FPP Revision Week 12 PDF

FPP revision Week 12 Lecture 1: Neuroanatomy and Physiology: Describe the structure of the heart: - Heart: The size of a fist and weighs around 300g. Beats around 100,00 times a day an...

FPP revision Week 12 Lecture 1: Neuroanatomy and Physiology: Describe the structure of the heart: - Heart: The size of a fist and weighs around 300g. Beats around 100,00 times a day and 3 billion times through a lifetime. - The heart is made of cardiac muscle. This type of muscle only exists in the heart. Unlike other types of muscle, cardiac muscle never gets tired. It works automatically and constantly without ever pausing to rest. Cardiac muscle contracts to squeeze blood out of the heart, and relaxes to fill your heart with blood. - Normal heart rate: 60 - 100 per min - Located in the mediastinum. ⅔ to the left and ⅓ to the right. - Structure of the heart: 1. Layers: Layers Structure Pericardium Outer layer (outermost) - fibrous pericardium, very tough and protects the heart Inner layer - a thinner serous membrane composed of two layers ➔ the outer parietal layer that lines the inner surface of the fibrous pericardium ➔ the inner visceral layer (also sometimes called the epicardium): these inner layers contain the pericardial fluid which like the pleural fluid allows the heart to beat smoothly within its sac The endocardium - A very thin layer of squamous epithelium resting on a thin layer of connective tissue (innermost) - Lines the myocardium and valves - Continuous with the epithelium of the blood vessels - If it gets damaged there is a risk of thrombus formation - Protects the valves and heart chambers The myocardium - Straited like skeletal muscle with features of smooth muscle (heart muscle) - Muscle fibers are aligned in a way so that when they contract they get smaller - Junctions between the muscle cells allow the muscle to contract as a single unit - The mitochondria is much larger to provide more fatigue resistance (10x the one in Sk.M). 5000 mitochondria per cell 2. Specialized function of heart muscle: - The rate at which these impulses fire controls the rate of cardiac contraction, that is, the heart rate - The cells that create these rhythmic impulses, setting the pace for blood pumping, are called pacemaker cells, and they directly control the heart rate - Action potential within the heart is initiated by autorhythmic cells which are specialized muscle cells that produce minimal contraction and spontaneously generate action potentials: ➔ Pacemaker cells: generate an action potential and establish the heart rhythm ➔ Conducting cells: transmit these action potentials 3. Valves: - Atrioventricular valve: - stop blood from re-entering the atria when the vertricles contract to push the arteries (systole) and are held in place by the chordae tendinae anchored by the papillary muscles - AV valves open when ventricles are relaxed (during diastole) and the atria has filled with blood pushing the AV cusps down into the ventricles and opening the valves – the papillary muscles are relaxed at this stage.  - When the ventricles contract the AV valves close as blood presses up against the valves pushing the valves back toward the atria. Contraction of the papillary muscles tightens the chordae tendinae and prevents the cusps from being pushed into the atria. ➔ Mitral valve (bicuspid): sperates left atria from left ventricle ➔ Tricuspid valve: separates right atria from right ventricle - Semilunar valves: - present in arteries leaving the heart - Cusps up open during systole - Cusps down closed during diastole ➔ Aortic valve: in the aorta (which has the coronary artery branching out of it) ➔ Pulmonary valve: in the pulmonary artery Describe the structure and function of the blood vessels Coronary system: - The intramuscular blood vessles are less compressed during myocardial relaxation (diastole) - Left and right coronary arteries: ➔ Arise from the aortic sinus above aortic semilunar valve ➔ Coronary sinus - Cardiac veins return blood to coronary sinus to the Right Atrium Blood vessels: Arteries Viens Capillaries - Carry blood away from the heart 1. Venules: - A single layer of endothelial cell - Larger arteries contain large - Walls