Cardiac Rehabilitation and Patient Education

Promoting Adherence to the Therapeutic Regimen

• Effective Therapeutic Regimen Management: Nurses can help patients with CAD and angina by promoting effective therapeutic regimen management.

• Assessing Patient Understanding: Assess the patient's knowledge and understanding of CAD and angina. This allows nurses to tailor teaching and interventions to the individual patient's needs.

• Providing Education: Teach patients about angina and atherosclerosis, building upon their existing knowledge base and helping them understand that angina can be managed.

• Enhancing Adherence: Provide both written and verbal instructions about prescribed medications and their use. Reinforce the importance of taking chest pain seriously while maintaining a positive attitude.

Cardiac Rehabilitation

• Interdisciplinary Program: Cardiac rehabilitation involves a multidisciplinary team with nurses, physicians, exercise physiologists, dieticians, and psychologists/behavioral medicine practitioners.
• Supervised Exercise and Education: Includes supervised, progressive exercise, education, nutritional and psychosocial assessment, and counseling.
• Emphasis on Lifestyle Change: Focuses on realistic application of information for long-term lifestyle changes.
• Outpatient Program: Most patients attend a 2-3 times per week outpatient program, for approximately 8 weeks.
• Progressive Program: Exercise intensity and duration gradually increase based on patient tolerance and physiological parameters.
• Commonly Covered Topics in Cardiac Rehabilitation:
  • Anatomy and Physiology of the Heart
  • CAD and Implications of Acute Myocardial Infarction
  • Purposes and Side Effects of Prescribed Medications
  • Importance of Adhering to the Medical Regimen

Example of Cardiac Rehabilitation Program

• Scenario: An example of a cardiac rehabilitation program implementation with a patient with AMI.
  • Patient: Nancy Williams, a 62-year-old woman with a history of type 2 diabetes, angina, hypertension, and a 45-year history of cigarette smoking.
  • Admission: Admitted to the ED with severe chest pain.
  • Diagnosis: Diagnosed with acute anterior MI.
  • Intervention: Thrombolytic therapy with alteplase (Activase) administered.
  • Outcome: Demonstrated successful reperfusion with relief of chest pain, return of the ST segment to baseline on the ECG, and peaking of CK levels.

Assessing a Patient with AMI

• Example: Dan Morales, RN, assesses Mrs. Williams, who is alert, oriented, and demonstrates reduced chest pain after receiving morphine sulfate. She verbalizes concern about the drug and understands its purpose.
• Nursing Diagnoses:
  • Acute pain
  • Anxiety
  • Fear
  • Inadequate protection
  • Potential for decreased CO

Planning Care for Patient with AMI

•  Goals:
  • Reduced chest pain
  • Verbalized reduced anxiety and fear
  • Absence of bleeding problems
  • Maintaining adequate CO

Implementing Care for Patient with AMI

• Initial Implementation:
  • Report chest pain to staff
  • Monitor and evaluate pain
  • Titrate IV nitroglycerin infusion
  • Administer morphine sulfate for unrelieved pain
• Addressing Anxiety and Fear:
  • Encourage the patient to express concerns.
  • Respond honestly to questions
  • Explain the purpose of thrombolytic therapy
  • Explain the need for close monitoring
• Monitoring for Bleeding and Reperfusion:
  • Assess for bleeding signs and symptoms
  • Test stools, urine, and vomitus for occult blood
  • Monitor for signs of reperfusion
  • Monitor ECG for changes
• Cardiac Care and Rehabilitation:
  • Discuss continuing cardiac care and rehabilitation.

Evaluating Care

• Evaluation:
  • Initial morphine reduced Mrs. Williams's pain from 8 to 4.
  • Nitroglycerin infusion further reduced pain after 24 hours.
  • Reperfusion indicated by relief of chest pain, return of the ST segment to baseline, and peaking of CK levels.
• Outcome: Mrs. Williams transferred to the floor after 36 hours in the CCU.

