Cardiac Rehabilitation

Introduction: Sudden Cardiac death is a major Clinical and public Health problem all over the world. Despite
the reduction of total cardiac mortality the proportion of cardiac Sudden Cardiac death remain unchanged. Depending on the availability of emergency medical service, 40% or more Sudden Cardiac death victims die before reaching the hospital.

Definition : Cardiac rehabilitation is a multi-dimensional program designed for those who suffer from heart
disease. The program reduces their future risk through medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling. WHO has defined cardiac rehabilitation as the sum of activity required to ensure cardiac patient the best possible physical, mental and social conditions. According to the US Public Health Service (USPHS), a cardiac rehabilitation program is defined as a program that involves the following: Medical evaluation Prescribed exercise Education Counseling of patients with cardiac disease

Goals:The main goals of a cardiac rehabilitation program are noted below. Short-term goals are as follows: "Reconditioning" the patient sufficiently enough to allow him/her to resume customary activities Limiting the physiologic and psychological effects of heart disease Decreasing the risk of sudden cardiac arrest or reinfarction Controlling the symptoms of cardiac disease Long-term goals are as follows:

Identification and treatment of risk factors Stabilizing or reversing the atherosclerotic process Enhancing the psychological status of the patients
Improve dietary habits and lifestyle

How does it help:Cardiac rehab helps people who have heart problems: Recover after a heart attack or heart surgery. Prevent future hospital stays, heart problems, and death related to heart problems. Address risk factors that lead to coronary heart disease (also called coronary artery disease) and other heart problems. These risk factors include high blood pressure, high blood cholesterol, overweight or obesity, diabetes, smoking, lack of physical activity, and depression and other emotional health concerns. Adopt healthy lifestyle changes. These changes may include a heart healthy diet, increased physical activity, and learning how to manage stress. Improve their health and quality of life. Each patient will have a program that's designed to meet his or her needs.

Who Needs Cardiac Rehabilitation?

People of all ages and ethnic backgrounds can benefit from cardiac rehabilitation (rehab). Rehab may help people who have had: A heart attack Angioplasty or coronary artery bypass grafting for coronary heart disease Heart valve repair or replacement A heart transplant or a lung transplant Stable angina Heart failure

Benefits
Cardiac rehabilitation (rehab) has many benefits. It can: Reduce overall risk of dying, the risk of future heart problems, and the risk of dying from a heart attack Decrease pain and the need for medicines to treat heart or chest pain Lessen the chance that patient to go back to the hospital or emergency room for a heart problem Improve overall health by reducing risk factors for heart problems Improve quality of life and make it easier for to work, participate in social activities, and exercise

Risks
Physical activity is safer in the rehab setting than at home. Very rarely, physical activity during rehab causes serious problems. These problems may include injuries to muscles and/or bones or heart rhythm problems that can lead to death or recurrent heart attack.

The Cardiac Rehabilitation Team

The cardiac rehab team may include Doctors (such as a family doctor, a heart specialist, and a surgeon) Nurses Exercise specialists Physical and occupational therapists Dietitians or nutritionists Psychologists or other mental health specialists.

Phases of Cardiac Rehabilitation

Cardiac rehabilitation services are divided into 3 phases, as follows:

Phase 1 - Initiated while the patient is still in the hospital Phase 2 - A supervised ambulatory outpatient program spanning 3-6 months Phase 3 - A lifetime maintenance phase in which physical fitness and additional risk-factor reduction are emphasized

Phase 1: in-hospital phase

This begins in the hospital following a heart attack, heart surgery or angioplasty. Low level physical activity begins in the ICU itself and is gradually increased during the stay in hospital. Education on cardiac risk factors is initiated and the patient is advised appropriate lifestyle modification. Phase 1.5: post discharge phase This phase begins after the patient returns home from the hospital. This phase of recovery includes low-level exercise and physical activity, as well as instruction regarding changes for the resumption of an active and

satisfying lifestyle. After 2-6 weeks of recovery at home, the patient is ready to start phase 2 of his/her cardiac rehabilitation.

