list on basis of findings
6. Determine functional status
7. Determine movement prognosis
Refer for investigation or treatment
by another healthcare professional
8. Establish functional goals with client
9. Plan evaluation methods
10. Plan treatment approach and methods
11. Ensure client understands and consents to treatment
12. Implement treatment
13. Charting
14. If goals met – discharge
15. If not met – review:
Treatment methods
Treatment approach alternative
Hypothesis
Revise goals
TREATMENT
PLANNING FOR
PATIENTS WITH
CARDIAC
DYSFUNCTIONS
Cardiac Dysfunctions
• Leading cause of death
• Myocardial infarction, angina,
heart failure, arrhythmias,
sudden death, valvular
dysfunctions.
• Most prevalent type:
Coronary heart disease (CHD),
Coronary artery disease
(CAD), or ischemic heart
disease.
Pathophysio…
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Atherosclerosis
Valvular dysfunctions
Arrthmias
Altered myocardial
muscle mechanics
• Hypertension
Heart failure…
• Congestive heart failure (CHF)
• Inadequate ventricular
contractility
• Inadequate ventricular
compliance
• S/Sx: chest pain, dyspnea,
fatigue, syncope, and
palpitations
Personal Risk Factors for CVD
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smoking
high cholesterol
hypertension
diabetes
emotional stress
family history
Framingham Heart Study
• obesity
• sedentary life-style
• elevated blood
hemocysteine and
fibrinogen levels
**Recent studies
Occupational Risk Factors for CVD
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toxins
environmental tobacco smoke
extreme heat
extreme cold
stress
occupational noise
shift work
physical activity at work
(NIOSH, 1995)
RED FLAGS…
• Anginal pain not relieved in 20
min.
• Angina combined with nausea,
vomiting, profuse sweating.
• Anginal pain radiating to jaw, (L)
arm; intensity continues to
increase after stimulus has been
eliminated
• Confusion, lethargy, changes in
mental and motor function in a pt
with diabetes
RED FLAGS…
• Symptoms of anaphylactic shock.
• Symptoms of inadequate ventilation/ CO2
retention
• Sudden worsening of intermittent
claudication
• Throbbing back, chest, abdominal pain
with exertion and with palpable pulsating
abdominal mass/ feeling of a heartbeat at
supine (abdominal aortic aneurysm)
Cardiac Cases
Collect initial data
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Referral note
History and present status
Review of medical record
Past medical history
Medications
Laboratory tests
Diagnostic studies
Collect initial data
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Patient interview
Chief complaint
Signs and symptoms
Life-style
Previous level of functioning
Recreational interests
Work requirements
Support systems
Patient and family goals
Please Generate PIP
list…
Impairments
Activity Limitations
Participation Restrictions
Formulate examination
strategies…
Examination…
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Vital signs
Blood pressure
Heart rate and rhythm
Exercise response (Stress Test)
Respiratory rate, rhythm, and
shortness of breath
Examination…
• Observation, inspection, and
palapation
• Skin color → Cyanosis or Pallor
• Diaphoresis
• Skin temperature
• Pulse patency
• Presence of edema → Pitting / Nonpitting
• Auscultation
Examination…
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ROM Assessment
FMT
Anthropometric Measurements
Gait Analysis
ADL Assessment
At this point…
Obtain NPIPs
Existing Problem
Anticipated problem
Refine Problem List
5. Revise diagnosis/ problem list on basis of findings
Establishing a PT diagnosis
• Label encompassing a cluster of signs
and symptoms, syndromes, or
categories
• Organize, interpret, analyze, and
integrate data
• Physical therapy impression
• Pathokinesiologic
• Participation Restriction → Activity
Limitation → Impairment → Health
Condition
PT diagnosis
• Example:
Patient’s
inability/limitation/restriction/difficulty
to _____ is due to _________
secondary to _________ in
association with _______.
Establish functional goals
with the client…
Goals and outcomes…
• Increase aerobic capacity
• Increase ability to perform physical
tasks related to self-care, home
management, community and work
integration or reintegration and
leisure activities
• Improve physiological response to
increase 02 demands
• Increase strength, power and
endurance
• Decrease symptoms associated with
inc oxygen demands
Goals and outcome…
• Increase ability to recognize a
recurrence
• Intervention is sought in a timely
manner.
