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What does it mean for Physical Therapists, especially those in Acute Care Practice to be practicing to the Top of their Licenses?
Approach to the patient with Myocardial Infarction (Case 2) – PT 783
Complexity Variations
It will be rare to find a case of myocardial infarction without any known risk factors, or post-infarction complications, but there are exceptions. There has been case reports on drug-induced isolated myocardial infarctions that were treated medically (including PCI interventions), and discharged. Long-term outcomes on these specific case reports are not available.
Most cases of MIs will have numerous competing complexities, all of which need to be taken into account while considering rehabilitation. The organ systems, – kidneys, brain, liver, fluids & electrolytes, all have impact on the patient.
Pre-condition to Plan of Care
It appears extremely attractive to jump to the plan of care of a patient. However, the plan should be LAST thing to do, unless it is an emergency. There is a checklist of thoughts that need to be organized before we get to the intervention on a patient
It is not just customary, but to organize your thoughts on the condition of the patient. This organization is represented by your writing the examination & assessment of the patient. You should have a good understanding of how medical documentation (including physical therapy in acutely ill patients should flow, because this has to universally appreciated across your stakeholders, including your physician colleagues, as well as insurance providers, and other medical & non-medical personnel. I am listing a few resources to allow you to review organized documentation structures in medical documentation.
- University of California, San Diego – Writing Guidelines
- UNC School of Medicine – Examples of History & Physicals
The Summary Statement
The Summary Statement in an interpretative & executive summary – Defined as providing a concise summary statement that uses semantic vocabulary to highlight the most important elements from the history, exam, and testing and to interpret and represent the patient’s main problem.
minimal to none
some to many elements
most or all elements
Following examples will highlight Summary Statements & Problem Lists that could be written by physical therapists for variations of patients presenting with Acute Myocardial Infarctions. Where possible, I have included actual case reports that show more details than is included in the summary statement
Examples of Summary Statement
Example 1 – Write-up
This is a 50-year old female with acute myocardial infarction after ingestion of Sumatriptan for presumed migraine. On examination, her ECG revealed an acute anterior ST-elevation MI, with troponin I elevation of >100 μg/L & a transthoracic echocardiography revealed a dilated, severely imparied left ventricle with an akinetic, aneurysmal, anteroapical segment.
Physical examination of function reveals exercise intolerance, need for continued high level oxygen support, and functional impairment of basic gait. See the following problem list:
- Impaired transfers due to orthostatic hypotension – likely multifactorial, but presumably related to primary diagnosis of MI.
- Impaired gait secondary to #1 – motor mechanisms are intact and orthostatic hypotension combined with general exercise intolerance due to loss of cardiovascular endurance.
Discussion on example 1: Note the succinct but complete nature of the summary statement that rapidly summarizes with enough details to give a quick lead into the diagnostics of the case, and its problem list (relevant to your role in the case) without repeating any of the examination minutiae that exists only to inform your critical thinking & decision-making. Also note the semantic vocabulary. Vocabulary is important to show your maturity of thinking and expression.
Reference for this case:
Weir, Robin A.P. et al. Myocardial Infarction After Oral Sumatriptan Use in a Woman with Normal Coronary Arteries. The American Journal of Medicine , Volume 120 , Issue 11 , e7 – e8.
Example 2 Write-up
This is a 62 year old male who presents with:
a. Cardiogenic shock secondary to Acute myocardial infarction – currently on prolonged ventilation > 2 weeks. Weaned off sedation. Ventilation is being weaned.
b. Hemodynamic instability
c. Acute renal failure
Additional issues are per history & physical in the medical chart. From our standpoint, patient is has severe exercise intolerance due to impairment of cardiopulmonary endurance related to his cardiac issues. His problem list from our standpoint:
- Impaired motor function – likely multifactorial, but cognition impairment while on vent, sedation, paralytic agents, all have major contributions.
- Severe Weakness (note to student – non-neurologic severe weakness is most-usually due to PICS – Post-intensive Care Syndrome).
- Impaired global functional activities (note to student: The word “global” would cover all functional activities. However, if you, or your clinical instructor want you to be specific, just break it down into bed mobility, transfers, gait, endurance).
Interventions in Case II – Patient with MI
Interventions will be relative to stage at which you find your patient.