Phase 2: supervised exercise

The patient attends the program 3 times a week at the Rehabilitation Center. During each session the patient exercises using state-of-the-art portable heart monitoring equipment, known as telemetry. This ensures optimal amount of exercise in the safest manner possible. An individualized program of lifestyle modification, including in-depth nutrition counseling is planned. All of the patients risk factors are monitored, and kept under strict control. Patients are also introduced to Yoga meditation techniques. The duration of the program is between one and three months, depending on the medical condition. Patients who have completed hospitalization and 2-6 weeks of recovery at home can begin phase 2 of their cardiac rehabilitation program. Phase 2: Exercise testing and training on a treadmill. Cardiopulmonary exercise testing to objectively determine the functional capacity in patients with congestive heart failure before they begin a rehabilitation exercise program. Exercise treatments usually are scheduled 3 times a week at the rehabilitation facility. Constant medical supervision is provided; this includes supervision by a nurse and an exercise specialist, as well as the use of exercise ECGs. In addition to exercise, counseling, and education about stress management, smoking cessation, nutrition, and weight loss also are incorporated into this phase. Phase 2 may last 3-6 months.

Exclusion criteria for phase-2

Exercise is not recommended for patients who are found to have one of the following: Fever or systemic illness. Unresolved unstable angina Resting SBP>200 mm of Hg and DBP>110 mm of Hg. Significant unexplained drop in BP during exercise. Resting tachycardia(HR>100b/min) Uncontrolled arterial or ventricular arrhythmias. Unstable/uncontrolled DM. Symptomatic hypotension. New or recurrent symptoms of breathlessness, palpitation, dizziness or lethargy.

Phase 3: maintenance phase

This begins on completion of Phase II, once the patient is more independent. The focus continues on education and lifestyle modification and risk reduction. Exercise is performed under supervision, and telemetry is used if indicated. Phase 3 of cardiac rehabilitation is a maintenance program designed to continue for the patient's lifetime. The exercise sessions usually are scheduled 3 times a week. Activities consist of the type of exercises the patient enjoys, such as walking, bicycling, or jogging. A registered nurse supervises these classes. ECG monitoring usually is not necessary. The main goal of phase 3 is to promote habits that lead to a healthy and satisfying lifestyle. Sexuality: Patients may start sexual activity 2-3 weeks following an uncomplicated myocardial infarction. They must be instructed to report any untoward symptoms to the physician or to a member of the rehabilitation team.

Health Assessment
Before start cardiac rehab program, rehab team will assess patients health. This includes taking medical history and doing a physical exam and tests.

Medical History
A doctor or nurse will ask about previous heart problems, heart surgery, and any heart-related symptoms such as diabetes or kidney disease. The doctor or nurse may ask: Whether family has a history of heart disease. What medicines One're taking, including over-the-counter medicines and dietary supplements (such as vitamins and herbal remedies). Describe how much, how often, and when One take each medicine. Whether One smoke and how much. How One check blood sugar level, and how often One do it (if One have diabetes). Whether One've ever had hypoglycemia. This condition can occur in people who take medicines to control their blood sugar levels. Rehab team will ask questions to help them assess quality of life and well-being.

Physical Exam
A doctor or nurse will do a physical exam to check overall health, including heart rate, blood pressure, reflexes, and breathing.

Tests
Doctor may recommend tests to check heart,ECG, Blood cholesterol and blood sugar levels,HbA1C

What to Expect During Cardiac Rehabilitation

During cardiac rehabilitation (rehab), patient will learn how to:

Increase physical activity and exercise safely Follow a heart healthy diet Reduce risk factors for future heart problems Improve emotional health The rehab team will work with patient to create a plan that meets patient ne eds. Each part of cardiac rehab will help lower pts risk for future heart problems.

Over time, the lifestyle changes pts make during rehab will become more routine. They will help patient maintain a reduced risk for heart disease.

Increase Physical Activity and Exercise Safely

Physical activity is an important part of a healthy lifestyle. It can strengthen heart muscle, reduce risk for heart disease, and improve muscle strength, flexibility, and endurance. Rehab team also will work with patient create an easy-to-follow exercise plan. It will include time for a warm up, flexibility exercises, and cooling down. It also may include aerobic exercise and muscle-strengthening activities. Patient will get a written plan that lists each exercise and explains how often and for how long patient should do it.

