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sensation, areaso decreasedcirculation, DVT,inection,malignancy, overcement orplastic, over apacemaer,vascularinsu!ciency

infammatoryand analgesics#

Moist Heat  1odulate pain,increaseconnectivetissuee8tensibility,reduceinfammation,increase tissueand *oundhealing, reducemuscle spasm#

'mpairedcirculation,'mpairedcognitiveunction,'mpairedsensation,1alignanttumors, overblood clot, overpacemaer, overplasticcomponents#

Decrease musclespasm, decreasetone, increaseblood fo* totreatment area,increasecapillarypermeability,increasedcollagene8tensibility,increased nerveconductionvelocity

;urns, rashes,sin irritation

Parafn 1odulate pain,increase

connectivetissuee8tensibility,reduceinfammation,increase tissueand *oundhealing, reducemuscle spasm#

'mpairedcirculation,

'mpairedcognitiveunction,'mpairedsensation,1alignanttumors, overblood clot, overpacemaer, overplastic

Decrease musclespasm, decrease

tone, increaseblood fo* totreatment area,increasecapillarypermeablity,increasedcollagene8tensibility,increased nerve

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components# conductionvelocity

Fluidotherapy  1odulate pain,increaseconnectivetissuee8tensibility,reduceinfammation,increase tissueand *oundhealing, reducemuscle spasm#

'mpairedcirculation,'mpairedcognitiveunction,'mpairedsensation,1alignanttumors, overblood clot, overpacemaer, overplasticcomponents#

Decrease musclespasm, decreasetone, increaseblood fo* totreatment area,increasecapillarypermeability,increasedcollagene8tensibility,increased nerveconductionvelocity

=pread obacteria, burns,

Diathermy  1odulate pain,increaseconnectivetissuee8tensibility,reduceinfammation,increase tissueand *oundhealing, reduce

muscle spasm#

'mpairedcirculation,'mpairedcognitiveunction,'mpairedsensation,1alignanttumors, overblood clot, over

pacemaer, overplasticcomponents#

Decrease musclespasm, decreasetone, increaseblood fo* totreatment area,increasecapillarypermeability,increasedcollagen

e8tensibility,increased nerveconductionvelocity

2ot spots, dullache, periostealpain

Ice Massage 'nfammation,pain control,abnormal tone,acute or chronicpain, bursitis,muscle spasm,

>old intolerance,cold urticaria(hypersensitivity), inection, overan area ocompromised

Apply the icemassage to anarea no largerthan ?8@ inchesin slo*overlapping

Decrease bloodfo* to area,decreasespasticity,decreasededema,

>old, burning,aching, andnumbness

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1= trauma,trigger points,tendonitis

circulation, overregeneratingperipheralnerves, 9VD,old intolerance,cold urticaria(hypersensitivity)

>an providehours o mildcooling

Decrease bloodfo* to area,decrease

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most oten usedon the nee andpost operativelyto decrease pain

, inection, overan area ocompromisedcirculation, overregenerating

peripheralnerves, 9VD,

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spasticitymanagement

disorders, overcarotid sinus,active bleeding,metal implants,

duration 3%33 usec

spasticitymanagement

improperelectrodeplacement

Premod 1odulate pain,increase musclestrength,increase

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disorders, overcarotid sinus,active bleeding,metal implants,

duration% 3%-33 usec, modecontinuous,

improperelectrodeplacement#

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Descriptor Temperature

Cool 67.0-80.0F (19.0-27.0C)

Cold 55.0-67.0F(13.0-19.0C)

Very Cold 32.0-55.0F(0.0-13.0C)

a.Intermittent Compression Pump

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by atwo layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manuallymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, andcompression increases it further

Traumatic edema Infections at the site of treatment may

be spread by introducing bacteria into

the lymphatic or venous drainage

Dependent edema of pregnancy Any thrombi present may become

mobile

Venous insufficiency Edema in patients with congestive heart

failure should not be treated, because

the increased peripheral resistance

increases the work of the heart.

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by atwo layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manuallymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, andcompression increases it further

Amputations Edema in patients with kidney

dysfunction should not be treated,

because the kidney may not be able to

excrete teh additional fluid

Prevention of thrombophlebitis

postsurgically

Obstructed lymphatic channels do not

allow drainage. Treatment is ineffective,

and the patient may experience

increased pain

Stasis ulcers Displaced fractures. Treatment may

displace them further

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by atwo layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manuallymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, andcompression increases it further

Condition Ion (Polarity) Mode of Action Concentration of

Solution

Dosage

Athletes Foot Copper (+) Fungicidal 1% copper sulfate

sodium

10mA for 15 minutes,

2x/week

Slow Healing Wound Zinc (+) Bactericidal 1.0 M zinc oxide gel(8.138 g zinc oxide

powder, 10g glycerol,

10g bentonite, 71.862 g

water)

3-6mA for 20 minutes,increased to25-30

minutes at end of each

of first 2 weeks; 5 days

a week for 3 weeks.

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by a

two layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manual

lymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, and

compression increases it further

Posttraumatic Edema Hyaluronidase (+) Breaks down hyaluronic

acid

150 units of

hyaluronidase in 250

mL of a buffer solution

that consists of (1)

sodium acetate 3H2O:

11.42 g (2) Glacialacetic acid: 0.923 mL

(3) distilled H2O,

quantum satis (qs):

1000 mL

20mA for 20 0minutes

3x/week

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by a

two layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manual

lymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, and

compression increases it further

Plantar Warts Salicylate (-) Removal and relief of

pain

2% sodium salicylate in

aqueous solution

10mA times min; once

per week for 2-3

treatments

Trigger Points Procaine or Lidocaine

(+)

Local anesthesia (use

with caution)

1% solution in 60-80%

alcohol with 1:20,000

adrenalin

20-30 mA for 20-30

minutes 1-3 times per

week

Acute RA Citrate (-) Prevents local

autoimmune response

1% potassium citrate in

distilled water

7.5-10 mA for 20

minutes; daily 3x/week

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by a

two layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manual

lymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, and

compression increases it further

Peripheral Circulatory

Deficit

Histamine (+) Vasodilator 1:10,000 histamine

diphosphate

3-12 mA for 5-20 minute

(approximately 60 mA

times minute); 2-3

x/week

Gout Lithium (+) Competes with sodium

in formation of urate

lithium urate is soluble

2% lithium chloride 5mA for 20 minutes; one

time per week for 4

weeks

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Definition Indication Contraindications

Pneumatic unit designed to apply external

pressure to an edematous body part by a

two layered nylon or plastic appliances

shape to fit either the upper or lower

extremity used to help reduce edema.

Treatment should be a minimum of 2 hours

for every 24 hours and should provide

pressure less than 50mmHg for upper

extremities. and 60 mmHg for lower

extremities to be safe and effective. The

pressure is applied for 45-90 seconds andthen released for 15-30 minutes. The

frequency is between 304 weeks

Postmastectomy lymphedema. Open

the lymphatic channels using manual

lymphatic massage prior to using the

pup

Patients with arterial insufficiency have

increased peripheral resistance, and

compression increases it further

Myositis Ossificans Acetate (-) Absorption of calcium 3mL of 2% acetic acid

in distilled water

4 mA for 20 minutes;

followed by ultrasound

for 8 minutes at 1.5

W/cm2 at 50% duty

cycle

2. Choosing an Assistive Device

Amount of Weight Bearing Unilateral LE WB

Restriction

Bilateral LE WB Restriction

PWB almost full WB 1 Standard Cane 2 Standard Canes

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Amount of Weight Bearing Unilateral LE WB

Restriction

Bilateral LE WB Restriction

Dec PWB 1 Crutch Lofstrand Crutches

Dec, Dec PWB 2 Canes 2 Crutches or Walker

Dec, Dec, Dec PWB 2 Crutches 2 Crutches or Walker

TT 2 Crutches or walker Unable to walk

NWB 2 Crutches or walker Unable to walk

Amount of Strength Unilateral LE Weakness Bilateral LE Weakness

Minimal Weakness 1 Standard Cane 2 Standard Canes

Decreased Strength 1 Quad Cane 2 Quad Canes

Dec, Dec Strength 1 Crutch Lofsrtand Crutches

Significant Weakness 2 Crutches or Walker 2 Crutches or Walker

Balance Impairment Ambulatory Assistive

Device

Minimally Impaired 1 Cane

Min-Mod Impaired 1 Lofstrand crutch

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Balance Impairment Ambulatory Assistive

Device

Moderately Impaired 2 Crutches or Walker

Significantly Impaired 2 Crutches or walker and

guarding.

