Subject: Outpatient Phase Ii Cardiac Rehab Individualized Treatment Plan And Exercise Prescription

Transcription

1 CARDIAC REHAB POLICY & PROCEDURES Policy #: CR 208 Subject: Outpatient Phase Ii Cardiac Rehab Individualized Treatment Plan And Exercise Prescription Purpose: To establish guidelines for developing and reassessing Individualized Treatment Plans (ITP) and Exercise Prescriptions for Phase II Cardiac Rehab patients Policy: I. Individualized Treatment Plan (ITP) A. An Individualized Treatment Plan will be completed on all patients referred to Phase II Cardiac Rehabilitation. The ITP will address the participant s individual needs for lifestyle changes. The ITP will contain four clearly labeled Elements: Exercise, Nutrition, Psychosocial and Other Core Components/Modifiable Risk Factors. The ITP is to be contained in a single document and will reflect the rehabilitation process of assessment, plan (to include goals, intervention & education), reassessment and discharge/follow-up. Progression of the patient towards their individualized goals will be reflected in each domain as applicable every 30 days. The ITP, Exercise Prescription and individualized goals will be evaluated each 30 days while the patient is attending the program. 1. Psychosocial element will be evaluated using a relevant quality of life and depression screening instrument/tool to evaluate the patient s mental and emotional functioning as it relates to the patient s condition, recovery and rehabilitation initially and at discharge. The individual scores will be used as a guide to initiate referrals and follow-up screening as appropriate/recommended. The tools will be scored at least pre-program and upon graduation. 2. Other Core Components element will be evaluated (e.g. cholesterols, tobacco cessation, pre-diabetes/diabetes, environmental factors, medications, CHF exacerbation prevention/management, cholesterol, prediabetes/diabetes, etc.) with admission interview and relevant instruments/tools as appropriate. If applicable, the need for tobacco cessation and/or other core components/modifiable risk factors will also be assessed and integrated into the treatment plan as applies individually. 3. Nutrition element is evaluated using a relevant nutrition tool which will be reviewed 1:1 and goals/intervention/education will be set based on results. Weight management, waist, BMI, will be included as a part of the nutrition assessment. 4. Exercise element will be evaluated with a submax treadmill test, NuStep test or 6-minute walk test initially and upon graduation to evaluate

2 progress and exercise plan. Components of the exercise prescription required are mode, frequency, duration, and intensity. B. The ITP with exercise prescription will be sent to the primary physician, Cardiologist and/or surgeon for review and signature and date on initial assessment, each 30 days while the patient is participating in the program and upon discharge. A physician signature is required every 30 days. If the patient s rehab is on medical hold or the patient is out of town for an extended period (i.e. vacation, work-related travels), a note &/or on hold order will be sent to the appropriate physician for signature. The ITP will allow for the physician/s to make changes and will have a designated area for nursing communication/concerns. 1. Assessment: Data collected during the initial intake assessment includes, but is not limited to: Medical history & lifestyle assessment Fall Risk Functional Status Functional and physical assessment Education assessment The nurse will utilize a these tools to determine the appropriate equipment to best meet the individual physical and safety needs of each patient. The tools will also assist in the identification of individual risk for each patient. 2. Goal setting: Measurable goals that are individualized to the patient and are mutually agreed upon by patient and Cardiac Rehab staff. Target goals are indicated in each element. 3. Interventions: Plan of care to assist the patient in making lifestyle changes to impact the areas of needed improvement/lifestyle change. Education provided will be evaluated with a pre and post-test. The education plan will be individualized and education completed will be documented. Education will be provided as applicable to each individual in each element of their treatment plan. 4. Reassessment: Assessment of each area to determine the patient s progress toward achieving the mutually established goals. Reassessment will occur every 30 days throughout participation in the program, with revision of the ITP, exercise prescription and goals at that time. 5. Discharge: Progress toward goal achievement in each of the elements is individually measured. If goals are not met a plan is developed, again involving the patient, for continued therapeutic lifestyle modifications to continue to working toward reaching those goals not yet met. II. Exercise Prescription C. The recommended guidelines for prescribing exercise outlined by the American College of Sports Medicine (ACSM) and American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) are utilized by staff in developing individualized exercise prescriptions. Multiple activities are prescribed (e.g. differing modalities and resistance training to promote total physical reconditioning). Exercise prescriptions are individualized, developed, modified and progressed for each Cardiac Rehab patient. Exercise prescription guidelines will include but are may not be limited to:

3 1. All patients are assessed for risk stratification (see policy CR 204) and monitored continuously per telemetry system during Phase II. 2. Exercise prescriptions are developed utilizing the following but are not limited to: Results of the initial sub-maximal treadmill test, NuStep test or 6- minute walk test Levels of activity which precipitate cardiac symptoms/angina Response of systolic and diastolic blood pressures and HR to exertion ST segment response (e.g. depression) Presence/increased frequency of ventricular arrhythmias Other significant ECG disturbances (e.g. 2 or 3 degree AVB, atrial fibrillation, SVT, complex ventricular ectopy) Patient reported signs and symptoms of overexertion, RPE Heart Rate Reserve Co-morbidities and orthopedic or other limitations D. Exercise guidelines include but are not limited to: 1. Following completion of Phase II intake assessment, staff will determine that the patient has no contraindications to exercise see CR 200 (Entrance criteria). 2. If resting rates are consistently over 100, the PCP and/or Cardiologist will be notified. Exercise will be stopped at any point when subjective or objective assessment reveals signs and symptoms of intolerance (chest pain, arrhythmias, undue dyspnea or fatigue, etc). See also CR202 (general guidelines for termination of exercise) and CR218 (modification or termination of activity secondary to symptoms or change in physical status). See also individual policies CR 213, 214, 215, 216, 217). 3. Emergency treatment may be initiated for life-threatening events by the RN supervising the exercise session, the MET team may be utilized and/or Code Blue or the patient may be sent to the Emergency Room (see individual policy 209). 4. Exercise prescription will be individualized in accordance with the degree of cardiac impairment and/or initial evaluation of physical condition, comorbid or orthopedic or other limitations, and with specific restrictions identified by the patient s physicians (cardiologist, PCP and/or surgeon). 5. Each patient will be given specific instructions at the completion of his/her visit on the duration, intensity, frequency and mode of exercise to perform at home prior to his/her next rehab session. 6. All elements of the each patient s exercise prescription are guided by the patient s desired and individual health and functional outcome goals. E. The exercise prescription will be included within the ITP and require the following elements: modality, frequency, duration, intensity and progression. MODALITY: Based on the results of the admission assessment tools, staff will determine if a sub- maximal exercise evaluation should be performed on the treadmill or if the NuStep or a 6-Minute Walk Test is best to determine the patient s functional capacity. A variety of exercise modalities are made available to the patient including, but are not limited to the arm/leg ergometer, NuStep, recumbent-