Exercise training as part of cardiac rehab may not be safe for all patients. For example, if patient have very high blood pressure or severe heart disease, patient may not be ready for exercise training. Or patient may only be able to tolerate very light conditioning exercises. The rehab team will help decide what level of exercise is safe for patient.

Aerobic Exercise
Typically, rehab team will ask to do aerobic exercise 3 to 5 days per week for 30 to 60 minutes.

Muscle-Strengthening Activities
Typically, rehab team will ask patient to do muscle-strengthening activities 2 or 3 days per week. Patient exercise plan will show how many times to repeat each exercise.

Exercise at the Rehab Center and at Home

When patient start cardiac rehab, exercise at the rehab center. Members of rehab team will carefully watch to make sure patient is exercising safely. A team member will check blood pressure several times during exercise training. Patient also may need an ECG to check heart's electrical activity during exercise. This test shows how fast heart is beating and whether its rhythm is steady or irregular.

Follow a Heart Healthy Diet

Rehab team will help One create and follow a heart healthy diet. The diet will help one reach rehab goals, which may include managing weight, cholesterol levels, blood pressure, diabetes, kidney disease, heart failure, and/or other health problems that diet can affect. One will learn how to plan meals that meet calorie needs and are low in saturated and Trans fats, cholesterol, and sodium (salt). Rehab team also may advise one to limit alcohol and other substances. Alcohol can raise blood pressure and harm liver, brain, and heart.

Reduce Risk Factors for Future Heart Problems

Cardiac rehab team will work with one to control risk factors for heart problems. Risk factors include high blood pressure, high blood cholesterol, overweight or obesity, diabetes, and smoking.

High Blood Pressure.

Exercising, losing weight, limiting how much salt and alcohol one consumes, and quitting smoking can help one lower blood pressure. One may need medicine to lower blood pressure if lifestyle changes aren't enough.

High Blood Cholesterol

Too much cholesterol in the blood can cause heart disease. Rehab team will work with one to lower high blood cholesterol. One can do this by following a heart healthy diet, losing weight, exercising, quitting smoking, and limiting how much alcohol one drinks. Physical activity also can increase HDL cholesterol, which is sometimes called "good" cholesterol. This is because it helps remove cholesterol from arteries. One may need medicine to lower cholesterol if lifestyle changes aren't enough.

Overweight and Obesity

If the patient is overweight or obese, rehab team will help One set short- and long-term weight-loss goals. One can reach these goals by following the diet and exercise plans that the team creates for one.

Diabetes
If one have diabetes, rehab team will work with one to control blood sugar level. Following a heart healthy diet, losing weight, and exercising can lower blood sugar level. One may need medicine to lower blood sugar level if lifestyle changes aren't enough.

Smoking
Smoking is a risk factor for heart disease. If one smoke, quitting can help one avoid future heart problems. Quitting can help lower blood pressure and keep cholesterol levels healthy.

Improve Emotional Health

Psychological factors increase the risk of getting heart disease or making it worse. Depression, anxiety, and anger are common among people who have heart disease or have had a heart attack or heart surgery. Get treatment if one feel sad, anxious, angry, or isolated. These feelings can affect physical recovery. Depression is linked to complications such as irregular heartbeats, chest pain, a longer recovery time, the need to return to the hospital, and even an increased risk of death.

Counseling for Sexual Dysfunction

People who have heart problems sometimes have sexual problems. The most common problem is less interest or no interest in sex. Impotence or premature or delayed ejaculation may occur in men. Depression, medicines, fear of causing a heart attack, or diabetes can contribute to sexual problems. Talk to doctor if One having sexual problems or to find out whether sexual activity is safe for One.

Conclusion:
Cardiac rehabilitation improves subsequent prognosis. The future of Cardiac rehabilitation programs includes offering more individualized services to a greater variety of Patients and families regardless of their geographical location. Findings from research of highly structured and uniform aspects of Cardiac rehabilitation programs that is available to all patients who have experienced a cardiac event and their families. Prevention, education for self care and lifestyle modification are key components for improved outcomes.

