Cardio Pulm: Random stuff for patient cases 4 + 5 (plus acute care considerations)
Why do they not take both left and right IMAs?
Because then they find that the chest wall tissue doesn't get very good perfusion and then you have healing issues They often will take the left over the right because the left can stay attached at one end which is easier
What is a normal ABG?
Between 80 and 100 mmHg Remember this is the most accurate test for ensuring effective oxygen delivery
How can coronary heart disease cause chronic heart failure?
Coronary heart disease can cause: Dysrhythmias if SA and AV node do not get blood supply and then this causes decreased contractility which is one cause of chronic heart failure Valve incompetence if the valves do not get blood supply which causes increased preload which can cause chronic blood supply Impaired contractility just from general ischemia of heart wall muscle which leads to chronic heart failure
Talk to me about PT and hematocrit levels
HCT less than 25% of normal = no physically demanding interventions Patient feels fatigued, poor activity tolerance No strength/endurance training
What would be the best way to teach Mr. Cabbage bed mobility?
Have them log roll and then use his legs as a counter weight to get up Could have him cross arms or push a little on the bed (less than 10 pounds!) Make sure to educate the wife so she doesn't just pull him up
Talk to me about Mr. CHilF's acid base problem
His pH is acidic (within normal limits of 7.35 to 7.45 but on the low side) And he has a kidney problem (and bicarbonate is lower than his CO2) so it is likely metabolic (vs. respiratory) So we think METABOLIC ACIDOSIS
What is the procedure for suctioning?
Hyper-oxygenate the patient to 100% 3-5 breaths Pts neck in extension Upward, backward motion (because if not you close off trachea) 10-15 seconds (PR hold breath) Allow patient to rest and repeat if needed (10-15 seconds ideal, less than 10 is not effective, more than 15 seconds you risk anoxic damage)
What are the three main types of delirium?
Hyperactive (more common!) - impaired balance and often combative Hypoactive - do dehydration checks and check for pressure sores Mixed
What would you give Mr. CHilF on the NY heart association classification?
I would probably give this a patient a 4 because he has ¼ dyspnea at rest and also has worsening orthopnea which would also be at rest and he certainly has a lot of discomfort with physical activity (¾ dyspnea after 3 minutes of standing)
With what lab values are you at risk for hemoarthrosis?
INR greater than 3.0 (pay close attention in PT, exercise only if allowed) Remember that hemarthrosis is bleeding into the joint spaces
What INR levels are you worried about?
If INR is greater than 3.0 then you have to pay close attention in PT and exercise only if allowed You have a risk of bleeding into joint spaces (hemarthrosis)
Order to evaluate patient, patient has INR of 4 and is going home that day What else do you need to check? Course of action?
If INR is greater than 3.0 then you need to pay close attention in PR, exercise only if allowed Risk of bleeding into joint spaces (hemaarthorsis)
What is the critical value for PTT?
If PTT is greater than 60 seconds then PT is a no-go No PT if PTT is 2.5x greater than or equal to the reference value (which I think is what the greater than 60 seconds is)
Would ankle pumps be a reasonable exercise for Mr. Cabbage?
If he was sitting the majority of the day then it wouldn't be crazy to give him ankle pumps every hour But would prefer him to be up and moving around
What are the exercise guidelines related to hemoglobin levels?
If hemoglobin is less than 10 g/dL then you can't do any physically demanding interventions No strength/endurance training below this 10 g/dL level
What are the exercise guidelines related to WBC levels?
If the WBC count is less than 1000 mm^3 (same as a microliter) then you have the patient wear a mask and take special care to avoid transmitting infectious disease to patient
What are the activity precautions / limitations following coronary artery bypass surgery?
Incisional precautions (2 weeks): -No submersion in water, running water is OK -No cream or lotion directly in incision -No betadine unless prescribed by MD Median sternotomy precautions (6-8 weeks): -No lifting, pushing, or pulling > 10 lbs -Avoid unilateral shoulder abd/flex > 90 degrees -Bilateral shoulder ROM in pain free range -Ambulatory assistive device use-> variable -Cough with splinting -No driving
What are the activity limitations / precautions for a patient recovering from pacemaker placement?