• Reduce risk of recurrence.
• Acquire behaviors that foster healthy
habits, wellness and prevention.
• Decision making is enhanced
regarding health of patient and the use
of health care resources by patient,
family, significant others and
caregivers.
(APTA Guide to PT Practice as cited in Sullivan, 2003)
Goal setting…
• Existing and Testing Criteria
• Anticipated and Predictive Criteria
• Phases of cardiac rehabilitation
Goal setting for Phase I
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1.
2.
In-patient phase
Goals include:
Providing appropriate medical care
Preventing deleterious effects of
bed rest through physical activity
3. Assessing hemodynamic response
to exercise
4. Managing psychosocial issues
5. Educating the patient and family
Goal setting for Phase II
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Immediate out-patient program
Major goals:
To increase the patient’s functional capacity
through an individualized exercise program
and to teach safe activity guidelines
To educate the patient as to risk factor
modification
To educate the patient regarding
medications, signs and symptoms of heart
disease and its progression, and sexual
activities
To promote psychological, behavioral, and
educational improvement
Goal setting for Phase III
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Intermediate out-patient phase
Goals focus on exercise training and
risk factor modification
1. To prevent or delay the progression of
the disease
2. To restore optimal physical,
psychological, emotional, social and
vocational function.
Goal setting for Phase IV
• Maintenance out-patient phase
• Survival, attainment of optimal
functional capacity, return to work, riskfactor changes
• Goal is for the patient to continue
indefinitely with their exercise and
educational programs, either formal
setting or on their own.
Plan the treatment
approach
What’s the game
plan?
Strategies and Tactics
Aerobic Exercise Prescription
• Intensity
– HR or RPE
– 70-85% of HRmax
(common aerobic
prescription)
– 50-60% of HRmax
(deconditioned patients)
– Light vs. Heavy
Aerobic Exercise Prescription
• Frequency: 3-5 x per week
• Duration:
– 30 - 40 min aerobic exercise
– 5-10 minute warm-up/ cool
down
– deconditioned: brief rests
every 5 minutes
Aerobic Exercise Prescription
Which is the best
equipment?
***THE ONE THAT
PATIENTS BEST
ENJOY AND THE
ONE THAT THEY
WILL USE.
• Modality
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Walking
Treadmill
Stair climbers
Stationary
Bicycles
– Rowers
– Cycle ergometer
– Jogging
Exercise Prescription for Patients
following Revascularization
• PTCA
– aerobic exercise ~ 2 weeks after
to allow inflammatory process to
subside
• CABG
– patients more deconditioned
– pain at operative site
– split sternum - takes 6 weeks for
solid bone healing
– PT should address any soft tissue
impairments
Exercise Prescription for CHF
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Systemic conditioning
Peripheral endurance training
Low-level endurance training
Respiratory muscle training
keep intensity low, duration
gradually increased as patient
tolerates.