9recautions DeGnition 'ndications >ommon =ituations=tandard 9recautions Hniversal precautions and

are designed or the careo all patients in hospitalsregardless o inection or

diagnosis#

9rocedure 2and *ashing,*ear gloves and changebet*een tass, *ear masor go*n i ris o

spalashing body fuids#

Cvery hospital patient#

Droplet 9recautions

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transmission o inectiousagents through evaporateddroplets in air or dustparticles

monitored air pressure, @% air changes *ithin theroom per hour, room doorshould remain closed *ithpt remaining in room,

respiratory protection *orn*hen entering the room,limit pts transport outsidethe room, pt should *earmas during transport#

tuberculosis

ontrol "roup A group against *hich the treatment group iscompared# =hould be statistically identical to thetreatment group, e8cept or the variable o interest that

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is being evaluated in the e8periment# Hsed to helpisolate the e6ect o the 'V and eliminate theunintended infuence o e8traneous actors that canconound the results#

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Erdinal ase control, >ross%sectional study, case or report or case series#

Eui!ment " De#ices:

$ssisti#e and $da!ti#e De#ices:

L9ressure relie push%ups are re0uired, typically ever %3 minutes#L/olding rames mae *heelchair transport and storage easier#

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-@3B turning space 5 @3 inches M @3 inches (t 8 t)N3B turning space5 minimum o -@ inches1inimum or door*ays and halls5- inK ideal is -@ inches>ountertops5 no higher than - inchesonsider seat cushion

@%@# inches

Armrest height 1easure rom the seat o the chair tothe olecranon process *ith the userselbo* fe8ed to N3B and then add 1 inc+# L>onsider seat cushion

N inches above the chair seat

De#ice $scendin( stairs Descendin( stairs

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Walker: >an be used *ith all levelso *eight bearing# =hould allo* 3%B o elbo* fe8ion#

 The pt should place the *aler on theopposite side o the handrail and turnthe *aler side*ays# The pt shouldthen grasp the handrail *ith onehand and the top o the *alers

handpiece *ith the other hand# Hsingthe handrail and *aler or stability,the pt taes a step up *ith inuninvolved e8tremity# The involvede8tremity is then advanced to thesame step and the *aler ollo*s#

 The *aler is positioned in a similarmanner as described previously# Thept uses the handrail and top o the*aler or stability *hile lo*ering theinvolved lo*er e8tremity# The

uninvolved .C is then lo*ered andthe *aler ollo*s#

$3illary crutc+es: >an be used *ithall levels o *eight bearing, ho*everre0uire higher level o coordinationor use# >rutch height should be

adjusted no greater than - Gnger*idths rom the a8illa# 2andgripshould be adjusted to the ulnarstyloid process and allo* or 3%Belbo* fe8ion#

 The pt should use the handrail andturn the crutch side*ays# This *illresult in pt grasping the handrail andcrutch *ith the same hand# 9t *ill

advance *ith uninvolved e8tremityollo*ed by involved#

9t lo*ers involved .C and the crutchto the ne8t step ollo*ed by theuninvolved e8tremity#

Cane: 9rovides minimal stability andsupport or pts during ambulation# Astraight cane should not be utili$edor pts that are partial *eightbearing# =mall base & large base0uad canes proved a larger ;E= &can better assist * limiting *eightbearing# >ane is typically used onopposite side o an involved .C#

 The pt should use the handrail andturn the cane side*ays# This *illresult in the pt grasping the handrailand the cane *ith the same hand# The pt should use the handrail andadvance the uninvolved .C to thene8t step# The pt *ill then advancethe involved .C#

9t lo*ers involved .C to ne8t stepollo*ed by uninvolved .C#

Ort+otics:

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# 4oot ort+osis 54O)%may be attached to the interior o the shoe (inserted pad) or the e8terior (Thomas heel)#=ot inserts reduce areas o high loading, restrict orces, and protect painul or sensitive areas#C8 1etatarsal pad%located posterior to 1T headsK moves pressure rom the heads to the shatsK allo*s morepush%o6 in *ea or infe8ible eet#C8# >ushion heel%cushions and absorbs orces at heel contactK used to relieve strain on plantar ascia in

plantar asciitis#C8# 2eel%spur pad#6on(itudinal arc+ su!!orts: prevent depression o the subtalar joint and correct or pes planusK fat ootcan be fe8ible or rigid#C8# =caphoid pad%used to support the longitudinal arch#C8# Thomas heel%a heel *edge *ith an e8tended anterior medial border used to support the longitudinal archand correct or fe8ible pes valgus (pronated oot)Postin(:

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%9osterior stop (plantar fe8ion stop) determines the limits o anle 9/# ' set or too much 9/, neerecurvatum could result#%=olid A/E%limits all oot and anle motion#

L1olded A/Es are contraindicated or individuals *ith changing leg volume#-0 8nee-ankle 'oot ort+osis 58$4O7-consists o a shoe attachment, anle control, uprights, nee control, andbands or shells or the cal and thigh#

>raig%=cott nee%anle%oot Erthosis%designed speciGcally or persons *ith paraplegia, This design allo*s a person tostand *ith a posterior lean o the trun#

209i!-knee-ankle-'oot ort+osis5 98$4O7-indicated or pts *ith hip, oot, nee, and anle *eaness# 't consist obilateral nee%anle%oot orthoses *ith an e8tension to the hip joints and a pelvic band, The orthosis can control

rotation at the hip and abd+add# The orthosis is heavy and restricts pts to a s*ing%to or s*ing%through gait pattern#

0/eci!rocatin( (ait ort+osis 5/;O7-is a derivative o the 2OA/E and incorporates a cable system to assist *ithadvancement o the .es during gait# Ihen the pt shits *eight onto a selected .C, the cable system advances theopposite .C# The orthoses are used primarily or pts *ith paraplegia#

6o%er 6imb Prost+etics

.ranstibial 5belo% knee7 !rost+esis:

/oot anle assembly /unctions to% absorb shoc at heel strie, plantarfe8 in early stance, permitsmetatarsophalangeal hypere8tension in late stance, cosmetic replacement o oot#

#Solid ankle cus+ion +eel 5S$C97 'oot%the most commonly prescribed ootK non%articulatedK contains an energy%absorbing cushion heel and internal *ooden eel that limits sagittal plane motion, primarily plantarfe8ion# 9ermits avery small amount o mediolateral and transverse plane motion# Assists in hypere8tension o nee during stance#

*0Solid ankle

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=tores energy in early stance or later use during push%o6K prescribed or more active individuals#

?#Sin(le a3is 'oot%an articulated oot *ith the lo*er shanK motion is controlled by anterior and posterior rubberbumpers that limited D/ and 9/K more stable (permits only sagittal plane motion)K may be prescribed or individuals*ith bilateral transemoral amputations#

=ocets

10P. 5!atellar tendon-bearin(7 socket% a total contact socet that allo* or moderate loading area o thepatellar tendon#

9ressure%sensitive areas o the transtibial residual limb include anterior tibia, anterior tibial crest, Gbular head andnec, Gbular nerve#

9ressure%tolerant areas o the transtibial residual limb include patellar tendon, medial tibial plateau, tibial andGbular shats, distal end (rarely, may be sensitive)

.rans'emoral 5abo#e knee7 !rost+esis:#=ingle a8is%permits nee motions to occur around a G8ed a8is, nee fe8ion is needed during late stance ands*ing, sitting, and neeling#

9ressure%sensitive areas o the typical transemoral residual limb distolateral end o the emur, pubic symphysis,perineal area#

9ressure Ptolerant areas o the typical transemoral residual limb ischial tuberosity, gluteals, lateral sides o residuallimb, distal end (rarely, may be sensitive)

.rans'emoral (ait de#iations:

#>ircumduction%prostheis s*ings out to side in arc# 9ossible causes a long prosthesis, loced nee, small or loosesocet, inade0uate suspension, oot plantar fe8ed, abduction contracture, poor nee control

#Abducted gait%prosthesis is laterally displaced to the side# 9ossible causes crotch or medial *all discomort, longprosthesis, lo* lateral *all or malignment, tight hip abductors

-#Vaulting%pt rises up on the sound limb to s*ing the prosthesis through# 9ossible causes prosthesis too long,inade0uate suspension, socet too small, prosthetic oot set in too much plantarfe8ion, too little nee fe8ion

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?#.ateral trun bending during stance%trun bends to*ard the prosthetic side# 9ossible causes lo* lateral *all, shortprosthesis, high medial *all, *ea abductors, abductor contracture, hip pain, short amputation limb

#/or*ard fe8ion during stance%trun bends or*ard# 9ossible causes unstable nee unit, short ambulatory aids, hipfe8ion contracture