thinner, than arterioles - and basement membrane amounts of elastic and fibrous very little smooth muscle - Smallest and thinnest walls tissue that are able to withstand - Smaller in size than arterioles ~ - 5 ~10 micromillimetre (10-6 20microm diameter meters) in diameter and to 0.5 high pressure 2. Veins: micromillimetre wall thickness - As arteries become smaller the - Same size as arteries, but bigger - Primary site for material exchange amount of elastic tissue decreases internal diameter ~ 5mm; wall - Sometimes called the and smooth muscle increases thickness only 0.5microm microcirculation (artrioles) - Valves present in peripheral veins - but…not in central veins (inside - Arterial system behaves as a the thoracic cavity) pressure reservoir - Serves to prevent blood going ➔ when stretched the backwards. elastic forces are stored - Assisted by the surrounding until diastole, the muscles acting as a pump Serve as a volume reservoire for ventricles arterial walls then recoil of the heart passively, propelling - Sensitive to autonomic nervous blood forward and system and other electrolytes  enabling continuous - Capacitance vessels flow and so maintaining blood pressure (but at a lesser pressure than during systole) Describe the mechanism of the heart muscle contraction Heart muscle contraction meshcanisms: - Diastole: ➔ The phase of the heart beat when the muscle relaxes and allows the heart chambers to fill with blood ➔ Isovolumetric ventricular relaxation - all valves are shut ➔ Ventricular filling - atria relaxed with the AV valves open and the Semilunar valves shut ➔ Ventricular filling - atria contract to ‘top them up’ again, with the AV valves open and the Semilunar valves still closed - Systole: ➔ the phase of the heartbeat when the heart muscle contracts and pumps blood from the chambers into the arteries ➔ Isovolumetric ventricular contraction - both the AV and the Semilunar valves are shut ➔ Ventricular ejection – AV valves are shut, the Semilunar valves are open and blood flows into the aorta and the pulmonary artery - Blood: 1. Plasma - made up of water, proteins, nutrients (glucose, lipids, amino acids), metabolic waste products, gases and electrolytes 2. Cells - Red blood cells (erythrocytes) containing haemoglobin - White blood cells (leucocytes) involved in the defence mechanisms of the body: Neutrophils, eosinophils, basophils, monocytes and lymphocytes 3. Platelets - cell fragments from bone marrow that are vital for clotting Lecture 2: The cardiac cycle: https://www.youtube.com/watch?v=zU90AkcTJEs&pp=ygUkZnVuY3Rpb24gYW5kIHN0cnVjdHVyZSBvZiB0aGUgaGVhcnQg https://www.youtube.com/watch?v=KmNHqqrFqG8&pp=ygUOY2FyZGlhYyBjeWNlbCA%3D Explain the factors affecting cardiac output, heart rate and blood pressure - Heart rate: ➔ Heart rate is controlled through the nervous and hormonal systems and affected by venous return and cardiac centers in the medulla ➔ The heart rate is modified by: 1. The autonomic nervous system: supplies internal organs including blood vessles 2. Sympathatic nervous seystem: a network of nerves that helps the body activate fight or flight response Sympathetic input increase the heart rate and speed of contraction 3. Parasympathetic nervous system: A network of nerves that relaxes the body after periods of stress and danger Parasympathetic input visa vagus nerve decreases heart rate and speed of contraction 4. Hormons and ions: Adrenaline, noradrenaline and thyroxine increase the heart rate The heart is very dependent on the concentration of potassium (K+), sodium (Na+), calcium (Ca2+), magnesium (Mg2+) Derangements in the body’s hormonal balance or ionic plasma concentrations can lead to tachycardia/bradycardia or other arrhythmias 5. The terms inotropic and chronotropic - An inotrope affects the contractility of the heart (treats heart failure) - A chronotrope affects the heart rate (increses or decreases) - Both can have a positive or negative effect - Cardiac output: ➔ Generation and maintenance of arterial blood pressure in the artries during systole and diastole is mainly dependant on: 1. Myocardial function: rate of contractility (cardiac output) 2. Elastic properties of the arterial system 3. Resistance forward flow