Exercise Prescription for CHF
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HR limited to RHR + 10-20 bpm
HR < 115 bpm
RPE kept to “fairly light”
prolonged warm-up and cooldown
• Functional assessment - 6MWT
Strengthening Exercise
• Shown to be safe and effective
method for improving strength for
patients with cardiac dysfunctions
Strengthening Exercise
• 4 to 6 weeks after MI or CABG
• 1-2 weeks following
revascularization except CABG
• after completion of phase 2 (4-6
weeks)
• DBP = <105 mmHg
• not compromised by CHF, unstable
symptoms or arrhythmias
Cardiac Cases: Special Considerations
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Post Pacemaker placement
Post Heart transplantation
Valvular Dysfunction
Cardiomyopathy
Arrhythmia
At this point you should…
11. Ensure client understands and consents to treatment
12. Implement treatment
13. Charting
14. If goals met – discharge
15. If not met – review:
Treatment methods
Treatment approach alternative
Hypothesis
Revise goals
TREATMENT PLANNNING FOR
PATIENTS WITH PULMONARY
DYSFUNCTIONS
Chronic Lung Diseases
• Chronic obstructive
pulmonary disease
Chronic bronchitis
Emphysema
Bronchiectasis
• Restrictive lung disease
• Asthma
• Cystic fibrosis
Pathophysiology (COPD)
• Inhaling pollutants → goblet cells
hypertrophy → hypersecretion →
airway obstruction → air trapping →
hyperinflation → atelectasis → V/Q
mismatch → hypoxemia →
hypercapnea → capillary destruction
→ reflex vasoconstriction →
increased pulmonary vascular
resistance → right ventricular
hypertrophy / failure → cor
pulmonale
Asthma
• Common respiratory disease
• Widespread narrowing of airways
due to allergens
• Bronchospasm → narrowing
airways → bronchitis → increase
secretion
• Narrow airways → increase airflow
resistance → air trapping →
hyperinflation
Restrictive lung disease
• Difficulty in expanding the lungs and
a reduction in lung volume
• Thickening of the alveoli and
interstitium
• Fibrosis
1. Collect initial data from:
• referral information
• medical record
• via observation before
any formal evaluation
is begun
• laboratory tests
• interview
2. Generate a differential diagnosis
Generate client’s problem statement
Px interview
At this point…
3. Frame presenting problem
• Generate PIP’s List
• Formulate examination
strategies
• Consultation c other
medical professionals if
needed
Examination…
• What assessment procedures will
you perform on this patient?
Examination…
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Vital signs
Observation, inspection, palpation
Auscultation
Breathing assessment
Cough and sputum assessment
Dyspnea assessment
ROM, MMT, ADL Assessment,
Exercise testing, Posture, Gait,
Chest mobility expansion
measurement, Anthropometry
At this point, you should be able to . .
Obtain NPIPs
Existing Problem
Anticipated problem
Refine Problem List
5. Revise diagnosis/ problem list on basis of findings
PT diagnosis and
prognosis
At this point, you should be able to
6. Determine functional status
7. Determine movement prognosis
Refer for investigation or treatment
by another healthcare professional
8. Establish functional goals with client
9. Plan evaluation methods
Goals and Outcomes
• Increase understanding of px and family of
disease process, expectations, goals and
outcomes
• Increase cardiovascular endurance
• Increase strength, power and endurance of
peripheral muscles
• improved performance of physical tasks
(ADLS)
• Increase strength, power and endurance of
ventilatory muscles
• Improved independence
• Decrease work of breathing
• Enhance self-management of symptoms
(APTA Guide to PT Practice)
Plan the treatment approach
What’s the game plan?
Formulation of strategies and tactics
Strategies…
• Breathing exercises
• Dyspnea relieving
positions
• Aerobic exercises
• Strengthening exercises
• Chest mobility exercises
• Endurance training
• Airway clearance
techniques
• ADL re-training
PLAN
Pt will be seen at the PT department, OD, and will be given the following
management: (Note: Pt is supplied c O2 through a nasal cannula at 1.0 lpm)
1. Pursed-lip breathing training x 5 reps x 1 set c rests
in between
2. Deep diaphragmatic breathing exercise x 5 reps x 1
set
3. Autogenic drainage x 3 cycles
4. Chest mobility exercise incorporating shoulder
flexion and lateral trunk bending x 5 reps x 1 set.
5. Strengthening exercises for (B) UE using green
exercise band for shoulder flexors and
abductors, scapular retractors and elbow flexors
and extensors x 10 reps x 1 set
6. Modified squats (sit ↔ stand) x 10 reps x 2 sets
Plan
6. Aerobic Exercise on
treadmill (interval training)
x 10 minutes or as
tolerated
Warm up: 2-3 mph for 3
minutes
Cool down: 3-1 mph for 3
minutes
Plan
7. Teaching of dyspnea relieving techniques
Is our PT management effective?