4 elliptical, elliptical, treadmill, stationary bike. Resistance training will be included for most patients to improve muscular strength, balance, and endurance unless otherwise ordered or physical limitations (e.g. orthopedic). Patients will be encouraged to exercise large muscle groups before small. Light resistance bands or weights are used in coordination with breathing and proper extremity motion. See also resistance training policy CR220. Each patient is also given instructions for gentle stretching to perform following their rehab sessions and with home exercise. Throughout the patient s rehabilitation, modality will continue to be evaluated based on the above criteria if changes occur and as additional equipment and resistance training is added to the patient s exercise regimen. Cardiac Rehabilitation staff may also utilize additional disciplines as an expert/multidisciplinary approach in determining modality when needed. FREQUENCY: Daily exercise will be encouraged, five days per week at minimum; one to three times a week at a supervised session and all other days at home. A home program will be prescribed at the conclusion of each supervised session and will be based on each day s performance. Upon discharge, patients are encouraged to continue exercising 150 minutes per week and are given a home exercise prescription. Resistance training is recommended two-three times per week as the individual patient tolerates (e.g. RPE, hemodynamic response, absence of abnormal signs & symptoms, orthopedic limitations). Up to 8-10 exercises for up to reps of 1-3 sets will be recommended. DURATION: The goal of the program is to build endurance with exercise to minutes in duration. A warm-up and a cool-down period of at least 3-5 minutes will be included. For the patients who do not tolerate min of continuous exercise, they are encouraged to build to segments of 10 minutes to equal minutes. Durations of interval training, that is, exercise/rest periods and/or intervals of high/low intensities, may be individualized to each patient s fitness level and exercise mode and integrated into any exercise prescription. INTENSITY: Intensity of exercise is initially prescribed at 40-80% of their max HR/initial exercise capacity (i.e. submaximal test, NuStep or 6-minute walk test). Intensity of exercise will also be prescribed at 40-80% of maximum target heart rate using the heart rate reserve method unless otherwise ordered by the physician. For the first four weeks, MI, CABG, transplant and CHF patients are kept at 40-60% of their initial heart rate reserve (HRR). Following the first four weeks, these patients are advanced to 60-80% HRR as tolerated per RPE (Rating of Perceived Exertion Borg 6-20 Scale). Angioplasty and coronary stent patients are allowed to elevate their heart rate to a level of 60-80% HRR initially as tolerated and again based on RPE and hemodynamic response. With stable angina patients, the peak exercise heart rate will be kept at least 10 BPM below a heart rate that precipitated cardiac symptoms/angina during this test. The intermittent claudication rating scale will be utilized to direct an exercise prescription with peripheral artery disease. Special consideration will also be taken into account if

5 beta blockers are a part of the individual patient s medication regimen. In addition to target heart rate, an RPE rating of is desired and is used to identify appropriate thresholds. Intensity is progressed when a client achieves comfort (RPE 11-13) for the sustained desired duration. As cardiovascular fitness levels increase, exercise thresholds necessary for further functional improvement increases, therefore intensity levels will be increased (see progression below). Increase in duration should precede an increase in intensity and at times lowering exercise intensity is needed to permit an adequate volume/duration of exercise. The intensities of interval training will be individualized in regards to exercise tolerance with rest periods or High Interval Intensity Training (HIIT) (RPE 15-17) with recovery Moderate Interval Intensity Training (MIIT) periods (RPE 12-14). Interval training may begin with bursts of seconds (HIIT) interspersed with 1-5 minutes MIIT. For higher conditioned/functioning patients interval training may begin with 30 seconds to 5 minutes of HIIT. For lower functioning/conditioned patients, may intersperse shorter intervals of HIIT (30-60 second) at more frequent intervals of every 3-5 minutes. PROGRESSION: Exercise progression is guided by the goals associated with the vocational and recreational needs of each patient within limits imposed by disease, cardiac, pulmonary and orthopedic limitations. Progression or the speed at which a patient might advance is affected by many factors that may include, but are not limited to, fitness level, vocation, motivation and orthopedic/co-morbid limitations. Intensity is progressed after the patient achieves comfort (RPE l1-13), is dictated by the absence of signs and symptoms of exertional intolerance, and is maintained at the current intensity level for a minimum of one exercise session. PAD and Stable Angina patients are progressed dependent on symptom onset and may also benefit from interval training. Advancement is based on patient s signs and symptoms, monitored response, (e.g. telemetry, HR, BP), RPE, fatigue and target heart rate. For resistance training progression see CR220. How often and the duration of intervals will be determined and progressed based on individual physical condition/functioning, example tolerance and hemodynamic response. Effective date: November 2017 Authorized by: Medical Director Date Revision date: Review date: Director of Nursing Date X:\Policies\Cardiac Services\CR208 ITP Exercise Prescription.docx