in the arterial system 4. Any resistance in the venous system ➔ The volume of blood that each ventricle ejects in a minute: CO = SV(stroke volume)x HR(heart rate) (5 liters at rest - normal volume) ➔ Determinants of myocardial function: - Starlings law: reaction of venous return: Venous return affects SV/CO by influencing the preload Enhanced by: 1. Respiratory pump 2. Valves in the leg veins 3. Muscle activity 4. Autonomic input to the venous musculature as needed Dependant on: 1. Circulating blood volume 2. State of dilation/contraction of the venous vessels 3. Right ventricular function: if this is reduced you get back pressure through the systemic venous system and peripheral oedema - Volume of venous return: role of venous system in storing blood, ‘capacitance’ of vessels - Circulating hormones - Nervous system - Concentration of electrolytes ➔ Distribution of the blood in the body at rest: - Systemic venous system 65% - Pulmonary system 10% - In the heart 7% - Systemic arterial system 20%  - Blood pressure: Pulmonary (from heart to lungs) vs systemic (from heart to the rest of the body) circulation and pressure: - Pulmonary vascular resistance (PVR) is around 1/8th - 1/10th of the systematic vascular system (SVR) (shorter vessels and musch less muscle. - Right ventricle generates less force (left ventricle is thicke) Cardiac centers in the medulla that control noth HR & BP - Accelatory and inhibitory: have input from higher centers in the cerebrum - Input from various cardiac reflexes: ➔ Sensory fibers from the peripheral vascular system and heart ➔ Baroreceptors: mechanoreceptors located in blood vessels near the heart that provide the brain with information pertaining to blood volume and pressure, by detecting the level of stretch on vascular walls. ➔ Respond to hypoxemia (too little oxygen in the blood) and hypercapina (too much carbon dioxide in the blood) ➔ Hormones Vascular resistance is dependant on: 1. Vessel diameter 2. Vessel length 3. Inc. friction with inc. length - direct relationship 4. Viscosity of blood: 4-5x that of water 5. Whether flow is turbulent or laminar. Cardiac outcome measures: - Heart rate and rhythm - Blood pressure, systolic and diastolic, mean and pulse pressure (120/80 normal rate) - ECG - Echocardiagram (often termed as Echo): cardiac output estimation/ valve function/ ejection fraction : An important measure of cardiac function ejection fraction is defined as the SV/EDV x 100 – usually 60-70%. The remaining 30-40% acts as a reserve for exercise. Ejection fraction falls in heart failure Review the electrical events of the cardiac cycle - The conduction system of the heart: 1. An action potential is initiated in the sinoatrial node first (in the right atrium) 2. Action potentials are conducted from the sinoatrial node to the atrial muscle 3. Action potential spreads form the atrai to the atrioventricular node where the conduction slows down. (the Atrioventricular (AV) node transmits AP with a 0.1 sec delay allowing full atrial contraction) 4. Action potential travels rapidly through the conduction system (through the bundle of HIS – left and right) to the apex of the heart 5. Action potential speads upward through the ventricular muscle (purkinje fibers) 6. The entire heart returns to the resting state, remaining there antil another action potential takes place in the sinoatrial node. Describe a simple ECG trace - The electrocardiogram: 1. Records the spread of electrical activity around the heart by measuring voltage difference between electrodes placed on the skin 2. Hence measures both polarization and depoilarization of the heart 3. Either measured with 3 leads or 12 for more detailed result 4. Depends on which lead you are looking at as to the trace. - Parts of the ECG: 1. P-wave: upper deflection (atrial contraction) 2. QRS complex: a series of upward and downword deflections (ventricular and incorporates atrial repolarisation but this is lost in the standard ECG) 3. T- wave: upward deflection (ventricular relaxation) - ECG intervals and segments: 1. P-Q (or P-R) interval: an estimate of the time of conduction through the AV node 2. Q-T interval : ventricle contraction (ventricular systole) 3. T-Q segment : ventricle relaxation (ventricular diastole) 4. R-R interval: time between heartbeats Lecture 3: respiratory anatomy and physiology: - Discuss what we need for respiration to occur. 