@#.umbar lordosis during stance%e8aggeration o the lumbar curve# 9ossible causes insu!cient support romanterior or posterior *alls, painul ischial *eight bearing, hip fe8ion contracture, *ea hip e8tensors or abdominals#

F#2igh heel rise%during early s*ing, the heel rises e8cessively# 9ossible causes inade0uate nee riction, too littletension in the e8tension aid

#Terminal s*ing impact%the prosthesis comes to a sudden stop as the nee e8tends during lat s*ing# 9ossiblecauses insu!cient nee riction or too much tension in the e8tension aidK pt ears that the nee *ill bucle, orceulhip fe8ion#

N#=*ing phase *hips at toe%o6, the heel moves either medially or laterally# 9ossible causesK socet it rotated, nee

bolt is rotated, oot is malaligned# LIhip termed by direction o heel#

3#/oot rotation at heel strie%as the heel contacts the ground, the oot rotates laterally, sometimes *ith vibratorymotion# 9ossible causes oot is malaligned, sti6 heel cushion, or plantar fe8ion bumper#

#/oot slap%e8cessive 9/ at heel strie# 9ossible causes heel cushion or 9/ bumper is too sot#

#Hneven step length%pt avors sound limb and limits *eight%bearing time on the prosthetic limb# 9ossible causessocet discomort or poor alignmentK hip fe8ion contracture or hip instability#

.ranstibial am!utation:

# C8cessive nee fe8ion during stance# Possible causes socet may be aligned too ar or*ard or tiltedanteriorlyK plantar fe8ion bumper is too hard and limits plantar fe8ionK high heel shoesK nee fe8ioncontracture or *ea 0uads#

# 'nade0uate nee fe8ion during stance# Possible causes socet may be aligned too ar bac or tilitedposteriorlyK plantar fe8ion bumper or heel cushion too sot, ho* heel shoesK anterodistal discomort, *ea0uads#

-# .ateral thrust at midstance# 9ossible causes oot is inset too much?# 1edial thrust at midstance# 9ossible causes oot is outset too much#

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# Drop o6 or premature nee fe8ion in late stance# 9ossible causes socet is set too ar or*ard or e8cessivelyfe8edK dorsife8ion bumper is too sot, resulting in e8cess dorsife8ion o the ootK prosthetic oot eel tooshortK nee fe8ion contracture#

@# Delayed nee fe8ion during late stance pt eels as though *aling Quphill#R 9ossible causes socet is set tooar bac or lacs su!cnet fe8ionK dorsife8ion bumper is too sti6 causing e8cess plantar fe8ionK prosthetic

oot eel too long#

Sa'ety and !rotection

SCrgonomics

% A therapist must consistently use proper body mechanics *hen treating patients and avoid unnecessarystress and starin by maintaining proper alignment *ithin the musculo system#

% 9rinciples o proper body mechanicso Hse the shortest lever arm possibleo =tay close to the patient *hen possibleo Hse large muscles to perorm heavy *oro 1aintain a *ide base o supporto Avoid any rotary movement *hen litingo Attempt to maintain your center o gravity

S9osture A*areness

% Hse plumb line as a tool to determine verticality# Although desirable, rarely *ill a given patient

demonstrate ideal posture *ith all the anatomical landmars#

S1edical C0uipment

% /eeding deviceso :asogastric tube (:" tube)% short term li0uid eeding and medication administration#o "astric tube (" tube)% 'nserted into a small incision in the abdomen, long term eeding#o  ejunostomy tube ( tube)% inserted into the jejunum, used or long term eeding#

% 1onitoring deviceso Arterial line% used to measure blood pressure or to obtain blood samples#

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o >entral Venous pressure >atheter% 1easuring pressures in 9<o >ompression comes Grst, then ocus on air*ay and breathing#o :o more loo, listen, and eeling# >all N immediatelyo 9ush chest at least inches do*n on adultso 33 compressions+mino Dont stop pushing, no interruptions

% /irst Aido Hse gloves *hen touching all body fuids

o >hange gloves bet*een tasso Iear mas+eye protection

SAbuse

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'ncreased depression 1alnutrition =ubstandard care o personal hygiene

Pro'essional /es!onsibilities

Documentation:

.egal re0uirements 1ust comply *ith applicable jurisdictional re0uirements, all hand*ritten entries should be in in,charting errors should be corrected by dra*ing a single line through the error and initialing and dating the chart,should include the reerral method (direct access, sef%reerral), should include indication o no sho*s andcancellations#

Deensible documentation .imit use o abbreviations, date and sign all entries, document legibly, report progressto*ards goals regularly, document at the time o the visit *hen possible, clearly identiy note types (daily, progress),include all related communications, include missed or cancelled visits, demonstrate silled care, demonstratedischarge planning through the episode o care#

Patient /i(+ts:

2'99A%9t conGdentiality is maintained in all oral, *ritten, and electronic orms, physical identiabilitiy o pts must bereduced, charts and other documentation must be stored out o public vie* and secured, a8es must be sent *ithcover sheets, cover sheets should be used on clip boards t hat contain pts paper*or# An individual can access all o their medical records# 9roviders have -3%@3 days to respond#

a. Ethical Issues:

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i.Autonomy- requires the wishes of competent individuals must be honored. Autonomy is often referred to as self-

determination

ii.Beneficence- A moral obligation of heath care professionals to act for the benefit of others

iii.Confidentiality- the holding of professional secrets or discussions keeping client information within appropriate limits

iv.Duty- the obligation that individuals have to societyv.Fidelity - Related to confidentiality and is defined as the moral duty to keep commitments that have been promised

vi.Justice- The quality of being just of fair; righteousness

vii.Nonmaleficience- the obligation of health care providers to above all else, do no harm.

viii.Paternalism- A term used when someone fails to recognize another individuals rights to autonomy

ix.Rights- The ability to take advantage of a moral entitlement to do something or not to do something

x.Veracity- Obligation of heath care providers to tell the truth.

b.Legal

Term Definition

Abandonment unacceptable one-sided termination of services by a health care professional without patient

consent or agreement

Administrative law administrative agencies at the federal and state level develop rules and regulations to supplement

statutes and executive orders

Common Law Refers to court decisions in the absence of statutory law often creates legal precedent in areas

where statues have not been enacted.

Constitutional law Involves law that is derived form the federal constitution. The US Supreme Court is responsible for

ultimately interpreting and enforcing the Constitution

Informed Consent- The patient is required to sign a document and given permission to the health care professional to

render treatment. This should be obtained from the patient in accordance with the standards of

practice prior to initiation of treatment. The patient has the right to full disclosure of treatment

procedures, risks, expected outcomes, and goals.

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Term Definition

Malpractice The failure to exercise the skills that would normally be exercised by other members of the

profession with similar skills and training. this can include areas of professional negligence, breach

of contract issues, and intentional conduct by a health care professional

Negligence The failure to do what a reasonable and prudent person would ordinarily have done under the

same or similar circumstances for a given situation. In order to prove negligence the plaintiff must

prove all of the following:

1.THere was a duty owed to the plaintiff by the defendant

2.There was a breach of that duty under conditions that constituted negligence and

the negligence was the proximate cause of the breach

3.there was damage to the plaintiff’s person or property

Risk management The identification analysis and evaluation of risks and the selection of the most advantageous

method for treating them

Statutory law Congress and state legislatures are responsible for enacting status. Examples of federal statutes

affecting health care include the Americans with Disabilities Act and the Family and Medical Leave

Act

Tort- A private or civil wrong or injury, involving omission and/or commission.