Incisional precautions for 2 weeks No ipsilateral shoulder abduction/flexion greater than 90 degrees for 4 weeks (because you have little barbs in your heart, they need to settle) Watch for signs/symptoms of malfunction Avoid close exposure to strong electromagnetic fields (at this point just don't lean over a car engine while it is running)
Why would oxygen saturation be at 100% and patient still feel dizzy?
It could be anemia (the HgB is still saturated there are just less of them) Or maybe something like heart failure or orthostatic hypotension when the blood is still oxygenated but it just isn't making to the brain
Talk to me about Mr. Cabbage's swelling
It is a little tricky because he has both bilateral swelling from the CHF and unilateral swelling from the saphenous vein removal (surgery on leg) So his pulses are diminished throughout but worse on left than right
Why might someone be at risk for pneumonia after heart surgery?
Less about deep breathing and more about being upright, moving and coughing and you struggle with all of these things after heart surgery Coughing hurts, and are generally more sedentary from being in the hospital
What should you examine if you are a worried about a patients platelet count?
Look for unexplained bruising, serious bleeding This includes thinks like purpura (5-9 mm) and petechia (less than 5 mm) Remember if the patients platelet count is less than 20,000 cells/mm^3 then you can't do exercise with the patient, or only can do light activity
What is thrombocytopenia? What levels?
Low platelet counts Less than 20,000 cells/mm^3 = no exercise, or light activity only
What is calculation for mean arterial pressure (MAP)?
MAP = SBP + 2(DBP) all divided by three Diastolic takes up more time so it is a greater proportion of MAP
What is the ideal MAP for early mobilization?
MAP between 60 and 100 mmHg
Hemoglobin is 7.9 in a patient with very few comorbities who just had a TKA What else do you need to check? Course of action?
Maybe check how much blood loss there was during surgery because that could be a contributing factor You could proceed with physical therapy but couldn't do any physically demanding interventions (no strength/endurance training)
What does Mr. CHilF have as far as metabolic/respiratory alkalosis/acidosis?
Metabolic acidosis Because he has an acidic lean Metabolic: -has kidney problems (high BUN, creatine and on dialysis) -and also his bicarbonate is lower than his CO2
What is metabolic syndrome?
Metabolic syndrome is a cluster of issues including hypertension, dyslipidemia, hyperglycemia (diabetes/pre-diabetes), and obesity (particularly central obesity) It associated with an increased risk of CVD and stroke.
How are some ways to make sure our interventions are not making Mr. CHilF worse?
Monitor vitals! Some bad signs are: Increased RR Abnormal heart sounds (extra murmur, worsening of murmur, crackles get worse) HR and systolic BP dropping more than 10 (shows CO is getting less)
What are the side effects of cardiopulmonary bypass machine use?
More blood loss Atrial fibrillation (cross clamp SA node) Cognitive/memory impairments because of systemic inflammation, cerebral hypoperfusion, atheromatous debris and microemboli)
Talk to me a little about the cardiac enzymes
Myoglobin = early indicator (peaks within 6 hours but gone within 24), not specific CK = mid-term indicator (peaks within 24 hours but gone within 4 days), MB isoenzyme relatively specific) Troponin = late indicator (doesn't go away for a whole week!), very specific
Would you put Mr. Cabbage on a treadmill?
Nah because its harder to stop and sit down and also it is hard to balance But some nice general walking not on a treadmill would be a great intervention (bike would be fine too)
Would compression stockings be appropriate for Mr. Cabbage?
No because then you are just pushing all the fluid back to the heart Possibly could do it on the side with the saphenous vein but then you would need to be careful with the incision, so basically he is not a candidate
If platelets are 19,000 what activities should you complete with your patient?
No exercise or really light activity only If the patient is thrombocytopenic (less than 20,000 cells/mm^3) then you should do no exercise or only light activity
What are the sternal precautions?
No lifting, pushing, or pulling > 10 lbs Avoid unilateral shoulder abd/flex > 90 degrees Bilateral shoulder ROM in pain free range Ambulatory assistive device use-> variable Cough with splinting No driving
What is a normal PR interval? What is Mr. Cabbage's?