Interventions while on Ventilator
Problems
- ROM Impairments & Compromised Skin Integrity
- Impaired peripheral circulation
- Risk of venous thromboembolism
- Impaired global functional mobility
Goals: This is where you use relevant outcome measures
- Pressure Ulcer Prophylaxis
- Venous Thromboembolic Prophylaxis
- Independent in Bed Mobility by LOS (length of stay)
Monitor
- Hemodynamics*
- IV Lines
- Arterial Lines
- PA Catheter (Swan-Ganz)
- MAP > 65 mm Hg
- Medications
- Inotropic support
- Negative inotropes
- Other drugs
- Life-Support
- Ventilator – Weaning parameters
- PEEP – < 10 cms of H20
- Responsiveness
- Follows commands –
- Squeezes hands
- Opens / Closes eyes
- Follows commands –
*References for Monitoring:
a. *Hemodynamics in critically ill – monitoring for cardiac output
b. Fundamentals of Critical Care – Hemodynamics, Monitoring, Shock
Perform
- Positioning & ROM: Verify that patient is on turning schedule and discuss with nursing. Also, recruit help of nursing personnel (if not already in process), and also family members, if available for PROM, and AAROM.
- Airway clearance on Ventilator is a very specialized service and mostly covered by Respiratory Therapists. If PTs are performing this in your setting, you will need on-the-site training & check-offs to be certified to perform this.
- If patient is awake, alert, & instructable at any stage: Circulatory Venous Thromboembolic Prophylactic Exercises must be instituted.
- Bed mobility: As patient becomes more awake, provided monitoring parameters are safe, progress to sitting, and dangling the legs. Turning in bed may be difficult in scenarios where patient might be post-CABG – these patients will have chest tubes.
- Transfers: Sit to stands – can be deferred until patient is off-ventilator in patients who are expected to come off the vent soon. This can also be done when patients are on vent, but hemodynamically stable enough to stand.
- Gait training: Initiate similar to transfers guidelines above. Use daily outcome measures to evaluate progress made.
Interventions Off-the Ventilator
Consider a patient who came off the ventilator, or, a patient who was never on the ventilator but is being hemodynamically monitored in the ICU.
Problems
- ROM Impairments & Compromised Skin Integrity
- Impaired peripheral circulation
- Airway congestion, Pulmonary Collapse, & Alveolar Atelectasis
- Sternotomy related chest pain & instability
- Weak Cough & Airway congestion
- Risk of venous thromboembolism
- Impaired global functional mobility
- Post-operative neurologic complications (if present – Brachial Plexus lesions – wrist drop; Foot drop due to dorsiflexor paralysis)
Goals
- Pressure Ulcer Prophylaxis
- Venous Thromboembolic Prophylaxis
- Independent in Bed Mobility by LOS (length of stay)
- Independent in Transfers by LOS (use same outcome measure as at evaluation)
- Independent in Gait over 80 meters or house-hold-distances using least restrictive device (use same outcome measure as at evaluation)
- Patient will demonstrate independent auto-airway-clearance techniques and sternal bracing during coughing
- Improve oxygenation as imposed by O2 Saturations > 92%. (may be less if patient has COPD)
Perform:
- Positioning & ROM: Verify that patient is on turning schedule and discuss with nursing. Also, recruit help of nursing personnel (if not already in process), and also family members, if available for PROM, and AAROM.
- Circulatory Venous Thromboembolic Prophylactic Exercises must be instituted.
- Airway clearance & Reversing Pulmonary Atelectasis exercises
- Incentive Spirometer
- Acapella
- Splinted Coughing
- Bed mobility: As patient becomes more awake, provided monitoring parameters are safe, progress to sitting, and dangling the legs. Turning in bed may be difficult in scenarios where patient might be post-CABG – these patients will have chest tubes.
- Transfers: Sit to stands – can be deferred until patient is off-ventilator in patients who are expected to come off the vent soon. This can also be done when patients are on vent, but hemodynamically stable enough to stand.
- Gait training: Initiate similar to transfers guidelines above. Use daily outcome measures to evaluate progress made.
Early Resistive Exercises to Prevent, or, Reverse PICS development
- Progressive Resistive Exercises – use any convenient resistance
- Begin with low repetitions, high frequencies – e.g. 5-10/hour at 50% of 1 RM, and ensure at least 10 hour of exercises on a schedule.
- Exercise beds e.g. MoveoXP (TM)
- Adjust up as tolerated.
Note:– BID is not enough. How to work-around this? – A schedule for patients to follow. Also, education for patient’s to understand why a day-long schedule is imperative
Personnel – Team up with OT, and get nursing, RRT, even physicians involved.
