Cardiac Surgery and Rehabilitation Quiz

Patient Positioning

• Sit in a new part of the room next to someone you usually don't sit with.

Ischemic Conditions & Med/Surg Management

• Medical Management for CAD and MI: Optimize blood pressure with medication, manage weight, increase exercise, lower myocardial oxygen demand with medications that lower heart rate and/or lower contractility, optimize coronary blood flow with blood thinners, cholesterol management, and physical activity optimization.
• A more in-depth lecture on pharmacology will follow.

Surgical Interventions for CAD & MI

• Percutaneous Transluminal Coronary Angioplasty (PTCA): Balloon angioplasty using a balloon-tipped catheter to compress plaque and restore blood flow in blocked coronary arteries. Can be used with stents.
• Stents: Used in conjunction with PTCA, designed to prevent re-stenosis, and often combined with blood thinners.

Surgical Interventions - CABG

• Coronary Artery Bypass Graft (CABG): Taking a saphenous vein, internal mammary/internal thoracic artery, or brachial vein to bypass a blockage and restore blood flow to the heart.

Surgical Treatments: Coronary Artery Bypass Graft (CABG)

• Harvesting a vessel from the body (e.g., saphenous vein, ulnar artery).
• Connecting the harvested vessel from the aorta to the distal area of occlusion.

Mid-CAB: Indications & Contraindications

• Indications: Blocked arteries on the anterior surface of the heart.
• High risk: High-risk patients for bypass surgery.
• Benefits: Absence of sternotomy (open chest incision) reduces functional impairment, shorter hospital stay, and a lower risk compared to heart-lung machines.

Chart Review: Surgery

• Necessary elements to review from patient charts:
  • Type of surgery performed
  • Method of surgery
  • Location of vein harvesting
  • Any unusual occurrences during the peri-operative or operative period.

PT Examination

• Assessment beyond standard examination components:
  • Cardiovascular screen (heart auscultation, color/perfusion observation).
  • Sternal stability assessment.
  • Sternal precautions education.
  • Cardiac/Respiratory fitness testing.
  • Education on risk factors.
  • Referral to cardiac rehabilitation.
  • Vital signs and cardiorespiratory response to activity assessment.
  • ECG/Telemetry.

Examination Continued: Special Tests CV

• Special tests for the cardiovascular system include heart auscultation, capillary refill assessment, peripheral pulse strength assessment, lung auscultation, blood pressure measurement (ortho/hypotension assessments), and sternal stability assessment.

Examination - Sternal Incision

• Wound evaluation: Assess color, odor, and discharge from the surgical wound.
• Sternal stability: Assess sternal stability.
• Risk factors for dehiscence: Older age, smoking, diabetes, overweight/obesity, and poor nutritional status are risk factors for sternal wound dehiscence.

Sternal Instability

• Method: Palpate sternal halves during flexion/extension and rotation.
• Palpation Technique: Identify grade of motion, any bony gap, and tenderness during movements. Assess during coughing and deep inspiration/expiration.
• Assessment of Sternal instability scale: Includes 0(normal), 1(slight increase in motion), 2(moderate increase), and 3 (marked increase in motion).

Sternal Precautions

• General Precautions: Avoid pushing, pulling, lifting, or carrying greater than 5-10 pounds for 8 weeks; Avoid bilateral shoulder elevation past 90 degrees; Unilateral shoulder elevation is allowed, and limit reaching behind back; Splint coughing; Avoid driving for 8 weeks.

Modified Sternal Precautions "Move in the Tube"

• Alternative to sternal precautions: Pilot program in several institutions.
• Patient Positioning: Patients keep their movements within the tube (or green area) in the hospital room to preserve the integrity of the sternum.
• Open-Chain Activities: Movement out of the tube (green area) is allowed for activities of daily living (ADLs).

Sternal Precautions – Move in the Tube

• Bilateral arm movements: Horizontal, backward, over the shoulder at a pain-free level.
• Loaded movements: At a pain-free level.
• Upper arms: Close to body for 6-8 weeks.
• BMI ≥ 35: Support vest (6-8 weeks).
• Coughing & Sneezing: Use pillow pressure to the surgical site to splint the cough for 6-8 weeks.
• Chest Support: Sterno vest for full chest circumference or a supportive bra for women.

Keep Your Move in the Tube

• Each healthcare institution or surgeon makes the choice of whether to use Traditional Precautions or Move in the Tube precautions.

Ischemic Conditions: Medical & Surgical Management

• Video & Movement System: Analyze patient history, systems review, outcome measures, task analysis, movement speed, range of motion, symmetry, smoothness, and symptoms (orthopnea, pain).

Movement System

• Evaluate systems contributing to movement (e.g., using the ICF model).
• Initial clinical hypothesis
• Additional assessments to support or alter the hypothesis

Documentation of Level of Assist

• Independent (I): Patient performs the task independently and safely.
• Supervision (S): Patient may require supervision to ensure safe performance.
• Contact Guard Assist (CGA): Therapist maintains contact with the patient for mobility & balance support.
• Minimal Assist (Min A): Patient performs 75% of the task independently; clinician assists 25%.
• Moderate Assist (Mod A): Patient performs 50% of the task independently; clinician assists 50%.
• Maximum Assist (Max A): Patient performs 25% of the task independently; clinician assists 75%.
• Dependent (D): Clinician performs the entire task.

Functional Measures

• Assessing functional status.
• Impact of medications and/or surgery on function.
• Risk stratification for mortality, readmissions, and falls.
• Baseline data for home exercise programs.

Aerobic Capacity

• 6-minute walk test (25 m MCID in MI/CAD).
• 2-minute marching/step test (time to move).
• Functional activities: 5 sit-to-stand repetitions, 30-second sit-to-stand.

Ready, Set, Go!

• Stand up straight, mark the wall midway between patella and iliac crest.
• March for 2 minutes, and lift knees to 90 degrees.
• Count the number of times the right knee touches the marked level.

Men's and Women's Results

• Provides age-based averages. Categorizes results as below average, average, or above average.

2-Minute Step Test

• Alternative to 6MWT.
• Minimal equipment required (tape measure & timer).
• Low correlation with VO2.
• Insufficient data on reliability and responsiveness.

AM-PAC Inpatient Basic Mobility Short Form

• Patient assessment for activities in bed, sitting, and moving.
• Standardized scale; 6 items.
• Difficulty assessed for each item (Unable, A Little, A Lot, None).
• Help needed scores.

QOL (SF-36)

• Physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, mental health.

Seattle Angina Questionnaire

• Questionnaire to understand activity limitation due to chest discomfort.
• Measures frequency of chest discomfort (chest pain, tightness, angina).
• Determines the impact on daily activities and lifestyle.

Test your knowledge on key aspects of cardiac surgery procedures and physical therapy interventions. This quiz covers topics such as MID-CAB procedures, PTCA, and post-operative patient evaluations. Enhance your understanding of cardiac care and rehabilitation practices with these questions.