/ole o' P.$:

9TA is a technically educated health care provider *ho assists the 9T in the provision o 9T# The 9T is directlyresponsible or the 9TA s actions related to pt+client management# 'n general, the 9T is not re0uired to be on%site ordirection and supervision but must be available at least by telecommunications# The 9TA maes modiGcations toselected interventions either to progress the pt as directed by the 9T or to ensure pt saety and comort#

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/eimbursement Practices:

9rivate health insurance companies ee or service basis# =toc, mutual, and non%proGt insurance companies#

"overnment 2ealth 'nsurance%uses private contractors to manage the payment process o each health plan#

1edicare 9art A provides beneGts or care provided in hospitals, outpatient diagnostic services, e8tended careacilities, hospice, and short term care at home re0uired by an illness or *hich the pt is hospitali$ed# Cnrollment isautomatic and unding is through payroll ta8es#

1edicare 9art ; provides beneGts or outpatient care, physician services, and services ordered by physicians suchas diagnostic tests, medical e0uipment, and supplies# Cnrollment is voluntary and unding is through premiums paidby beneGciaries and general ederal ta8 revenues#

1edicaid provides basic medical services to the economically indigent population *ho 0ualiy by reason o lo*income or *ho 0ualiy or *elare or public assistance beneGts in the state o their residence#

'/> model%'nternational >lassiGcation o /unctioning, Disability and 2ealth 1odel5's a classiGcation o health andhealth%related domains#

P. E3amination>Cardio!ulmonary

;reat #essels o' t+e +eart:

# Aorta%the bodys largest artery and the central conduit o blood rom the heart to the body# The

aorta begins at the upper part o the let ventricle, and ater ascending or a short distance archesbac*ard and to the let (arch o the aorta)# 't then descends *ithin the thora8 and passes intothe abdominal cavity (abdominal aorta)#

# =uperior vena cava%the vein that returns venous blood rom the head, nec, and arms to the rightatrium#

-# 'nerior vena cava%the vein that returns venous blood rom the lo*er body and viscera to the rightatrium#

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?# 9ulmonary arteries%the arteries that carry deo8ygenated blood rom the right ventricle to the letand right lungs#

# 9ulmonary veins%the veins that carry o8ygenated blood rom the right and let lungs to the letatrium#

9eart c+ambers and #al#es:

S=uperior chambers o the heart (right atrium and let atrium)# The *all bet*een the atria is the atrialseptum#

SThe t*o inerior chambers o the heart are the right ventricle and let ventricle# The *all bet*een theventricles is the ventricular septum#

SThe right chambers collect blood rom the body and pump it to the lungs# The let chambers collect bloodrom the lungs and pump it to the rest o the body#

SThe heart has ? valves that unction to maintain unidirectional blood fo*# The atrioventricular valves (AV)are bet*een the atria and ventricles and are named by the number o leafets or cusps# The right AV valveor triscupid valve, has -# 't controls blood fo* bet*een the

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Ventricular systole%contraction o the right and let ventricles pushing blood into the pulmonary arteriesand aorta#

Ventricular diastole%the period bet*een contractions *hen the ventricles are repolari$ing#

=troe volume%the amount o blood ejected *ith each myocardial contractionK normal range is %33ml+beat# 'ts infuenced by .et Ventricular end diastolic volume the amount o blood let in the ventricle atthe end o diastole, also no*n as preload# The greater the preload, the greater the 0uantity o bloodpumped#

Aterload%the orce the .V must generate during systole to overcome aortic pressure to open the aorticvalve#

>ardiac Eutput%the amount o blood discharged rom the let or right ventricle per minute# :ormal range is?%.# Determined by measuring 2< 8 =V#

Cjection raction%percentage o blood empties rom the ventricle during systoleK a clinically useul measureo .V unction# :ormal averages U4#

LDiastolic Glling time decreases *ith increased 2< and *ith heart disease#

9eart Sounds:

= sound (QlubR)%normal closure o mitral and triscupid valvesK mars beginning o systole# 2igh re0uencysound *ith lo*er pitch and longer duration than =# Decreased in st degree heart bloc#

= sound (QdubR)%normal closure o aortic and pulmonary valves, mars end o systole# 2igh re0uency

sound *ith higher pitch and shorter duration than =# Decreased in aortic stenosis#E3tra sounds: Murmurs

# =ystolic%alls bet*een = and =# 1ay indicated valvular disease or may be normal## Diastolic%alls bet*een = and =# Hsually indicates valvular disease#-# Thrill%an abnormal tremor accompanying a vascular or cardiac murmur, elt on palpation#

ruit%adventitous sound or murmur (blo*ing sound) o arterial or venous origin, common in carotid oremoral arteriesK indicative o atherosclerosis#

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;allo! r+yt+m%an abnormal heart rhythm *ith three sounds in each cycleK resembles the gallop o ahorse#

# =-K vibrations o the distended ventricle *alls due to passive fo* o blood rom the atria during therapid Glling phase o diastole# :ormal in healthy young children, abnormal in adults, may be

associated *ith heart ailure# Qventricular gallopR# =?K pathological sound o vibration o the ventricular *all *ith ventricular Glling and atrial

contraction# 1ay be associated *ith 2T:, stenosis, 1'# Qatrial gallopR

$uscultation o' +eart sounds

9rocedure

 The bell or diaphragm o the stethoscope is held directly on the pts bare sin *ith enough pressure to provide a sinseal *hile the pt breathes 0uietly through the nose#

.isten over our designated auscultatory areas$ortic area%nd intercostal space at the right sternal border

Pulmonic area%nd intercostal spaceat the let sternal border

Mitral #al#e%th intercostal space, medial to the let midclaviciular line

.riscu!id area%?th intercostal space at the let sternal border

9icture on page @? o scorebuilders#

E3amine +eart r+yt+m:

A lead CO" provides vie*s o the heart# 't is used to assess cardiac rhythm, to diagnose the location, e8tent,and acuteness o myocardial ischemia and inarction, and to evaluate changes *ith activity#

Wa#e'orms and Inter#als:

# 9 *ave%atrial depolari$ation

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# 9< interval%time or atrial depolari$ation and conduction rom the =A node to the AV node# :ormal duration is3# to #3 seconds#

-# J

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emboli# =igns and symptomsinclude palpitations,lightheadedness, and angina dueto a rapid rate# =tagnation oblood may predispose to thrombi

in the atriaAtrial Gbrillation%a commonarrhythmia *here the atria aredepolari$ed bet*een -3 and @33times a min#

Eccurs in healthy hearts and inpts *ith coronary artery disease,hypertension, and valvulardisease# =ymptoms may includepalpitations, atigue, dyspnea,lightheadedness, syncope, andchest pain# =tagnation o bloodmay predispose to thrombi in theatria#

CO" sho*s characteristicallyirregular undulations o CO"baseline *ithout discrete 9 *aves#

@entricular arr+yt+mias:

Condition: Clinical si(ni?cance: E8; readin(:9remature ventricular comple8 (9V>)%premature depolari$ation arising thein ventricles due to an ectopic ocus#Hniocal 9V>s arise rom the sameectopic ocus and have the sameconGguration# 1ultiocal 9V>s ariserom di6erent ectopic oci and havedi6erent conGgurations#;igeminy%normal sinus impulse isollo*ed by a 9V># Trigeminey%9V> occurs ater everyt*o normal sinus impulses#

A common arrhythmia that occurs inhealthy and diseased hearts# 9t maybe asymptomatic or havepalpitations# >ommon causes includean8iety, ca6eine, stress, smoing,and all orms o heart disease#

En CO", the 9 *ave is usually absentand the J

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more consecutive 9V>s at aventricular rate o U3 bpm#

lie threatening arrhythmia andre0uires immediate medicalintervention# 9ts are not able tomaintain an ade0uate blood pressureand eventually become hypotensive#

V%tach may degenerate intoventricular Gbrillation causing cardiacarrest# >ommon causes include 1',cardiomyopathy, and valvulardisease#

comple8es are *ide and aberrant inappearance#

Ventricular Gbrillation (v%Gb)%Ventricles do not beat in acoordinated ashion, but Gbrillate or0uiver asynchronously andine6ectively# :o cardiac outputK pt

becomes unconscious#

A lethal tachyarrhythmia re0uiresimmediate deGbrillation# Additionalmeasures include medications tosupport the circulation andintravenous antiarrythmic agents#

>ommon causes include heartdisease o any type, 1', and cocaineuse#

CO" sho*s characteristic Gbrillatory*aves *ith an irregular pattern thatis either coarse or Gne#

Ventricular asystole%Ventricularstandstill *ith no rhythm#

ommon causesinclude acute 1', ventricular rupture,cocaine use, lightning stries, andelectrical shoc#

CO" records a straight%line pattern#

$@ Conduction locks:

st  degree AV bloc 9< interval is longer than 3# seconds, but relatively constant rom beat to beat#

S>linical signiGcance :o symptoms or signiGcant change in cardiac unction# 9< interval may become prolonged ormany reasons include medications that suppress AV conduction#

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nd  degree AV bloc AV conduction disturbance in *hich impulses bet*een the atria and ventricles ail intermittently# T*o major types 1obit$ type bloc (also called Iencebach bloc) and 1obit$ type bloc

S>linical signiGcance 1obit$ '%progressive prolongation o 9< interval until one impulse is not conducted (generallybenign)

1obit$ ''%consecutive 9< intervals are the same and normal ollo*ed by nonconduction o one or more impulses (amore serious condition)# ' heart rate is slo*, cardiac output *ill decrease *ith the bloced impulse# Also, nd degreeAV bloc may progress to - rd degree AV bloc

-rd  Degree AV bloc (complete heart bloc)%All impulses are bloced at the AV node and none are transmitted to theventricles# The atria and ventricles are paced independentlyK atrial rate U ventricular rate#

S>linical signiGcance >onsidered a medical emergency re0uiring a pacemaer# ' the ventricular rate is too slo*, thecardiac output drops and the pt may aint# >ommon causes include degenerative changes o the conductionsystems, digitalis, heart surgery, and acute 1'#

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Signs and Symptoms

Right Sided Heart

Failure

Nausea

anorexia

weight gainascites

right upper quadrant pain.

