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Cardiac Conditions Hypertension Pathophysiology Increased PR or CO, vasoconstriction or narrowing of blood vessels Issue in renin-angiotensin-aldosterone system Risk Factors CAD Older age...

Cardiac Conditions Hypertension Pathophysiology Increased PR or CO, vasoconstriction or narrowing of blood vessels Issue in renin-angiotensin-aldosterone system Risk Factors CAD Older age Male Diabetes Obesity Smoking High sodium diet Pre-eclampsia S&S Elevated: >120-129 AND 130-139 OR 80-89 Stage 2: >140 OR >90 Treatment RPE 12-15 if just HTN, may have comorbidities Moderate intensity ○ 12-15 RPE ○ 40-60% HRR >30 min, 5-7 days/week Low weight, high reps Precautions/ Resting SBP >180 or DBP >100 Implications Exercise SBP >220 or DBP >105 Watch for medication hypotension Avoid valsalva Orthostatic Hypotension Pathophysiology Rapid drop in BP due to positional changes ○ Decrease SBP by 20+ mmHg ○ Decrease >10 DBP Risk Factors Elderly Dehydration Blood loss Parkinson’s or SCI Diabetes Medications: vasodilators, anti-HTN S&S Dizzy/lightheaded Visual blurring Fatigue HA  Palpitations Nausea Syncope Cognitive slowing Treatment Midodrine Slow when changing positions Diet ○ Exercise prior to meals ○ Avoid alcohol and large meals ○ Increase caffeine and salt Hydration Limit exposure to heat Compression stockings or abdominal binders Elevate HOB 15-20 Physical maneuvers! Precautions/ Monitor for supine hypertension Implications CABG and valve surgery Description Sternotomy Improves cardiac circulation Treatment Balance (edge of bed and standing) Education ○ Splinted cough ○ Sternal precautions Increase chest expansion ○ Diaphragmatic breathing using lateral costal technique ○ Incentive spirometer Mobilization ○ Keep RPE 4 increased risk Wells: >2 increased risk Constans UE Virchow’s Triad Treatment Preventative ○ Early ambulation ○ Compression ○ Anti-coagulants Venous Insufficiency Description Damaged valves create pooling and backflow S&S Itching and tingling Dull ache Heaviness Swelling Cramping in legs Increase in pain with standing Decrease in pain with elevation Treatment Compression Wound management Elevation Ankle pumps  Pulmonary Conditions Obstructive Lung diseases vs Restrictive Lung disease Trouble getting air out Trouble getting air in High V, relatively low Q Low V, relatively higher Q FEV1 reduced but FVC relatively normal so reduced Description FEV1/FVC ratio is normal because both values are FEV1/FVC ratio reduced No significant changes in IRV and TRV, but ERV is Decreased chest wall expansion reduced COPD ARDS Bronchiectasis Pneumonia Asthma Types Pulmonary edema Chronic bronchitis Pulmonary embolus Cystic fibrosis Bronchogenic cancer Musculoskeletal issues Decrease dyspnea Increase inspiration ○ Diaphragmatic breathing ○ Pursed lip breathing ○ Segmental breathing ○ Paced breathing Apical, lateral costal, or post. Basal ○ Positive expiratory pressure devices Treatment Add quick stretch, use belt or band Airway clearance for resistance or assistance ○ Summed/stacked breathing ○ Incentive spirometer ○ Huffing/cough assist techniques Improve chest wall expansion ○ Postural drainage ○ Trunk and UE exercises (ext/flex, PNF chops, ○ Percussion, shaking, vibration rotation with cane) ○ Posture education and exercises Productive cough Dry cough Wheezes (due to narrowed airways) Crackles (due to inflammation) Cor pulmonale (because hyperexpansion of lungs Cor pulmonale (due to restricted pulmonary vessels) smooshes the pulmonary vessels) JVD and edema Pulsus paradoxus Loss of appetite/weight loss (working so hard to Polycythemia (compensate to get more O2) Symptoms breath) Dyspnea, hypoxemia, fatigue, weakness, chest Dyspnea, hypoxemia, fatigue, weakness, chest discomfort, cyanosis or clubbing, increased HR and discomfort, cyanosis or clubbing, increased HR and BP, Diminished breath sounds due to reduced gas BP, Diminished breath sounds due to reduced gas exchange exchange  COPD: Emphysema, Asthma, Chronic Bronchitis Description Diseases of the respiratory tract that produce an obstruction to air flow which ultimately affects both the mechanical function and gas exchange capability Pathophysiology Inflammation of mucosal lining and mucosal thickening Spasm of bronchial smooth muscles Examination Decreased fremitus in general, not sure about chronic bronchitis Rib angle/shape of chest: > angle with COPD S&S SOB Increased mucus production Cough, wheezes Pulmonary artery hypertension Respiratory muscle fatigue Muscle dysfunction: weakness, atrophy, dec endurance Dyspnea with activities→ more sedentary to avoid dyspnea producing activities→ aggravates dyspnea→ further reduces activity Digital clubbing Treatment General Airway clearance Pursed lip breathing ○ Dec RR, premature airway closure/trapping, PaCO2 ○ As blow out, inc resistance to