1. Pulmonary ventilation (breathing - the whole process): - Intrapulmonary pressure: in alvioli - Intrapleural pressure: in pleural cavity 2. Inspiration: - Diaphragm and intercostal muscles contract - Decreases the intrathoracic pressure and increases the intrathoracic volume - Intrapleural pressure decreases and intrapleural volume increases - Intrapulmonary pressure decreases and intrapulmonary pressure increases - Air rushes into the lungs 3. Expiration: - Passive process - Ungs recoil - Intra-thoracic, intrapleural and intrapulmonary volumes decrease - Intra-thoracic, intrapleural and intrapulmonary pressure increases - Gases flow out of the lungs 4. Internal respiration: - The exchange of gases within the internal environment of the body  - Describe the structure of the respiratory system. Trachea Divides into two primary bronchi at the carina. Left and Right Main Bronchus, which then divide into: - Lobar bronchi (secondary bronchi): Right upper lobe, right middle lobe, right lower lobe bronchus/ Left upper lobe, left lower lobe bronchus which further divide into: Segmental bronchi (tertiary bronchi): Leading to a segment of the lobe Further bronchiolar divisions: 20–23 orders of branching Bronchioles (less than 1 mm diameter): Terminal ( the last division of bronchioles without alveoli attached) and respiratory bronchioles/ cartilage decreases & smooth muscle increases (support, permit changes in resistance to air flow)  ➔ Upper respiratory tract: 1. Nasal and oral passages - Cilia: move the particles trapped in the mucus out of the nose - Mucus membrane: provides moisture that humidifies and warms incoming air - Blood capillaries: provides nutrients to the epithelium and glands, and allows passage of water into the lumen for evaporation and air-conditioning. 2. Pharynx - Passage way between nasal cavities and larynx - Tonsils: help filter out germs that enter through your nose or mouth to protect the rest of your body from infection. 3. Larynx - Eppiglottis - Vocal folds (voice box)  ➔ Lower respiratory tract: 1. From below the larynx to the alveoli. Conducting zone Respiratory zone All the airways that transport gases from The area of the lungs that contain the atmosphere to the gas exchange respiratory me regions mbrane (mouth, nose - terminal bronchioles) - The respiratory bronchioles Structure: which terminate in the alveolar - Epithelum: the lining of the ducts at attach to the alveoli tubes it changes according to the - A cluster of alveoli is called an function as you go down the alveolar sac. bronchial tree - Smooth muscle: gets relatively Describe the function of the alveolus. greater as you go down. - Function of the alveoli: - Cartilage: dense CT/ organized 1. Predominantly gaseous in rings gets less and less as you exchange: O2 in/ CO2 out go down/ non-existant in 2. Defence mechanisms of the bronchioles. body: Functions: - alveolar macrophages/ - Humidification - these phagocytoses - Warming remove any particles that - Filtration and cleaning haven’t been removed by - Passage of gases to and from the the mucociliary escalator alveoli and the atmosphere 3. Lung inflation: - By the time the air reaches the - Surfactant alveoli the air reaches 37 deg and fully saturated with water vapour. - Describe the control of respiration. - Neural control: ➔ Medullary respiratory centers responsible for the rhythm: Two groups of neurons, one that allows inspiration and the other inhibits it to allow expiration: 1. Diaphragm via the phrenic nerve 2. External intercostal muscle via the intercostal nerve ➔ Pontine respiratory center: responsible for the activity of medulla ➔ Both receive input from higher levels of control and from the periphery. ➔ Factors influencing rate and depth of breathing: Chemical factors: - Arterial CO2: central chemoreceptors: rising CO2 results in increase in rate & depth of breathing  - Arterial O2: peripheral chemoreceptors: only becomes a major stimulus if levels become very low - Arterial pH: peripheral chemoreceptors Higher brain centers: - Strong emotions and pain acting via the hypothalamus - Voluntary control via the cerebral cortex - Reflex activity according to irritants or inflation Tutorial 1: Gas exchange: https://www.youtube.com/watch?v=6qnSsV2syUE&pp=ygUcTW92ZW1lbnQgb2YgYWlyIGluIHRoZSBsdW5ncw%3D%3D - Explain how gaseous exchange occurs in the lungs. ➔ After inspiration and before expiration actual gas exchange takes place in the alveoli. ➔ Movement of air in the lungs: 1. Convection: the movement of currents within the fluids 2. Diffusion: how the molecules intermingle as a result to their kinetic energy of random motion. It is extremely rapid and can only occur over very short distances. ➔ Respiratory zone: - Respiratory zone (clusters of alveoli) - 300 million alveoli account for most of the lungs’ volume and are the main site for gas exchange - The total alveolar surface area is aprox. 30-50 square meters - equivalent to a tennis court ➔ Diffusion and gas exchange: - Gas exchange occurs in the alveolar sacacross the alveolar membrane - Provides a boundary between the external environment and the interior of the body - Gases cross the respiratory membrane by diffusion - In accordance to fick’s law, diffusion is dependant on: 1. Concentration/ pressure gradient 2. Gas solubility 3. Surface area of alveolar membrane 4. ventilation/ perfusion coupling 5. Thickness of alveolar membrane - (inversely proportional to tissue thickness) In accordance with fick’s law which suggests that the rate of transfer of a gas through a sheet of tissue is proportional to the: 1. Tissue area 2. Difference in gas partial pressure between the 2 sides  3. Diffusion coefficient (determined by the solubility of the gas and its molecular weight) ➔ The respiratory membrane: - Three thin layers (0.2 micrometers) to facilitate gaseous exchange: 1. Alveolar epithelium: mainly made up of a single layer of cells called type I cells 2. Fused basement membrane 3. Capillary endothelium ➔ Type II cells: - Each alveolus is surrounded by elastic fibrous tissue that tends to make the alveoli collapse inwards and there is surface tension from the fluid on the internal surface of the alveoli that also encourages it to collapse in on itself. - So that the surfactant produced by type II cells is crucial to alveoli remaining inflated - Surfactant is an oily secretion contains phospholipids and proteins coats internal alveolar surfaces and reduces surface tension - Neonates – born without surfactant – can go into respiratory distress syndrome. Adults can develop Adult Respiratory Distress Syndrome ➔ Blood supply to the lung tissue itself: - Bronchial arteries provide oxynated blood to lung tissue itself - Bronchial viens anastamose with pulmonary viens  - Pulmonary veins carry most of the bronchial venous blood back to the heart - Describe how the partial pressures of oxygen and carbon dioxide vary between the atmosphere, the alveoli and the blood. ➔ Concept of partial pressure of gas in a gaseous mixture: - The total pressure exerted by a gas mixture is the sum of its constituent parts (dalton’s law) - Atmospheric pressure at see level = 760 mmHg = 101.335 - Gas percentages stay the same as altitude rises but the overall pressure P (atm) exerted by each gas reduces in relation to the overall pressure of the air - The reduced effect of gravity reduces the number of gas molecules in a certain volume of air. ➔ Composition of air: - Oxygen: 21% - Nitrogen: 79% - Carbon dioxide: 0.04% - P(atm) = PO2+PCO2+PN2 = 760mmHg (101kPa) - Nitrogen plays a vital role in keeping the alveoli inflated as it does not participate in gaseous exchange and it is very insoluble in water. therefore 100% O2 for extended periods is not a good idea - The percentage of oxygen molecules in the air is 21% per unit volume of the atmosphere whether you are at sea level or at the top pf Everest- but on Everest it is 21% of a much lower number of molecules per unit volume - Boyles law: the greater the number of gas molecules in area the greater the pressure they exert. ➔ Factors affecting the partial pressures of gases in the alveoli and the ability of gas exchange: - Level of oxygen in inspired air: normally constant but varies at altitude, when receiving oxygen