Increase in RAP, CVP,

Jugular venous distention

Positive heptojugular reflex

right ventricular eave

Murmur of tricuspid insufficiency

Hepatomegaly

Peripheral edema

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Signs and Symptoms

Left Sided Heart

Failure

Fatigue

cough

shortness of breathDOE

Orthopnea

PND

Diaphoresis

Tachycardia

S3 Gallop

Crackles

Increased PAP, PAWP, SVR

Laterally displaced PIM

Left ventricular heave

Pulsus alternans

confussion

decreased urine output

Cheyne Stokes respiration (advanced failure)

Murmur of mitral insufficiency

.ests o' !eri!+eral arterial circulation:

$nkle brac+ial inde3 5$I)%the ratio o lo*er e8tremity pressure divided by upper e8tremity pressure#

%9erormed in HC at brachial artery, .C at posterior tibial and dorsalis pedis arteries#A;' assists in ris stratiGcation or cardiovascular disease 3#N3 is associated *ith %? old increased ris or cardiovascular events and death#A;' 3#3 increased ris o progression to severe or critical limb ischemia in year#

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U#?3 'ndicates non%compliant arteries#33%#?3 :ormal3#N%3#NN ;orderline or e0ual to 3#N3 Abnormalor e0ual to 3#3 =evere arterial diease, ris or critical limb ischemia, may

have pain at rest

E3ercise Stress&.olerance .estin(:

%=erves as a basis or e8ercise prescription, used as a screening measure or >AD in asymptomatic individuals#

%A pharmacological stress test is used *hen a patient is unable to perorm a regular CTT#

 Testing modes Treadmill and cycle ergometry (leg or arm tests), step test#

Ma3imal E..: deGned by target endpoint 2

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Muscles o' ins!iration diaphragm (primary), e8ternal intercostals, and internal intercostals and consideredprincipal muscles o inspiration#

Accessory muscles o inspiration sternocleidomastoid, scalenes, pec major & minor, and serratus anterior#

Muscles o' e3+alation results rom passive recoil o the lungs and rib cage# During orceul breathing the rectus

abdominus, e8ternal obli0ue, internal obli0ue, and transverse abdominus depress the lo*er ribs and compress theabdominal contents, thus pushing up the diaphragm and assisting *ith active e8halation#

$l#eolar-ca!illary units%The bronchi branch many times beore terminating in the acinus or respiratory unit o thelung# E8ygen di6uses across the alveolar%capillary septum into the red blood cells in the lung capillaries *here itcombines *ith hemoglobin to be transported bac to the heart# >arbon dio8ide di6uses in the opposite direction#

Pleurae%a membranous serous sac called visceral pleura covers each lung# The pleura covering the surace o thelungs is called the visceral pleura# The pleural tissue covering the inner suraces o the chest *all, ribs, vertebrae,diaphragm, and mediastinum is called parietal pleura# :ormally, the t*o pleurae remain in contact throughout therespiratory cycle, separated only by serous fuid# Hnder abnormal circumstances, the pleural space may contain air

(pneumothora8) blood (hemothora8), pus or increased amounts o serous fuid, *hich compress the lung and causerespiratory distress#

Pulmonary circulation% the portion o the circulatory system that carries deo8ygenated blood rom the heart to thelungs via the pulmonary arterial trun, right and let pulmonary arteries, lobar arteries, arterioles, and capillaries# The pulmonary circulation returns o8ygenated blood rom the lungs to the let atrium via the pulmonary veins#

ronc+ial circulation%the portion o the circulatory system that supplies o8ygenated blood to the bronchi andconnective tissue o the lungs via the bronchial arteries, *hich drain directly into the bronchial veins#

6un( @olumes " Ca!acities:

Anatomic dead space volume (VD) The volume o air that occupies the non%respiratoryconducing air*ays

C8piratory reserve volume (C

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/orced vital capacity (/V>) The volume o air e8pired during a orced ma8imale8piration ater a orced ma8imal inspiration# F4

/unctional residual capacity (/) The volume o air in the lungs ater normal e8halation#/5C

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$d#entitous breat+ sounds:

>racles (also termed rales, crepitations) a cracling sound heard usually during inspiration that indicates pathology)atelectasis, Gbrosis, pulmonary edema)

Ihee$es a musically pitched sound, usually heard during e8piration, caused by air*ay obstruction (asthma, >E9D,

oreign body aspiration)

Lung Lobe Location & Postural Drainage Position

Lobe Position

Right or Left Anterior Upper

Lobe/Segment

Supine in a reclined seated position with knees supported

Right or Left Posterior Apical Segment Seated and slumped over a pillow with lower extremities supported

in a comfortable position

Right and Left Anterior Segments Supine with knees supported with a pillow

Right Posterior Segment Prone slightly on the left side

Left Posterior segment Prone with left side of torso propped up on pillows. Torso is at a 45

degree angle.

Right Middle Lobe Supine with right side propped up on pillows and lower extremities

elevated 12 inches

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Lobe Position

Left Ingular Supine with left side propped up on pillows and lower extremities

elevated 12 inches

Anterior Segments (Lower Lobes) Supine with knees supported with pillows and lower extremities

elevated 18 inches

Right Lateral Segment Left sidelying with lower extremities elevated 18 inches

Left Lateral Segments Right sidelying with lower extremities elevated 18 inches

Posterior segments Prone in comfortable position/neutral spine with pillows under

abdomen and comfortable feet position with pillows under lower

legs with lower extremities elevated 18 inches

Superior Segments Prone in comfortable position/neutral spine with pillows under

abdomen and comfortable feet position with pillows under lower

legs.

$rterial blood (ases:

p2 F#? (F#-%F#?)9a>E (amount o carbon dio8ide *ithin arterial blood) ?3 mm 2g at sea level breathing ambient air (-%?mm2g)

9aE NF mm 2g at sea level breathing ambient air (3%33mm 2g)

2>E-% (amount o bicarbonate ions *ithin arterial blood) ? mC0+. (%@)=aE N%N4L;y convention, A;" results are *ritten or spoen in theollo*ing order p29a>E9aE2>E-% (e#g#

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F#?+?3+NF+?)Acidemia Clevated acidity o blood (p2 F#-)Alalemia Decreased acidity o blood (p2 U F#?)Cucapnia :ormal level o >E in arterial blood (-%? mm 2g)2ypercapnia Clevated level o >E in arterial blood( U ? mm 2g)

2yopcapnia .o* level o >E in arterial blood (- mm 2g)2ypo8emia .o* level o E in arterial blood (9aE  3 mm 2g)1ild hypo8emia 9aE @3%FN mm2g1oderate hypo8emia 9aE ?3%N mm2g=evere hypo8emia 9aE  ?3 mm2g2ypo8ia .o* level o E in the tissue despite ade0uate perusion

o the tissueLAn increase in the 9a>E decreases the bodys p2# A decrease in the 9a>E raises the bodys p2#

L=upplemental o8ygen is usually prescribed *hen the 9aE  alls belo* mm2g#

Ot+er #alues:

Ihite ;lood >ells (I;>s) ?-33%3,33ells (s) 1ale ?#@%@# /emale ?#%#NCrethrosedimentation

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Acid%;ase balance

.y!e !9 PaCO* 9CO=- Causes Si(ns "Sym!toms

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dilation o a bloodvessel, usually anartery# >ommon sitesinclude the thoracic& abdominal aorta

and vessels *ithinthe brain#

*eaness in the *allo vessel oten due tochronic 2T:,connective tissuedisease (1aran

=yndrome), trauma,inection

site# Aorticaneurysms areusuallyasymptomatic, butmay include

generali$edabdominal or .;9#Abdominal aorticaneurysms maycause pulsations nearthe navel# A cerebralaneurysm can causea sudden and severeheadache, nausea &vomiting, sti6 nec,sei$ure, loss o

consciousness, &double vision#

medications may berecommended or2T:# =urgery isrecommended torepair large aortic

aneurysms andconsists o replacingthe aneurysm *ith asynthetic abric grat# T*o surgical optionsor ruptured brainaneurysms aresurgical clipping &endovascular coiling#