expiratory air flow which results in positive pressure and keeps airways open Paced breathing Tripod position and postural reeducation Balance training (they have risk of falls) Progressive aerobic and strength Energy conservation Education Oxygen esp during exercise Inspiratory mm training (controversial in literature) Steroids, antibiotics Inpatient Interval training: short bouts several times a day Balance at edge of bed and standing Strength training (low resistance or bodyweight) ○ Sit to stands (increase strength of quads and glutes) Walking and aerobic exercise In exacerbation, may require steroids, antibiotics, and bronchodilators MONITOR VITALS → inc risk of desaturation Outpatient  Walking and aerobic exercise Continuous training (preferred over interval, interval more for severe COPD) Strength training ○ Include upper limb training bc sig dyspnea with ADLs that involve the UE Non-invasive ventilation: face mask, nasal plugs ○ Inc exercise duration and 6MWD ○ Acute exacerbations/acute respiratory failure ○ Outpatient setting FITT Aerobic F: 3-5 days a week I: Mod to vigorous, 50-80%, 4-6 BORG dyspnea, 12-14 RPE T: 20-60 minutes T: Treadmill, bike, UE bike FITT Resistance F: At least 2 days a week, nonconsecutive I: 60-70% of 1RM for beginners, > or = to 80% for experienced T: Strength: 2-4 sets, 8-12 reps; Endurance < or = to 2 sets, 15-20 reps T: weight machines or free weights Tips Increase oxygen for exercise just be sure to decrease it when done Avoid supine exercises Keep bronchodilators close by Exercise often limited by pulm system and not the cardiac system Interval training may be good alternative to continuous endurance training Treatment Example of COPD Acute 6 min walk test: listen to breath sounds before and after 30 sec sit to stand: look at how they breathe, vitals Do sit to stands, early mobility, progressive exercise, strengthening, education, breathing and airway clearance Discharge to home or pulm rehab or home health Outpatient Endurance: treadmill, LE bike, walk with rollator Higher level strength Maintain airway clearance Education Goals Pt will be able to ambulate 300ft w/ appropriate vital sign response and BORG scale of < 3/10 Pt to understand the red flags of COPD exacerbations Pt to cough to clear secretions to improve oxygenation Emphysema Pathophysiology Alveolar walls are destroyed leading to dilated air sacs which trap air Risk Factors Smoking Examination Decreased fremitus: damaged and less elastic tissue don’t transmit vibrations as effectivley S&S Thin, malnourished Will see them using pursed lip breathing and forward leaning posture on their own Hypertrophied accessory muscles Treatment Improve breathing ○ Pursed lip breathing ○ Paced breathing ○ Positive expiratory pressure devices Education ○ Energy conservation ○ Nutrition Chronic Bronchitis Pathophysiology The presence of a chronic presence of a chronic cough for 3 months in each of the 2 successive years Risk Factors Obesity (correlated but not necessarily a direct cause) Smoking (more likely to be the cause) Examination Increased fremitus: excessive mucus can obstruct airway and consolidate lung tissue? S&S Hypersecretion of mucus SOB upon exertion Cough a lot in morning Lots of gunk Treatment Airway clearance ○ Shaking for obese individuals (percussion or vibration also a possibility) ○ Postural drainage Pursed lip breathing Meds = mucolytic agents Interval training to get them moving as much as possible Asthma Pathophysiology Airway obstruction due to inflammation and bronchospasm that is mostly reversible Hyperactive airways to various stimuli and manifests as recurrent episodes If get >35 it’s more obstructive that goes with COPD and is intrinsic If get 20-25 mmHg) Risk Factors COPD and pulmonary fibrosis S&S SOB Fatigue Treatment Avoid activities that would cause increase in intrathoracic pressure or rapid change in pulmonary hemodynamics ○ Heavy weightlifting or resistive exercise that requires Valsalva Aerobic: low intensity 5 days/week Resistance: low/moderate resistance (50% 1RM)/high reps (10-15) Monitor BP,HR,SpO2, s/s of R heart failure Pneumonia Pathophysiology Viral Bacterial Aspiration Risk Factors Impaired swallowing, consciousness, neuro involvement, recent anesthesia Examination Increased fremitus: increased density S&S Viral Nonproductive cough Normal WBC Loss of appetite Fever, dyspnea Breath sounds: normal with scattered inspiratory crackles Bacterial Productive cough Increased WBC Tachycardia and tachypnea Hypoxia Fever, dyspnea Treatment Antibiotics, nebulizer, and O2 if needed Breathing exercises ○ Diaphragmatic breathing ○ Incentive spirometer Coughing and huffing Postural drainage Functional mobility training and aerobic exercise Early mobilization ○ 20 min within 1st 24 hrs in hospital to dec length of stay ○ Walking help them get off O2 because taking