Reference:1. Black .joyce M, Hawks.Jane.H . Medical-Surgical Nursing.St Louis,Missouri 63146: Elsevie,2010,8th Edition. 2. Suzanne C.Smeltzer,Brenda Bare,Bruner . Suddarth, Medical-Surgical Nursing.U.S.A:Lippincott Williams &Wilkins,2004 , 10th Edition. 3. Lewis, Heitkemper, Dirksen,O Brien, Bucher, Medical-Surgical Nursing.New delhi:Mosby,2007,7th Edition. 4. Susan. L W. , Sandra Adams , Cardiac Nursing.,U.S.A Phialadelphia, 2000,4th Edition. 5. Shirley P Hoeman, Rehabilitation Nursing, New Delhi: Elsevier, 2010, 4th Edition. Website:Health assessment taken from- : www.wikipedia.org Journal:Elise Blake,Costas Tsakitides,Lee Ingle.Hospital verses Community based phase III Cardiac Rehabilitation,British Journal of Nursing;2;January.2009.

Key Points:

Cardiac rehabilitation (rehab) is a medically supervised program that helps improve the health and wellbeing of people who have heart problems. Rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help One return to an active life. Cardiac rehab involves a long-term commitment from the patient and a team of health care providers, such as doctors, nurses, exercise specialists, physical and occupational therapists, dietitians or nutritionists, and psychologists or other mental health specialists. Many people who have heart problems can benefit from cardiac rehab. Rehab can help people who have had a heart attack, angioplasty or coronary artery bypass grafting for coronary heart disease, heart valve repair or replacement, a heart transplant or a lung transplant, or stable angina. The goals of cardiac rehab include helping One recover after a heart attack or heart surgery, addressing risk factors for heart problems, adopting healthy lifestyle changes, and improving health and quality of life. rehab team will work with One to meet goals. One will do this through increased daily physical activity, following a heart healthy diet, quitting smoking, and improving emotional health. Before starting any cardiac rehab program, rehab team will assess health. They'll ask about medical history and do a physical exam. They may recommend tests to check overall health. During cardiac rehab, team will help create a physical activity plan and heart healthy diet for One to follow. They will work with One to reduce risk factors for heart problems. If One feel sad, anxious, angry, or isolated, the team can help One get treatment to improve emotional health. Cardiac rehab has many benefits. It can improve overall health and quality of life. It also can reduce overall chance of dying, the chance of future heart problems, and the chance of dying from a heart attack. Cardiac rehab also can decrease pain and lessen the chance that One will have to go back to the hospital or emergency room for a heart problem. The lifestyle changes One make during cardiac rehab have few risks. At first, physical activity is safer in the rehab setting than at home. Members of the rehab team are trained and have experience teaching people who have heart problems how to exercise. Very rarely, physical activity during rehab causes serious problems.

Outcomes of Cardiac Rehabilitation Training

Cardiac rehabilitation provides many benefits for patients. The most important of these are discussed in this section. Improved exercise tolerance Control of symptoms Improvement in the blood levels of lipids Effect on body weight Effect on blood pressure Reduction in smoking Improved psychosocial well-being Reduction of stress Enhanced social adjustment and functioning Return to work Reduced mortality Pathophysiologic measures

When combined with intensive dietary intervention, with or without lipid-lowering drugs, exercise training may result in the limitation of progression or in the regression of angiographically documented coronary atherosclerosis. Exercise training in patients with heart failure and compromised LV ejection fraction produces favorable hemodynamic changes in the skeletal musculature. Therefore, cardiac rehabilitation exercise training is recommended for the improvement of skeletal muscle functioning. However, such training does not seem to improve cardiac hemodynamic function or collateral circulation to any significant degree. This program begins while patients are still in the hospital. Phase 1 includes a visit by a member of the cardiac rehabilitation team, education regarding the disease and the recovery process, personal encouragement, and inclusion of family members in classroom group meetings. Low-risk patients should be encouraged to sit in a bedside chair and to begin performing self-care activities (eg, shaving, oral hygiene, sponge bathing). On transfer to the step-down unit, patients should, at the beginning, try to sit up, stand, and walk in their room. Subsequently, they should start to walk in the hallway at least twice daily either for certain specific distances or as tolerated without being unduly pushed or held back. Standing heart rate and blood pressure should be obtained followed by 5 minutes of warm-up or stretching. Walking, often with assistance, is resumed, with a target heart rate of less than 20 beats above the resting heart rate and an RPE of less than 14. Starting with 5-10 minutes of walking each day, exercise time gradually can be increased to up to 30 minutes daily. Team should incorporate in the discharge planning an appropriate emphasis on secondary prevention through risk factor modification and therapeutic lifestyle changes (TLC), such as aspirin and beta-blocker use in all patients, angiotensin converting enzyme (ACE) inhibitor use in patients with left ventricular ejection fraction of less than 40%, smoking cessation, lipid management , weight management , and stress management. They must also ensure that phase 1 patients get referred to appropriate local, convenient, and comprehensive phase 2 programs