Normal is 3-5 small boxes Mr. Cabbage's is 5-6 boxes so it is a little long
Would you suggest Mr. Cabbage go to outpatient PT or cardiac rehabilitation?
Outpatient! Cardio would be better because the monitoring, but his balance is really bad and so he needs 1 on 1 attention Outpatient cardio rehab is a group setting so if they have problems with balance or they need an AD then it is hard for them to be in that setting, so using monitoring in an outpatient PT would be better (he needs 1 on 1)
Ventilator settings: what do you want PEEP to be? FiO2? Mode? RR?
PEEP = less or equal to than 10 (3-5 is normal) FiO2 = less than 60 (more than 60 is a red flag) Mode = better to be spontaneous (suggests the patient is less involved) RR = 12-22 bpm
What things worry us about PVCs? Why worry? Does Mr. Cabbage have this going on?
PVCs falling on T-waves (R on T phenomenon Bigeminy/trigeminy Multiform and multifocal PVCs (many PVCs that look different) Frequent PVCs of more than 5 or 6 per minute Runs of more than 3 in a row (these might lead to ventricular tachycardia or fibrillation so we worry about them, Mr. Cabbage doesn't have any of this going on - he just has one)
What would be an appropriate ambulation goal for Mr. CHilF?
Patient will ambulate 50 feet with FWW stand by assist in 1 week
What would be an appropriate bed mobility goal for Mr. CHilF?
Patient will be independent with bed mobility in 4 days
What would be an appropriate trasnfer goal for Mr. CHilF?
Patient will be min assist with sit to stand transfers in 4 days
What are some precautions to early mobility?
Patients returning continuous vasodilator medications New dysrhythmia Cardiac ischemia Intra-aortic balloon pump Also patients who are mechanically ventilated with a FiO2 of less than 0.60 and PEEP of greater than 10 cmH20 or less than 88% oxygen saturation
What risk does atrial fibrillation pose? Why?
Patients with chronic atrial fibrillation are at risk for cerebral emboli if on the left and PE if on the right!!! All the blood just swirls around stagnantly and then clots might form And therefore are often medically managed with Coumadin
Does Mr. Cabbage's lung sounds suggest atelectasis or pulmonary edema?
Probably a bit of both because his crackles improved with activity but did not completely resolve But his oxygenation is fine His peripheral edema is worse than his pulmonary edema
Is Mr. CHilF a candidate for a heart transplant?
Probably not because he's too involved (too many comorbidities, likely high risk for CABG) With the kidney failure his body would probably reject it
What medical tests are used to diagnose acute myocardial infarction when a patient arrives at an emergency room?
Pt presents with acute onset of AMI signs and symptoms Cardiac Enzymes and 12-lead ECG (would do a stress test instead if not having signs or symptoms of an acute AMI) Then an invasive angiography followed by a treatment decision
What is RDW-CV? What does an elevation indicate?
RBC Distribution Width: Measures variation in size of RBCs Inc= Mixed population of RBCs i.e. increased amount of immature cells Could be compensation by body for lack of oxygen
What is a good tool to assess delirium?
Richmond agitation sedation scale (RASS)
Are PTs allowed to titrate oxygen?
The short answer is yes But basically if there is no standing order (such as keep SpO2 greater than BLANK %) then contact the referring practitioner And then at the end of PT SpO2 must be returned to original flow rate (based upon resting arterial blood gasses) and if you can't maintain this level then contact prescribing practitioner
Talk to me about vasopressor requirements and early mobility
There couldn't have been new or increased vasopressor requirements in the past 2 hours (also remember you want a MAP between 60 and 110 mmHg)
A 43 year old male is admitted for MI, when do you know it is appropriate to work with patient?
This is a tricker one As long as you don't go above 20-30 bpm above the resting then you aren't increasing enough to damage their heart So basically you need to figure out a system on how much effort they can do while still protecting their heart (i.e. take one step and then rest a certain amount of time)
What are the benefits for using oxygen as far as mortality?
Those that used oxygen during the night lived longer than those that didn't use it Those that used oxygen during day and night lived longer than those that used it just during the night So educate patients on this = tell them that it is really important to get the oxygen you need
If present on ECG, which arrhythmias would prohibit initiation of patient exercise?