Angina pectoris A transient precordialsensation o pressureor discomGt resultingrom myocardialischemia# >ommontypes o anginapectoris are Stable(occurs at predictablelevel o e8ertion,

responds to rest ornitroglycerin),nstable (usually ismore intense, lastslonger, is precipitatedby less e8ertion,occurs spontaneouslyat rest, isprogressive)

'nade0uate bloodfo* & o8ygenation o the heart musclemostly due tocoronary arterydisease#

Hsually described aspressure, heaviness,ullness, s0uee$ing,burning or achingbehind the sternum,but may also be eltin the nec and bac, ja*, shoulders, andarms# The sensation

may be associated*ith di!cultybreathing, nausea orvomiting, s*eating,an8iety, or ear# 't istypically triggered bye8ertion or strongemotion andsubsides *ith rest#

 T8 or acute anginainclude supplementalo8ygen, nitroglycerin,and rest# >hronic orrecurring anginapectoris is treated*ith long%actingnitrates, betablocers, and calcium

channel blocers#Angioplasty *ithstenting o thecoronary arteries orcoronary arterybypass surgery(>A;") may beperormed *henmedications are not

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Prin)metal or#ariant an(ina (occurs due tocoronary arteryspasm most oten

associated *ithcoronary arterydisease)

e6ective#

Atherosclerosis A slo* progressiveaccumulation o attypla0ues on the inner*alls o arteries#Ever time the pla0uecan restrict bloodfo*, causing a bloodclot#

Although the e8actcause is unno*n,the process maybegin *ith damage orinjury to the inner*all o the arteryrom 2T:, highcholesterorl, smoing

or diabetes# Evertime, atty pla0uesmade o cholesterorland other cellular*aste products buildup at the site o theinjury & harden,narro*ing the arteryand impacting bloodfo*#

Varies based on theseverity o disease &the artery a6ected#Ihen the coronaryarteries are a6ected,angina pectoris mayresult# Ihen cerebralarteries are a6ected,

numbness or*eaness o the armsor legs, di!cultyspeaing or slurredspeech, or droopingace muscles mayresult# Ihenperipheral arteriesare a6ected,intermittentclaudication may

result#

.iestyle changes,medications, &surgery# >hangesinclude cessation osmoing, regulare8ercise, healthydiet, stressmanagement#

1edications mayincludeantihypertensive,antiplatelet, andantilipidemic agents#=urgical proceduresmay includeangioplasty,endarterectomy, andbypass surgery#

>hronic venousinsu!ciency (>V')

A condition in *hichthe veins and valvesin the .C aredamaged and cannoteep blood fo*ingto*ard the heart# This causes veins toremain Glled *ith

Iea or damagedvalves inside theveins# ompressionstocings andelevation o the legshelp decrease chronics*elling# Varicosevein stripping may beperormed or cases*ith persistent leg

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blood# pain or sin ulcersdue to poorcirculation#

Atrial septal deect(A=D)

A hole in the *all oheart separating the

right & let atria# 'netal circulation,there is normally anopening bet*een thet*o atria to allo*blood to bypass thelungs# This opening istermed oramenovale and usuallycloses at birth# ' theA=D persists, blood

continues to fo*rom let to the rightatria and is called ashunt# 'n severecases, blood mayfo* rom the right tothe let atria#

>ongenital heartdeects arise rom

errors early in thehearts development#"enetics &environmentalactors may play arole#

=mall to moderatesi$ed deects may

produce nosymptoms orsymptoms thatappear ater -3 yearso age# .arge or longstanding atrial septaldeects may causeheart murmur, =E;,atigue, s*elling othe legs, heartpalpitations, re0uent

lung inections,stroe, cyanosis othe sin#

=urgical closure isrecommended i the

deect is large, theheart is s*ollen orsymptoms occur# Anon%surgicalprocedure involvesplacing a device intothe heart and acrossthe A=D using acatheter#

>or 9ulmonale Also no*n aspulmonary heartdisease, reers tohypertrophy o the

right ventricle casedby altered structureor unction o thelungs#

9ulmonaryhypertension romchronically increasedresistance in the

pulmonary circulation

 The cardinalsymptom isprogressive shortnesso breath, especially

*ith e8ertion# Ethersigns & symptomsare atigue,palpitations, atypicalchest pain, s*ellingo the .es, di$$iness,& syncope#

=upplemental o8ygensu!cient to maintain=aE UN34 and or9aE U@3 mm 2g#

"eneral measuresinclude diuretics &anticoagulation#

>oronary ArteryDisease (>AD)

's the narro*ing orblocage o the

>AD is thought tobegin *ith damage or

 The degree ostenosis re0uired to

AggressivemodiGcation o

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replacement therapy,being over*eight,obesity, andsmoing#

reaching the lungs#>ompressionstocings may berecommended toreduce blood pooling#

Cndocarditis 's infammation othe endothelium thatlines the heart andcardiac valves# ' letuntreated,endocarditis candamage and destroyheart valves andbecome liethreatening#

>aused by bacteriathat may enter theblood rom cathetersor needles, dentalprocedures, gumdisease, se8uallytransmitted diseaseor infammatorybo*el disease#'ndividuals *ith adamaged heart

valve, and artiGcialheart valve or otherheart deects are atthe greatest ris#

1ay develop slo*ly,depending on thecause o the inectionand i the heart isa6ected, but caninclude ever, chills,heart murmur,atigue, shortness obreath, *eight loss,blood in urine, andsin petechiae#

Antibiotics are theGrst line o treatment#=urgery may beneeded to treatpersistent inectionsor replace a damagedheart valve#

2eart /ailureQcongestive heartailureR

's a progressivecondition in *hichthe heart cannotmaintain a normalcardiac output tomeet the bodysdemands or blood

and o8ygen# 2eartailure oten developsater other conditionshave damanged or*eaened the heart# The ventricles*eaen and dilate tothe point that theheart cant pump

>AD, 2T:, D1, 1',abnormal heartvalves, andcardiomyopathy#

=E;, atigue and*eaness, s*elling inthe legs, eet andabdomen, rapid orirregular heartbeat*ith =- or =? heartsound, persistent

cough or *hee$ingand *eight gain romfuid retention#

=ometimes treatingthe underlying causecan correct heartailure (repairing adamaged heart valveor controlling anabnormal heart

rhythm)# 'n mostcases, t8 is a balanceo medications,devices, and liestylechanges to help theheart contractnormally# 1edicationsincludeanticoagulants,

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e!ciently# 't cana6ect the right side,let side, or bothsides o the heart,but typically begins

*ith the letventricle# The termQcongestive heartailureR comes romblood bacing up intothe liver, abdomen,.es, and lungs# Thecondition can beacute or chronic#

antihypertensives,and digitalis toincrease the strengtho contraction# 'nsevere cases, surgery

and medical devicesmay be needed tocorrect theunderlying cause othe heart ailure#

2eart murmur An abnormals*ishing or

*hooshing soundheard by auscultationsometime during thecardiac cycle#

'nnocent heartmurmurs occur *hen

blood fo*s rapidlythrough the heartdue to activity,pregnancy, ever,and anemia#Abnormal heartmurmurs may becaused by turbulentblood fo* through adamaged ornarro*ed heart valve

or a hole in one othe hearts *alls#Ether causes includerheumatic ever,endocarditis, calciGedvalves, and mitralvalve prolapsed#

'nnocent murmursare not usually

associated *ith othersigns or symptoms#Abnormal murmursmay be associated*ith cyanosis, limbedema, shortness obreath, enlargednec veins, *eightgain, chest pain,di$$iness, andainting#

'nnocent murmursusually do not re0uire

treatment# Treatmentor abnormal heartmurmurs depends onthe underlying causeand can includemedications orsurgery# >ommonmedications aredigo8in,anticoagulants,diuretics, and other

antihyperstensiveagents# =urgicalprocedures includevalve replacement orpatching atrial orventricular septaldeects#

2ypertension Arterial hypertensionin adults is a

9rimary or essentialhypertension has no

2T: is otenasymptomatic until

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sustained elevationo systolic pressureU?3 mm 2g ordiastolic pressureUN3 mm 2g#

no*n cause# 2T:*ith an identiGedcause (usually renaldisease) is calledsecondary 2T:#

complicationsdevelop in theorgans# An =? heartsound is an earlysign# =evere 2T:

(diastolic U3) cancause signiGcant >:=symptoms(conusion, corticalblindness,hemiapresis,sei$ures)cardiovascularsymptoms (chestpain, dyspena) andrenal involvement#

modiGcations (-3min+day e8ercise,*eight loss to a ;1'o #%?, smoingcessation, reduced

intae o sodium andalcohol, increasedconsumption o ruits,vegetables, lo* atdairy andmedications# >lasseso medications or2T: include diuretics,beta blocers,calcium channelblocers, A>C

inhibitors#.ymphedema Cdema, or s*elling,due to anaccumulation olymph in thee8tremities

