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