Uncontrolled dysrhythmias High AV-block w/ HR < 60 bpm
How long does swelling after a saphenous vein removal take to resolve?
Usually about 3-6 months out it completely resolves (but starts getting better a couple of weeks out) The other veins just compensate over time for taking the saphenous vein out
Talk to me about Mr. Cabbage's weight
Weight is significantly higher and you are also are hearing crackles, and he has feet swelling All of these make you think hmmm CHF exacerbation so you should call the physician (his oxygen saturation is fine so it is not a medical emergency)
Remind me what sinus arrhythmia is?
When everything is normal but the rhythm is irregularly irregular (the R to R ratio is different every time) Mr. Cabbage has this going on (strip 3)
Why do patients with chronic respiratory failure have more RBCs?
When patients are chronically hypoxic they will have tons of RBCs (to try and compensate) but then you end up with thicker blood which is bad
Why might patients have valves and a CABG at the same tine?
When they already need open heart surgery the threshold for what they replace is a lot lower so they might go in and fix a valve that is only a little impaired or vic versa with coronary arteries if they are already in there They also almost always fix the LAD even if there is only a little stenosis because it is such a big vessel
What are some key questions to ask when triaging patients?
Will a physical therapy session affect the patient's length of stay? Will the patient lose functional gains by not having physical therapy? (CVA - neuroplasticity) Will physical therapy influence discharge destination? (i.e. if a patient isn't being seen in acute they might not see them in inpatient)
How many leads does a biventricular pacemarker have?
With a biventricular pacemaker you have 3 leads (one into the right atria and into each of the ventricles) while with a normal pacemaker you have only two leads (onto into the right atrium and one into the right ventricle)
Based on his ECG, are we comfortable having Mr Cabbage exercise?
Yeah because we can see QRS complexes and all the really bad arrhythmias are when you can't see QRS complexes Also you would look for ST elevation (for infarct) but you can't really make a lot out of the exercise strip because artifact
Could you have Mr. Cabbage walk without the walker in clinic?
Yeah, this would be a good balance intervention He can walk fine without any perturbations so as long as you carefully guard him this would be a great intervention And a gait belt would be okay
Blood glucose is 90 in patient, you are planning on completing a 6 minute walk test What else do you need to check? Course of action?
You can exercise this patient because below 70 mg/dL is the contraindication But watch for signs and symptoms of hypoglycemia such as pale, moist, cool, diaphoretic skin, headache, fatigue, weakness, nausea, convulsions, etc.
Blood glucose is elevated to 320 in patient, you are planning on completing a 6 minute walk test What else do you need to check? Course of action?
You should check for signs and symptoms of hyperglycemia (such as acetone breath, rapid weak pulse, deep rapid ventilation or dry, flushed, and warm skin) You would not exercise this patient because exercise is contraindicated above 300 mg/dL even without ketones
A patient has a WBC of 1.0/microliter What modifications, if any would you make to this patient's treatment? What vital sign would you examine closely?
You would have the patient wear a mask because they are below 1000m^3 and then just generally take special care to avoid transmitting infectious disease to patient You would examine temperature closely
How long is ideal for suctioning?
10-15 seconds is ideal Less than 10 seconds is not effective and more than 15 seconds you risk anoxic damage
What do we see in Mr. Cabbage's ECG?
2nd strip = we see a PVC (not that worried because it is only one) 3rd strip = sinus arryhtmia, 2nd and 3rd from end are PACs or PJCs because they are early but the QRS is normal
What is a normal PEEP? What is PEEP?
3-5 mmHg Positive end expiratory pressure = how much pressure there is at the end of expiration so the lungs are completely inflated, they don't recoil back
What is the duration, RPE and HR for aerobic exercise?
60-90% of max HR (not appropriate judge if on beta blockers though) RPE of 4-6 of 10 Duration of 20-60 minutes On most days
How far should Mr. Cabbage be walking on a 6 minute walk test?
A 61-80 year old man is about 2260 feet He is currently only going 330 feet (with a rest)
What is a resynchronization biventricular pacemaker?