9rimary lymphedemais a rare, inheritedcondition caused byproblems *ith thedevelopment olymph vessels#>auses o secondarylymphedema includeany condition orprocedure that

damages or obstructslymph nodes orvessels

=*elling *ith therestricted motion othe upper or lo*ere8tremity, archingand heaviness or aelling o ullness,bra*ny, Gbrous, nonpitting edema in oneor more limbs#

 There is no cure, buttreatments ocusedon reducing s*ellingand controlling painmay lessensymptoms and slo*or halt progression# Treatments includegentle activee8ercise, pressure

gradient bandages,massage, pneumaticcompression, andcompressiongarments# =urgery toremove e8cess tissuein the a6ectede8tremity may beconsidered#

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1yocardial 'narction AOA heart attac, a1' occurs *hen theblood fo* throughone or more o thecoronary arteries is

severely reduced orcut o6 completely# This causesirreversible necrosisto the portion omyocardium suppliedby the bloced artery#

1ost occur *hen arupturedatheroscleroticpla0ue or blood clotblocs the fo* o

blood through acoronary artery# Anuncommon cause is aspasm o a coronaryartery

>hest discomort *ithpressure, s0uee$ingor pain, shortness obreath, discomort inthe upper body

including the arms,shoulder, nec orbac, nausea,vomiting, di$$iness,s*eating, andpalpitations#

 Treatment o 1'varies rommedication to surgeryor both, dependingon the severity and

the amount o heartdamage# 1edicationsused to treat theacute 1' includeanticoagulants andthrombolytic agents,pain relievers,antihypertensivesand cholesterollo*ering medications#=urgical procedures

may include coronaryangioplasty *ithstenting or bypasssurgery#aused primarily byatherosclerosis andthromboemboicprocesses that alterthe structure and

unction o the aortaand its branches

/atigue, aching,numbness, or painprimarily in thebuttoc, thigh, cal,or oot at rest or

*hen *aling, poorlyhealing *ounds othe legs or eet,distal hair loss,trophic sin changes,and hypertrophicnails#

/or pts *ithasymptomaticdisease, t8 consist osmoing cessation,lipid lo*ering

medications, andcontrol o diabetesand 2T: (*ith betablocers)# /or pts*ith disablingintermittentclaudication,treatment consists orevasculari$ation

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procedures (stent,lasers) and surgery(bypass) may berecommended#=upervised e8ercise

training should beperormed or aminimum o -3%?minutes, at least -8 a*ee, or a minimumo *ees#

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a e* days ater theoriginal disease ortrauma# Aonditions andactors that preventdeep breathing and

coughing can causeit# These include postoperataive pain,pleural e6usion,tumor, AE9D, andcystic Gbrosis#

' a small area o thelung is a6ected,there may be no

signs or symptoms# ' a large area isa6ected, there maybe cyanosis,shortness o breath,increased breathingrate, and increased2

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small cell lungcarcinomas, includings0uamous cellcarcinoma,adenocarcinoma, and

large cell carcinoma

'n these cases, thee8act etiology maybe unno*n#

disease is advanced#

;ronchiectasis A progressiveobstructive lungdisease thatproduces abnormaldilation o abronchus# This is anirreversible conditionusually associated*ith chronicinections, aspiration,

cystic Gbrosis orimmune systemimpairment# Thebronchial *alls*eaen over timedue to inection andallo* or permanentdilation o bronchiand bronchioles#

'njury to the air*aysor lung inection(pneumonia,*hooping cough,measles,tuberculosis, ungalinections)#

>onsistent productivecough, hemoptysis,*eight loss, anemia,cracles, *hee$es,and loud breathsounds#

1edications includeantibiotics,bronchodilators,e8pectorants, andmucolytics#

>hronic Ebstructive9ulmonary Disease

E9D# 9ts have anincreased total lung

>aused by long termsmoing

C8cessive mucusproduction, chronic

productive cough,*hee$ing, shortnesso breath, atigue,and reduced e8ercisecapacity#

1edications, surgery,maintaining good

nutrition, and air*ayclearnance, breathinge8ercises#

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capacity *ith asigniGcant increase inresidual volume#

>ystic Gbrosis 's an autosomalrecessive genetic

disease o thee8ocrine glands thatprimarily a6ects thelungs, pancrease,liver, intestines,sinusues, and se8organs# 9eople *hohave >/ inherit t*oaulty >/ genes, onerom each parent#

 The causative actoris a mutation o the

cystic Gbrosistransmembraneconductanceregulator orchromosome F# Adeective gene andits protein productcause the body toproduce unusuallythin, sticy mucusthat leads to lie

threatening lunginections, obstructsthe pancreas, andinhibits normaldigestion andabsorption o ood#

Vary *ith progressionand may include

salty tasting sin,persistent andproductive coughing,re0uent lunginections, *hee$ing,shortness o breath,poor gro*th+*eightgain in spite o agood appetite, andre0uent greasy,buly stools#

Antibiotics,nutritional

supplements,pancreatic en$ymereplacements,mucolytics, andbronchodilators# 9Tincludes air*ayclearance, breathingtechni0ues, assistedcough, andventilatory muscletraining# "eneral

e8ercise is indicatedto improve overallstrength andendurance, e8cept*ith severe lungdisease#

Cmphysema The alveolar *alls aregradually destroyedand the alveoli areturned into large,irregular pocets *ith

gaping holes in the*alls# 'n addition, theelastic Gbers thathold open thebronchioles aredestroyed, so thatthey collapse duringe8halation, notletting air escape

=moing is theleading cause#

=hortness o breath,*hee$ing, chroniccoughing, orthopnea,barrel chest, increaseuse o accessory

muscles, increasedrespiration rate,atigue, and reducede8ercise capacity#

1edications,supplementalo8ygen, antibiotics (i bacterial inection ispresent)# =urgery,

maintaining goodnutrition# Ctc#

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rom the lungs# Thealveoli arepermanentlyoverinfated anddead space increase*ithin the lungs#

9leural e6usion 's a buildup o fuid inthe pleural spacebet*een the lungsand chest cavity# Thee8cess fuid can pushthe pleura againstthe lung maing ithard to breath, and insome cases, causingatelectasis# ' the

fuid gets inectedand turns into anabscess, thecondition is calledempyema#

9leuritis, orinfammation o thevisceral and parietalpleura# 9leuritis canbe caused by a viralinection, pneumonia,and

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pulmonary veins andcapillaries, causingfuid to be pushedthrough the capillary*alls into the alveoli#:on cardiacpulmonary edema,fuid leas rom thecapillaries *ithin thealveoli since thecapillariesthemselves becomemore permeable#

blood tinged sputum,chest pain, irregularpulse#

9ulmonary embolism 9C is a condition*here one or morearteries in the lungs

become bloced# 9Ccan be liethreatening butprompt treatment*ith anti%clottingmedications cangreatly reduce theris o death#

>aused by bloodclots rom .Cs#

=udden onset o =E;,chest pain thatbecomes *orse *ith

deep breathing,coughing sputum#C8tremity s*elling,ainting#

9rompt treatment oanticoagulants andthrombolytic agents

greatly reduces theris o death# =urgerymay be done toremove the clot#9revention includescompressionstocings, pneumaticcompression,physical activity, anddrining fuids#

9ulmonary /ibrosis A condition in *hich

microscopic damageto the alveoli causesirreversible scarringo the interstitialtissue# :ormally, thetissue is highlyelastic, e8pandingand contracting *itheach breath# =carring

>ause is unno*n#

>hronic e8posure tosilica dust,asbestosis, graindust, sugar cane, andbird and animaldroppings can causepulmonary Gbrosis#

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maes the interstitialtissue sti6 and thicand the alveoli lessfe8ible, maingbreath more di!cult#

drugs, certainantiarrhythmicmedications, andsome antibiotics andcan also causeGbrosis#

une8plained *eightloss, and achingmuscles and joints#

lie# >orticosteriodsandimmunosuppressiveagents are otenprescribed initially#.ung transplantationmay be used in caseso advanced disease#=upplemental o8ygenand pulmonaryrehab#

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# >arotid ultrasound%uses sound *aves to e8amine and visuali$e the structure and unction o the carotidarteries#

@# >hest radiograph%used to visuali$e the location, si$e, and shape o the heart, lungs, blood vessels, ribs, andbones o the spine# >an also reveal fuid in the lungs or pleural space, pneumonia, emphysema, cancer orother conditions#