Refer ICU Rehab Video, featuring Dr. Darin Trees, PT, DPT & the MoveoXP bed.
Post-ICU Progression
Once patient is out of ICU –
- Ambulate ad lib (if feasible)
- Education: Life-style modification, including Smoking Cessation.
- Teach progression of gait for post-discharge aerobic program using RPE Scale at 11-13 of modified RPE/Borg
- Continue breathing exercises & coughing with sternal bracing for about 3 months – 6 months, using Incentive Spirometer.
- Sternal bracing until evidence of bone union verified by Chest X-ray (CXR) at roughly 3-months follow-up.
- No seat belt & no driving until sternotomy healed
- Sexual activity – best advice is until sternotomy heals, and patient able to perform activity at 11-13 level of modified Borg (RPE) Scale.
- Consider outpatient cardiac rehab program (if patient is able to go home from hospital which is common).
http://box5122.temp.domains/~sujoybos/home/courses/pt-783-cardiopulmonary-rehabilitation/rehabilitation-approach-to-the-patients-in-cases-presented-in-pt-783-class/monitoring-parameters-during-exercise/
Disposition
Options: Home vs. Inpatient Rehabilitation – Which one is appropriate?
Most Common Disposition is Home with family care and Outpatient Cardiac Rehabilitation.
If unable to achieve goals of independent functional mobility, option is usually inpatient rehabilitation.
The inpatient rehabilitation criteria are:
- If medically able to tolerate 3 hours of therapies between PT/OT
- Expectation of short-term stay with discharge home – usually 2 weeks; Rarely longer.
The Skilled Nursing Facility (Sub-acute Rehabilitation) option:
- Reserved for patients who would not tolerate 3 hours of combined therapies
- Patients who are more frail, and would likely need longer than 2-3 weeks of rehabilitative therapies
- Ultimate goal would still remain as discharge to home.
Durable Medical Equipment
The choice of DME is large and the decision may appear confusing. Among other things, do make sure to consider patient’s ability to pay for DME. These are not cheap, except for small items like canes ($10-15 at Walmart, or Drug Stores). Unlike healthcare that cannot be denied, DME certainly can be denied if no payment source. Do not promise DME without verifying payment source available.
- Walkers
- Wheelchairs
- Bedside Commodes
- Shower chairs & benches
- Oxygen – arranged by Respiratory Therapists on written prescriptions of Physicians
Decision-making with DME
Walkers Decision: Always best to have rolling walkers. A rolling walker decreases the workload by not having to pick-up and advance the device. Rollators make for the best option in patients with heart failure – it has 4 wheels, and a seat, often with a basket, that is helpful for various purposes.
Wheelchairs: Some patients will no longer be able to tolerate gait. One must think of wheelchair-level mobility for these patients.
These are covered by insurance. Exercise some analytical thought. A standard vs. a large wheelchair? (Often patients with advanced heart failure are also overweight or obese). Can the patient push the wheelchair themselves? If they cannot, do they have someone to always help? Can the patient be more functional AND be productive if they are independent in pushing the wheelchair by themselves? In such scenarios, a power wheelchair may be an option. However, analytical considerations in deciding a power wheelchair must ponder over life-expectancy. If patient is younger or has a chance at longer life-expectancy, then a power wheelchair expense makes sense. Be careful in promising equipment for which you cannot determine patient’s longevity, or, ability to pay for.
Bedside Commodes: There are many types. These are covered by insurance. Consider the types available (see the link – these will evolve over time as new kinds are engineered – so stay abreast of new equipment). A bedside commode (BSC) is best if they have removable buckets which then transforms into a raised toilet seat (RSC) that can be placed above a regular commode in the bathroom. There are BSCs with removable arm-rests if one would serve the cause better.
Shower Chairs: Shower chairs are NOT COVERED by insurance. Apparently, they are not considered “essential” items for life. These are not cheap either. One work-around is that a bath/transfer bench is ordered that is actually covered by insurance. With a transfer bench, a patient sits down on the bench outside of a bathtub, then swings legs over into the bathtub. Check the link for examples of Shower Chairs vs. Transfer Benches. Some patients will opt to buy shower-chairs out-of-pocket.
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DME Decision-Making
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The choice of DME is large and the decision may appear confusing. Among other things, do make sure to consider...
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Case 4 – PT 783
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Approach to the Patient with Cardiac Arrhythmia Quick Reference to the Case Sections Discussion on complexity variationsAssessment Write-upPlan of CareEducationDispositionDurable...