A biventricular pacemaker helps synch the two side of the heart, because with a bundle branch block the two sides of your heart are dyssynchronous With a biventricular pacemaker you have 3 leads (one into the right atria and into each of the ventricles) while with a normal pacemaker you have only two leads (onto into the right atrium and one into the right ventricle) Mr. CHilF is being considered for this because of his bundle branch block (from cardiomegaly and ischemia)
Is diastolic dropping so much (22 mmHg) from sitting to walking a red flag or a yellow flag?
A yellow flag because it is diastolic increasing (by 10 or more mmHg) that we are most worried about It could be orthostatic hypotension (standing measurements were not taken because Dr. Lapier couldn't control him in standing and also take his BP)
What is a non-STEMI myocardial infarction?
An acute MI that DOESN'T have ST elevation (like a STEMI MI) which is good because STEMI MIs have a poorer prognosis
What is the most effective test for ensuring effective oxygen delivery?
Arterial blood gasses! Remember your normal ABG is somewhere between 80 and 100 mmHg
Why might Mr. CHilF have an elevated BUN?
Because he had chronic kidney failure His level is 68 and normal is 5-27
Why are Mr. Cabbage's pulses weaker on the left?
Because he has more swelling on the left than on the right Which is also the leg that the saphenous vein was removed from
Why might Mr. CHilF's glucose be high?
Because he is in a stressful environment and also he has diabetes
Why is his cervical spine ROM limited?
Because he is old and also because of the surgery (skin pulling so he is reluctant) You wouldn't do AROM of the neck after a median sternotomy because the SCM attaches to the sternum and that would be painful
Why does Mr. CHilF have high protein levels?
Because his kidneys are damaged and can't clear the protein
Why does Mr. Cabbage have a potential new diagnosis of dyslipidemia?
Because his values currently look high but it could have just been the stress from the hospital (body breaks down a ton of fat), etc. So they usually wait a little bit to diagnose this, to see if values level out or not
Why is Mr. Cabbage's ankle ROM limited?
Because of all the swelling, there is a lot of tissue in the way
Why is Mr. CHilF being considered for a resynchronization biventricular pacemaker?
Because of his bundle branch block! Remember a biventricular pacemaker helps synch the two side of the heart, because with a bundle branch block the two sides of your heart are dyssynchronous - with a biventricular pacemaker you have 3 leads (one into the right atria and into each of the ventricles) while with a normal pacemaker you have only two leads (onto into the right atrium and one into the right ventricle)
Why is Mr. CHilF mod assist for bed mobility?
Because of strength, pain and ROM in wrist
Why is it common for lung sounds to get worse after an AMI?
Because the heart is not doing as well so it is common to have a CHF exacerbation and fluid back up into the lungs The heart wall, valves and pacemaker (SA node/AV node) all might not be functioning as well leading to an exacerbation Also if you have had an AMI and then had subsequent surgery then you heart is still recovering from that insult
What would you expect someone with kidney diseases creatine level in their blood to compare to their level in their urine?
Creatine in urine is also used to assess the effectiveness of filtering creatine out of blood With kidney disease you would expect increased levels in the blood and decreased levels in the urine because it is not being filtered out (which is what Mr. CHilF has going on)
What are some benefits of early mobilization?
Decreased length of stay Decreased delirium Decreased use of deep sedation
What is the difference between delirium and dementia?
Delirium = a sudden TEMPORARY state of severe confusion and rapid changes in brain function The key difference is delirium is a temporary condition
Why might Mr. CHilF have a bundle branch block?
Due to ischemia and cardiomegaly
Why might Mr. CHilF's monocytes by high?
Due to stress! But it also could be pneumonia (fluffy infiltrates on x-ray) or infection in his foot ulcer
How do you calculate heart rate on an ECG strip again?
Each tick is 3 seconds apart so you count each QRS complex and then multiply to 60
When is considered "early" mobilization?
Early = immediately upon stabilization of hemodynamic and respiratory physiology 24-48 hours after ICU admission
What are a highest priority deficits with Mr. CHilF and what are some ways to address them?