•
Evidence from six trials suggests that respiratory
rehabilitation is effective in COPD patients after acute
exacerbation (Puhan, et. al, 2005)
Aerobic Training
• Check-in VS
• warm-up: 5 -15 min
– same mode of exercise but lower intensity
• aerobic portion
• cool down: 5 - 15 min
Exercise Prescription
• MODE - aerobic exercise recommended
– LE , UE
– combination - improved functional status
– consider circuit training
Exercise Prescription
• Intensity
– mild to moderate: 50 to 70% of Max
HR
– severe: 70 to 85% of Max HR
• VO2 max - imprecise
• modified RPE (RPSOB)
– range 3-6
– 3(moderate) = 50% of VO2max
– 6(b/n severe and very severe)=
85% of VO2max
Exercise Prescription
• Duration - varies
– interspersed to accomplish a
total of 20 minutes of
exercise
• Frequency: 3-5 x / week
Aerobic Training
• Progression
– if px perceives session is
easier, with lesser SOB and
lower HR:
• increase duration
• decrease rest periods
Aerobic training
• No evidence that high intensity
aerobic exercise is better than
low-intensity (Puhan, et. al, 2005)
– Pros and cons
• Interval exercise instead of
continuous if high intensity
exercise is preferred because it
prevents high lactate
accumulation (Puhan, et. al,
2005)
Aerobic training
• Ambulatory oxygen improves
exercise performance in people
with moderate to severe COPD
(Bradley, 2004)
• most investigators agree that
endurance exercise for lower
extremities should be the main
exercise modality, the role of
strength and upper body exercise
remains unclear (Puhan, 2005)
Strength Training
• Px with COPD who desaturated
during GXT have shown stable
SaO2 values during weight training
• Strength training can improve the
general exercise performance in
COPD in a modest way (Morgan,
2005)
– Measures for activity limitations?
• strength exercise tends to improve
HRQL more than endurance
exercise (Puhan, et. al, 2005)
Pulmophysiotherapy
• Secretion Removal
Techniques
• Home Instructions / HEP
• Dyspnea Relieving Positions
• Energy Conservation
Techniques
– Pacing
• break down ADLs into
manageable components with
rest periods in between
Is our PT management effective?
• Evidence from six trials
suggests that respiratory
rehabilitation is effective in
COPD patients after acute
exacerbation (Puhan, et. al,
2005)
On dyspnea
• Exercise training improves exertional
dyspnea in patients with COPD (Giglioti, 2003)
• Pulmonary rehab reduces dyspnea
(Pearson, 2004)
Clinical practice guidelines
• Pulmonary rehabilitation leads
to statistically significant and
clinically meaningful
improvements in health
related quality of life,
functional exercise capacity
and maximum exercise
capacity
(Pearson, 2004)
RCT
• No difference between the effects of
interval and continuous training for
patients with COPD (Puhan, 2006)
• 8 week programme of pulmonary
rehabilitation maintains improvements
in exercise capacity and health status
for up to 6 months however these
were not sustained at one year
(Bestall, et. al, 2003 as cited in
Pearson, et. al, 2004)
At this point you should…
11. Ensure client understands and consents to treatment
12. Implement treatment
13. Charting
14. If goals met – discharge
15. If not met – review:
Treatment methods
Treatment approach alternative
Hypothesis
Revise goals
Have we achieved our objectives?
1. Review assessment procedures
for patients with cardiopulmonary
dysfunctions and relate it to PT
concerns (impairments, activity
limitations and participation
restriction), goal-setting and
treatment planning.
2. Design an appropriate treatment
plan for patients with
cardiopulmonary dysfunctions
reflecting sound clinical decision
making skills.
Have we achieved our objectives?
3. Choose appropriate and
evidence-based treatment
strategies for a given
impairment or activity
limitation.
4. Appreciate the value of
clinical reasoning in
designing a treatment plan.
SGD
A case of ASTHMA and A case of
CHRONIC BRONCHITIS
• SOAP format
• Subjective and objective info already
given
• Formulate problem list
• Formulate a sound PT diagnosis
• Select and justify appropriate
strategies
• To be submitted today
Assignment:
• A case of ASTHMA and A case of Chronic
Bronchitis
• SOAP FORMAT
• Create prioritized problem list
• Formulate a sound PT Diagnosis
• Write the patient’s prognosis
• Create 1 Long term goal
• Create 2 short term goals
• Create the plan of treatment with complete
prescription
• Submit on Friday (December 11, 2009)
Read:
•
O’Sullivan – Chapters on Heart Disease
and Chronic Pulmonary Dysfunction
• Clinical Algorithm:
 CABG
 Myocardial Infarction
 Emphysema
 Pulmonary Tuberculosis
Thank you!