big breaths Thoracic Surgeries Pathophysiology Thoracotomy Treatment Lobectomy; Pneumonectomy  Thoracotomy (Lobectomy sometimes can do VATS) Positioning restrictions for 4 weeks Avoid side lying with lung up for pneumonectomy (including postural drainage) Esophagectomy Types: L thoracotomy, Laparotomy and L or R neck incision HOB: >30 degrees at all times (avoid supine exercise) Abdominal lifting precautions (depends on doc) ○ Aspiration risk ○ Feeding tube for a few weeks Lung volume reduction surgery (surgically remove 20-35% of poor functioning tissue) Sternotomy or thoracotomy Palliative treatment for COPD patients Remaining lung tissue is more efficient - patients generally feel better after this so exercise tolerance is increased COPD damage is primarily in upper lobes After thoracotomies in general Early mobilization, airway clearance, breathing techniques ○ Monitor vitals and for signs of activity intolerance Teach arm ROM to prevent frozen shoulder Education: post op precautions, mobility progression, airway clearance ○ Don't lift more than 5-10 lb for 4-6 weeks Acute care 2-5 days, often don't need outpatient or home health Lung Transplant Pathophysiology End stage pulmonary disease due to CF, COPD, IPF What to watch Lungs denervated Signs of rejection (fever, tachycardia, SOB, cough, crackles, low O2, high CO2, significant drop in exercise tolerance, might develop a-fib) Treatment Surgery Single or bilateral thoracotomies Clamshell thoracotomy Airway clearance/breathing techniques They are used to having a barrel chest and purse lip breathingso need to retrain breathing ○ Summed/stacked breathing; diaphragmatic, segmental Postural drainage ROM and mobilization Will be stiff and painful Progress to treadmill walking when stable Strengthening anti -rejection steroids cause mm weakness Education Weakness, surgical precautions, signs of rejection, ect. *Discharge to OP rehab 6-12 weeks post transplant 5 days a week  Goal is 30 min on treadmill Balance training to dec fall risk Other Conditions Atelectasis Pathophysiology Partial collapse of the lung Can be obstructive or non obstructive Risk Factors Post op (not expanding lungs due to pain) Pleural effusion Pneumonia (secretions block airway so collapse) S&S Reduced chest wall movement Decreased breath sounds Shifted trachea (if severe) toward the collapsed side Treatment Increase ventilation ○ Segmental breathing (lateral costal, post. basal, apical) ○ Summed/stacked breathing\ ○ Diaphragmatic breathing ○ Incentive spirometer ○ Mobilization (rolling, sitting, sit to stand, balance, etc) ○ Airway clearance techniques ○ Monitor O2 Diabetes Pathophysiology Metabolic disease that involves inappropriately elevated glucose levels due to the body producing insufficient amounts of insulin or because cells do not respond to the insulin Risk Factors Type 1: Genetics (insulin dependent and juvenile onset) Type 2: diet and exercise (Non Insulin dependent and adult onset - more common about 90-95% of diabetics) ○ Diabetes can also be caused by other conditions and steroids Gestational: 40-60% chance of developing diabetes in the next 5 years S&S Complications Stroke and heart attack  Retinopathy, cataracts, glaucoma Nephropathy Peripheral neuropathy (can lead to deep ulcers on feet) PAD Hypoglycemia (more common with exercise - 40” for men; >34” for women ○ Fasting blood glucose: >100 (or undergoing treatment) ○ HDL: 130 or DBP >85 Obesity BMI ○ 25: overweight ○ >30: obese ○ >40: severely obese S&S Stress on heart and msk system (osteoarthritis, DDD, sarcopenia, decreased type 1/increased type 2 fibers) Heart rate is generally unchanged but SV increases in proportion to excess body weight Increased risk of a-fib and heart failure Restrictive effects: flattens diaphragm, Obstructive sleep apnea (OSA) Treatment Safe mobilization Body mechanics Get help as needed but move them as much as they can Bed mobility Rolling: use bedsheets, hovermat, turn-assist mode on bed Boosting up in bed: trendelenburg position (use gravity) Supine to sit: raise HOB Transfers Sit to stand: elevate height of bed, use momentum, parallel bars, standing frame Surface to surface: Go from high surface to low surface, use momentum, hoyer lift, bariatric chair, W/C, commode Interventions Energy conservation: rollators, pre-planned activities, seated exercises, water activities, interval training Walking program Interval training Lifestyle changes Post-surgical Abdominal precautions ○ Logroll ○ No heavy lifting ○ No resisted hip flexion Abdominal binder Educate on cough splinting FITT F: at least 5 days a week I: moderate to vigorous (initially 40-60% of HRR up to 75%) T: 30-60 minutes a day (150-300 min a week) T: aerobic exercise (resistance can promote lean mass) General May need exercise for 10 minutes 3 times a day initially to reach the 30 minutes recommended