Endurance = walk (CV exercise) Strength = functional exercise (sit to stand) Balance = reaching, etc. in standing
Why is Mr. CHilF min assist for standing?
Endurance, edema, pain and strength
What are our top priorities for educational needs for Mr. CHilF?
Energy conservation Self monitoring for CHF exacerbation - weight (watch for weight gain) - I think 2 to 3 pounds in 24 hours or 5 pounds or more in a week is worrying
Can regular exercise replace the need for pharmacological management of diabetes?
Exercise may replace the need for medication in type 2 and dec. the amount of insulin needed in type 1. (but not completely eliminate because with type 1 the issue is not enough insulin not insensitive insulin)
If patients are on mechanical ventilation, what are some precautions to early mobilization?
FiO2 of less than 0.60 PEEP (positive end expiratory pressure) of greater than 10 cmH20 Less than 88% of O2 saturation
What is the best position for nasotracheal/pharangeal suctioning?
Fowler or semi-fowler position
What are Mr. Cabbage's biggest problems?
Functional mobility Ventilation (deep breathing is the intervention!) Balance Aerobic
What is Mr. CHilF's prognosis?
Good to excellent across the board because he wasn't really doing a lot (was very sedentary and did not have a high PLOF)
What signs and symptoms of heart failure does Mr. CHilF present with?
Right-sided = Pitting edema (2+ EID, goes away in less than 15 seconds) bilateral lower extremities Jugular vein distension Left-sided = Pulmonary edema (crackles in lung, 6th-10th intercostal spaces bilateral posterior chest wall before and after activity) Tachypnea, needs to be on oxygen (3 liters) SOB and orthopnea (reason he came to the ER) Forward effects = Decreased pulses (⅓ radial, 0/3 dorsal pedal and posterior tibial )
What arrhythmias does Mr. CHilF have?
ST segment depression is shown on the ECG - this usually indicates that the patient had an MI (probably from an old MI) BBB (not a PVC because it happens every time and PVCs are usually inconsistent)
What vessels were used as grafts for Mr. Cabbage?
Saphenous vein LIMA (used for LAD because that is the biggest coronary artery and LIMA is the best replacement vessel)
Why is Mr. CHilF have balance issues?
Sensation and endurance (fatigue worsens with balance)
What is a piggy back graft?
Sequential graft Instead of connecting right into the aorta it connects into another aorta
What does ST elevation indicate?
Some kind of myocardial damage (for Mr. CHilF it is probably an old MI)
What are the two main types of modes of ventilator settings?
Spontaneous mode (SPON, CPAP, pressure support) = each patient breath is supported by a set amount o f inspiration pressure (this is less involved, often a weaning mode) Assisted mode = AC-assist control OR SIMV (basically both of these take a breath for the patient if they don't initiate one), patient is more involved
Why is Mr. CHilF mod assist for trasnfers?
Strength, pain, edema and sensation
What weight gain is worrying for CHF?
Sudden or steady gain in daily weight (for example, 2 to 3 pounds in 24 hours or 5 pounds or more in 1 week
What are some things to do to prevent delirium?
Sunlight (open blinds) Have a clock around at all times Encourage return to ADLs (clean glasses, bring in newspapers, sit up in recliner) Get out of bed Facilitate family visits Encourage drinking Frequent family visits Medication management (but we can't really do anything about this)
What is the best position for tracheostomy suctioning?
Supine
If present on ECG, which arrhythmias would result in termination of patient exercise?
Sustained V-tach ST elevation or depression PVCs (> 10/min, R-on-T, multifocal) Vtach Afib/flutter
Talk to me about oxygen retainers and COPD
Tend to be carbon dioxide retainers which can result in a decreased drive to breathe (carbon dioxide is what actually drives your need to breath in the medulla/pons) This means that supplemental oxygen increase is appropriate as long as patient's RR doesn't go down with a subsequent increase in oxygen saturation
What are BUN and creatine used for?
The creatine blood test is used along with BUN (blood urea nitrogen) to assess kidney function Creatine in urine is also used to assess the effectiveness of filtering creatine out of blood (with kidney disease you would expect increased levels in the blood and decreased levels in the urine because it is not being filtered out)