Critical Thinking

• Patient Not Candidate for Thrombolytic Therapy: If Mrs. Williams were not a candidate for thrombolytic therapy, the initial plan of care would have included alternative strategies such as percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).
• Palpitations and Frequent PVCs: If Mrs. Williams experiences palpitations with frequent PVCs, further assess for the cause, monitor for cardiac ischemia, and administer antidysrhythmic medications as ordered.
• Health Promotion Topics: Before discharge, teach Mrs. Williams about:
  • Lifestyle modifications (smoking cessation, healthy diet, exercise)
  • Medications
  • Importance of adherence to treatment plan
  • Cardiac rehabilitation and support groups.
• Addressing Smoking Cessation: Acknowledge Mrs. Williams's concerns about smoking cessation. Encourage her to consider the benefits of quitting and offer resources and support for smoking cessation.

Stroke

• A stroke is a sudden loss of brain function due to interruption of blood flow, resulting in neurological deficit.
• Stroke is the fourth leading cause of death in the United States.
• Every 40 seconds, someone has a stroke, and every 4 minutes, someone dies from a stroke.
• Approximately 795,000 Americans experience a stroke annually, with 160,000 succumbing to the event.
• Stroke risk increases with age, with those over 65 at the highest risk.
• Women are also at risk during pregnancy and the early postpartum period (6 weeks).
• Two main types of stroke:
  • Ischemic stroke: occurs when a blood clot, foreign matter, or narrowing of blood vessels interrupts blood supply.
  • Hemorrhagic stroke: occurs when a blood vessel ruptures and bleeds into surrounding tissue, damaging neurons.

Cerebral Blood Flow and Ischemia

• The brain accounts for 20% of oxygen consumption despite being only 2% of body weight.
• Autoregulation maintains constant blood flow to the brain during varying blood pressure levels.
• When blood flow is interrupted, even for a short time, cells become depleted of glucose, glycogen, and ATP, leading to swelling and further reduced blood flow.
• Even with restored circulation, vasospasms and increased blood viscosity can continue to impede blood flow.
• Severe or prolonged ischemia leads to cell death.

Ischemic Stroke

• Ischemic strokes are classified as:
  • Transient ischemic attack (TIA): a temporary period of localized cerebral ischemia lasting less than 24 hours, often a warning sign of an impending stroke.
  • Thrombotic stroke: occurs when a blood clot forms in a cerebral vessel, often in large vessels narrowed by atherosclerotic plaque.
  • Embolic stroke: occurs when a blood clot or other material travels from another location and lodges in a cerebral vessel.

Hemorrhagic Stroke

• Hemorrhagic strokes occur when a cerebral blood vessel ruptures, leading to bleeding into the brain tissue or spaces surrounding the brain.
• Common causes include hypertension, aneurysms, and trauma.
• Types of hemorrhagic stroke:
  • Intracerebral hemorrhage: bleeding within the brain tissue.
  • Subarachnoid hemorrhage: bleeding into the spaces around the brain.

Stroke Risk Factors

• Major risk factors:
  • High blood pressure
  • Heart disease
  • Diabetes mellitus
  • Sleep apnea
  • High cholesterol
  • Smoking
  • Substance abuse
  • Sickle cell disease
• Other risk factors:
  • Family history of stroke
  • Obesity
  • Sedentary lifestyle
  • Recent infections
  • Previous transient ischemic attacks (TIAs)
• Specific risk factors for females:
  • Hormonal contraceptive use, especially in smokers
  • Pregnancy and childbirth
  • Menopause
  • Migraine headaches with aura
  • Autoimmune disorders (e.g., diabetes, lupus)
  • Clotting disorders

Stroke Prevention

• Lifestyle Modifications:
  • Control blood pressure
  • Maintain a healthy weight
  • Exercise regularly
  • Eat a healthy diet, low in cholesterol and saturated fats
  • Avoid smoking
  • Manage diabetes
• Medications:
  • Antiplatelet drugs
  • Anticoagulants

Recognizing Stroke Signs and Symptoms

• FAST:
  • Face: Facial drooping?
  • Arm: Arm weakness?
  • Speech: Slurred speech?
  • Time: Call 9-1-1 immediately if any of these are present.

Other Stroke Warning Signs

• Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
• Sudden confusion, difficulty speaking, or difficulty understanding speech
• Sudden trouble walking, dizziness, or loss of coordination
• Sudden difficulty with vision in one or both eyes
• Sudden severe headache without a known cause

This quiz focuses on promoting adherence to therapeutic regimens in patients with coronary artery disease (CAD) and angina. It discusses effective management strategies, assessing patient understanding, providing education about heart conditions, and the role of interdisciplinary teams in cardiac rehabilitation.