therapy, if someone is artificially ventilated and on an aircraft - The rate and depth of ventilation: speed of expiration and inspiration - If tissue metabolism rises: (and hence the rate of O2 consumption and CO2 production rises) then the body should increase the rate and depth of ventilation (hyperpnoea) to compensate to maintain the amounts of O2 in the alveoli available for gaseous exchange and to remove CO2  - The fact that alveolar air is fully saturated with water vapour: vs atmospheric air that is not. ➔ Gases equilibrate between a gaseous mixture and a solution: - In the alveoli the oxygen and carbon dioxide meet across the respiratory membrane which is permeable so gas exchange occurs by diffusion - If a gas is next to a fluid then gas particles will move into the liquid until the partial pressures are the same in the liquid and the gas mixture - However this is also dependent on: The solubility of the gas in the liquid The temperature of the liquid ➔ Gas exchange in the lungs: - Diffusion across the respiratory membrane occurs: - From an area of higher partial pressure of gas to an area of lower partial pressure of the same gas across the respiratory membrane (down its partial pressure gradient) - This gradient is greater for oxygen (~100mmHg in alveolar air versus ~40mmHg in the deoxygenated blood in the alveolar capillary) than carbon dioxide (~40mmHg in the alveolar air versus ~45mmHg in the capillary blood) BUT Carbon Dioxide (CO2) is around 20 times more soluble than oxygen (O2) ➔ Tidal volume: - The normal breath that an individual takes - Air in the conducting zone: 1/3rd of a breath ➔ Collateral ventilation: Practical 1: Normal observations (cardiac and respiratory monitoring): (OSCE station 2: exercise prescription) - Understand the importance of non-invasive monitoring ➔ Can complement to clinical observations leading to rapid diagnosis ➔ Needed before establishing any clinical or exercise procedure considering the individuality of each patient ➔ NEWS2- National Early Warning Score 2 ➔ MEWS – Modified Early Warning Score ➔ Track & trigger - Practice and record blood pressure using a sphygmomanometer ➔ Normal value: 120/80 mmHg ➔ Use sphygmomanometer ➔ What is blood pressure: pressure in the arteries during diastole and systole ➔ Blood pressure control can be influenced by: - Central mechanisms: Baroreceptors (found in the carotid and aortic sinuses) Autonomic Nervous System Hormones (e.g. Anti-Diuretic Hormone -ADH) - Local mechanisms: Local vasoconstriction/vasodilation of arteries/arterioles Influencing factors affecting blood flow at tissue level (e.g. temperature, Hypoxia, Hypercapnia, inflammation etc.) ➔ It is dependent on: - Myocardial function/ efficiency: contractility and rate (cardiac output) - Resistance to forward flow in the arterial system - Elastic properties in the arterial system - Any resistance in the venous system - Blood volume - Practice and record pulse (heart rate) ➔ Check pulse from the wrist count for one minute ➔ Normal rate: 72 -80 pumps - Thermoregulation is a vital part of homeostasis (equilibrium) - Important to keep within a limited range to ensure correct metabolism 36.5-37.5°C - Avoids extremes of Hypothermia (core temp below 35°C) and Hyperthermia (38/38.5°C) - Broadly two type of temperature recorded: 1. Core body temperature (rectum, uterus, bladder, vagina) = 37°C 2. Peripheral body temperature (oral, tympanic, axilla, groin)= 36.5°C - Practice and record a respiratory rate ➔ Number of breaths in 1 minute with patient resting comfortably ➔ Patient should not be aware respiratory rate being measured ➔ Normal rate is 12-16 breaths per minute ➔ Get your patient sitting comfortably ➔ Say you are going to count their heart rate ➔ Place your fingers on their left or right radial pulse ➔ Using a clock with a second hand OR a stopwatch, count how many breaths the patient takes in 1 minute - Measuring oxygen saturation (oximetry) (96% and above) ➔ Two wavelengths of light (infrared & red) are shone through tissue (usually the nail bed or ear lobe) ➔ The amount absorbed vs. reflected is calculated and the SPO2 is indicative of how well saturated HB is with O2 ➔ Acts as a guide only to patients' peripheral