Lesson Plan on Cardiac Rehabilitation

Subject Topic Date Time Duration Place Group Medical Surgical Nursing Cardiac Rehabilitation

2 Hrs Class Room Post Basic Diploma in Orthopedic and Rehabilitation Nursing Students No of Group Members 3 Method of Teaching Discussion Teaching Aids Chart, Poster, OHP, Flash Card, Power Point, Name of Student Teacher Babli Ghosh Name of Supervisor Madam M Bose General Objective After completion of Discussion the group will be able to 1. Develop Knowledge Regarding Cardiac Rehabilitation 2. Develop Skill regarding Care of a Patient who need Cardiac Rehabilitation. 3. Develop Attitude regarding Care of a Patient who need Cardiac Rehabilitation.

Time 1 min 1 min 2 min 4 min 3 min 2 min

Specific Objective The Group will be able to Introduce the Topic Define Cardiac rehabilitation Enlist goals

Content Introduction:- : Sudden Cardiac death is a major Clinical and public Health problem all over the world. Announcement of the topic:-Today I am going to discuss Cardiac rehabilitation Definition:- Rehabilitation is a multidimensional program designed for those who suffer from heart disease Goals:-Short term and Long term.

Teaching Learning Activity Discussion

Teaching Aids

Evaluation

Discussion

Discussion

Chart

Enumerate helping group List down beneficiaries

How does it help:- after heart attack, coronary heart disease, Prevent future hospital stay etc Who needs: Heart attack Angioplasty Heart valve repair or replacement Heart transplant Lung transplant Stable angina Heart failure Benefits: Reduce overall risk of dying, Decrease pain Lessen the chance that patient to go back to the hospital Improve overall health Improve quality of life Risks:Injuries to muscles and/or bones or heart rhythm problems that can lead to death or recurrent heart attack. Team: Doctors Nurses, Exercise specialists, Physical and occupational therapists, Dietitians or nutritionists. Psychologists or other mental health specialists

Discussion Discussion

Flash card White Board

What is the definition of Cardiac rehabilitation? What are the goals of Cardiac rehabilitation? How does it help? Who are the beneficiaries?

3 min

Enlist Benefits

Discussion

OHP

What are the Benefits of Cardiac rehabilitation?

1 min

Enlist Risks

Discussion

Board

What are the risks of Cardiac rehabilitation? Who are the Team members?

1 min

List down Team members

Discussion

Poster

Time 10 min

Specific Objective Enlist Phase:

Content Phase:- 3 phases, as follows:

Phase 1 - Initiated while the patient is still in the hospital Phase 2 - A supervised ambulatory outpatient program spanning 3-6 months Phase 3 - A lifetime maintenance phase in which physical fitness and additional riskfactor reduction are emphasized

Teaching Learning Activity Discussion

Teaching Aids LCD Projector

Evaluation How many phases are there?

10 min

List down Health assessment List down expectation

Health assessment:- Before start cardiac rehab program, rehab team will assess patients health. This includes taking medical history and doing a physical exam and tests What to expect during cardiac rehabilitation:

Discussion

LCD Projector

How Health assessment is done? What to expect during cardiac rehabilitation?

12 min

Discussion

LCD Projector

Increase physical activity and exercise safely Follow a heart healthy diet Reduce risk factors for future heart problems . Discussion Discussion

7 min 3 min .

Summarize the topic

Improve emotional health Summarization:

Conclusion:- Cardiac rehabilitation improves subsequent prognosis Bibliography:-