oxygenation ➔ Dependent on skin, nail and superficial tissue composition, as well as on blood flow and variables effecting - Demonstrate an awareness of factors that may influence these recordings in healthy adults. ➔ General observations…. - Appearance - Deformities - Colour (peripheral/central) - Comfort/effort - Movement patterns - Posture - Tone - Fluid balance/Urine output - Pain score - Consciousness/alertness levels Practical 2: Exercise prescription (cardiorespiratory exercise): (OSCE station 2: exercise prescription) - Prescribe, justify and modify a range of different types of exercises targeting the cardiorespiratory system for both the warm up, cool down and the main exercise of a session. ➔ Physical activity guidelines for adults from 19-64 yrs for UK 2019: - Over a week you should at least perform 150 min of moderate intensity activity (2 ½ hours) such as brisk walking and cycling, or you can perform 75 min of vigours intensity activity such as running or stair climbing or even shorter durations of vigorous intensity activity such as sprinting, or a combination of both. ➔ Physical activity guidelines for the americans (adults) 2018: - Moderate intensisty of aerobic activity of 150 min per week/ 75 min of vigorous intensity of aerobic activity and 2 days of muscle strengthening activity is recommended for adults to establish a healthy life ➔ Sequence of physical exercise: - Prepare equipment and any needed explanation to comfort the patient and let them understand the sequence of the exercise. - Monitoring: before/ during/ after (HR/ RR/ RPE/ VAS/ VO2 max/ SO2) - Warm up: Preparing your body for exercise Prevent or lessen the risk of injury by gradually preparing the muscle for exercise Enhance motor performance by reducing any constraints to movement (this includes loss of joint movement) - Cardiorespiratory exercise - Cool down Voluntary low-moderate intensity exercise Prevent the consequences of the sudden pause of an intense training (such as passing) Returning the body to its normal heart rate and temperature Includes stretching - Monitor the exercises. ➔ before/ during/ after (HR/ RR/ RPE/ VAS/ VO2 max/ SO2) - Begin to consider suitable strategies to help motivation and to aid adherence and compliance. ➔ Prescribe an exercise for this person. - Ensure you are using the equipment safely and effectively - Monitor the person doing the exercise, use the rate of perceived exertion (RPE)  ➔ Teach - your model how to do the exercise - how to progress this exercise (make it more difficult). - how to regress the exercise (make the exercise easier). - Consider and justify a functional goal. ➔ Monitor - before/ during/ after (HR/ RR/ RPE/ VAS/ VO2 max/ SO2) ➔ Motivation - Point out the benefits of this exercise - Reward the patient after performing the exercise to encourage them to adapt to progression - Positive attitude to encourage and motivate the patient which will cause more effective results. ➔ Home exercise - Ensure you teach exercises they can do themselves at home. - Especially if the patient is an elder or obese - Modify the exercise for an elderly or obese patient. ➔ A 40 year old lady is mobilising after a prolonged period on bed rest. - Teach this lady an exercise to improve her cardiorespiratory fitness. 1. Mention the guidelines of PE 2. Monitor 3. Warm up: in the case of this lady: walking and progressing to slow jogg would be a suitable exercise to start with in order to monitor her gait after being in bed rest for a long time 4. Cardiorespiratory exercises: wall pushups/ sit to stand (badal squats and progress to squats) 5. Monitor 6. Cool down: child pose/ standing quad stretch (make sure that she has 7aga external tensed 3aleha)/ elbows bent and placed against a corner, push body towards the corner to stretch the pecs. (chest muscles) 7. Monitor - How would you modify this exercise for a 85 year old lady? 1. Mention the guidelines of PE  2. Monitor 3. Warm up: walking only 4. Cardiorepiratory exercise: semi-sits/ sit to stand 5. Monitor 6. Cool down: neck stretch/ stand calf stretch/ standing quad stretch (make sure that she has 7aga external tensed 3aleha) 7. Monitor - Use the equipment available safely and effectively.