F# >omputed tomography (>T)%uses an 8%ray machine that rotates around a pt lying on a table# The pictures areslices o the body called tomograms and each picture is called a computed tomograph## Cchocardiography%uses high re0uency sound *aves non invasively to evaluate the unctioning o the heart

via real time images# >an provide inormation on the si$e and unction o the ventricles, thicness o theseptums, and unction o the *alls, valves, and chambers#

N# /luroscopy%A continuous 8%ray procedure that sho*s the heart and lungs# 'nvolves a high dose o radiation, ithas largely been replaced by echocardiography#

3#1agnetic

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$ccident 5C@$7 is an interruption o cerebral circulationthat results incerebralinsu!ciency,destruction osurrounding braintissue, andsubse0uentneurological deGcit#

area o inarct inthe brain and itsvascular origin,ho*ever it canpresent asnegative or up toa e* days aterthe event# 1

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sho*s a pt cancontinue toimprove or anaverage o %-years post >VA#

Con(esti#e 9eart4ailure 5C9476e't sided +eart'ailure: generallyassociated *ithsigns o pulmonaryvenous congestion#/i(+t sided +eart'ailure: associated*ith signs osystemic venous

congestion#

Eccurs *hen theheart can no longermeet the metabolicdemands o thebody# The heartsinability to pump asu!cient amounto blood occurs*hen there ininsu!cient ordeective cardiac

Glling and+orimpairedcontraction &emptying o theheart# Theimpairment incardiac outputcauses the body tocompensate orthis deGcit and thisresults in an

increase in bloodvolume, cardiacGlling pressure, 22/ *ill initiallysho* signs otachycardia# Ethersigns include

Hrinalysis and a>;> count thatincludeselectrolyte, thyroidstimulatinghormone, bloodurea nitrogen(;H:), and serumcreatinine levelsshould beperormed# A chest

8%ray,electrocardiogram,andechocardiogramare alsorecommended# ADopplerechocardiogramcan determinesystolic & diastolicperormance, the

cardiac output(ejection raction),and pulmonaryartery andventricular Gllingpressures#

>2/ is a commondisorder# A pt canlive *ith >2/ andshould beneGt rom9T in order toimprove enduranceand strength ater adecline in unctionrom hospitali$ationor bed rest# Aterdiagnosis there is

mean o -# yearso survival or menand #? years oremales#

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venous congestion,high catecholaminelevels, & impairedcardiac output,sudden *eightgain, =E;, =-gallop#

Cystic 4ibrosis5C47

's an inheriteddisease that a6ectsthe ion transport o the e8ocrine glandsresulting inimpairment o thehepatic, digestive,respiratory, andreproductive

systems# Thedisease causes thee8ocrine glands tooverproduce thicmucus,overproducenormal secretionsor overproducesodium & chloride#1ostly a6ectschildren, Arican

American ollo*edby >aucasians#

:eonatesmeconium can betested as ascreening tool orincreased albumin# The 0uantitativepilocarpineiontophoresiss*eat test is the

sole diagnostic toolin determining thepresence o >/#=odium & chlorideamounts greaterthan @3 mC0+l(standard value is?3 mC0+l) is apositive diagnosisor >/# The s*eattest should be

perormed t*ice toensure accuracy#

>hest 9T should beperormed severaltimes a day andincludes bronchialdrainage,percussion,vibration, breathingand assistive coughtechni0ues &

ventilatory muscletraining# A pt *ith>/ *ill re0uireintermittent 9Tthought their lie# The goals are toma8imi$e secretionclearance rom thelungs, optimi$epulmonaryunction, and

ma8imi$e the pts0uality o lie# >/ isa terminal disease,ho*ever, themedian age odeath as increasedto - years o agedue to earlydetection and

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comprehensivemanagement# Themost commoncause o death isrespiratory ailure#1ales generallyhave a betterprognosis thanemales#

Em!+ysema E9D# >E9Dis the secondleading cause o

disability inindividuals under@ years o age*orld*ide#Cmphysema resultsrom a non%reversible injuryand destruction oelastic protein*ithin the alveolar*alls#

M%ray is utili$ed tovisually evaluatethe shape andspacing o thelungs# Etherimaging studiesinclude a

planogram todetect bullae and abronchogram toevaluate mucusducts and detectpossibleenlargement o thebronchi# Arterialblood gases mayindicated a Y 9aE#'mpaired /CV,vital

capacity and orcedvital capacity# Totallung capacity,residual volume,and unctionalresidual volume*ill be X#

9harmacologicalintervention,o8ygen therapy, 9T#9T interventionconsist ogenerali$ede8ercise,

endurance training,pursed%lipbreathing,ventilatory musclestrengthening,chest *alle8ercises, and pteducation onposture, air*aysecretionclearance#

Cmphysema is achronic progressivedisease process#9ts re0uire ongoingmedical care andintermittentphysical therapyintervention# .iee8pectancy

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decreases to lessthan years *ithsevere e8piratoryslo*ing measuredat a rate o . oair during /CV#

6ym!+edemaPost-Mastectomy

.ymphedemaollo*ing amastectomy istermed secondarylymphedema and isthe result odamage to thelymphatic nodesand vessels duringsurgery# C8cessive

accumulation olymph fuid *ithinthe sot tissues iscaused by ane8cess load olymph fuid orinade0uatetransport capacity*ithin thelymphatic systemsecondary to the

loss ohomeostasis#

.ymphedemaclassiGed into -stages# =tage 'pitting edema thatreduces *ithelevation overnightand does note8hibit any Gbroticchanges# =tage ''identiGed by some

Gbrotic changesthat being to occur& increase in non%pitting edema thatdoes not reduce*ith elevation#=tage ''' ischaracteri$ed bysin changes,re0uent inections,and severe edema

that is non%pittingand Gbrotic#Diagnosis isconGrmed throughhistory,observation, andseveral diagnostictools to rule outother disorders# A

9harmacologicalintervention ornatural substancesthat increaseproteolysis andmacrophageactivity# :o cure#=urgery is used inthe treatment osevere cases#9T

ollo*s a treatmentapproach termedcombineddecongestivephysiotherapy(>D9)#.ymphedema isprogressive i letuntreated, but canbe managedthrough

intervention andeducation# 9ts mustcomply *ith ahome program andmust remain a*areo all activities thatplace the pt at anincreased ris orlymphedema#

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Doppler is used torule out DVT# >T or1>H) andprogress througheach o the phaseso cardiac rehab# 9that that hase8perienced an 1'

may be able toreturn to allprevious activitiesater successulcompletion o acardiac rehabprogram# A pt mustcontinue to reducethe modiGable ris

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actors andmaintain anappropriate level o e8ercise in orderlimit another 1'#

/estricti#e 6un(Disease 5/6D7

's a classiGcation o disorders causedby a pulmonary ore8trapulmonaryrestriction thatproducesimpairment in lunge8pansion and anabnormal reductionin pulmonaryventilation# There

are multipleconditions that cancause restrictivelung disease#9ulmonaryrestriction can becaused by tumor,interstitialpulmonary Gbrosis,scarring *ithin thelungs, and

pneumonia#C8trapulmonaryrestrictions includepleural e6usion,chest *all sti6ness,structuralabnormality,postural deormity,muscle *eaness,

A chestradiography isutili$ed to evaluatelung structure andevidence oGbrosis, inGltrates,tumor, anddeormity# Arterialblood gas analysismay indicated adecrease in 9aE#

V>, /V>, and T.>*ill be impaired#:ormal residualvolume, ande8piration fo*rates# C

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and centralnervous systeminjury#

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>ardiac ;iomarers >ertain en$ymes lea out o the heart cells and into theblood ater a myocardial inarction# >ardiac en$yme studiesmeasure the levels o creatine phosphoinase (>O) and theprotein troponin in the blood# >O%1; is a relatively speciGctest or myocardial inarction# 't appears in bloodappro8imately ? hours ater inarction, peas at %? hours,and declines over ?%F hours# >ardiac troponin%' is also aspeciGc marer or inarction, and unlie >O%1; levels, itremains elevated or %F days#

>holesterol Test Also called a lipid panel or lipid proGle, a cholesterol testmeasures the amount o cholesterol and triglycerides in theblood in order to determine the ris o atherosclerosis#>holesterol is carried in the circulation in association *ithlipoproteins# A complete lipid proGle includes themeasurement o ? types o lipids in the blood totalcholesterol, high%density lipoprotein (2D.) cholesterol, lo*%

density lipoprotein (.D.) cholesterol, and triglycerdies# 2D.cholesterol is reerred to as the QgoodR cholesterol becauseit helps carry a*ay .D. cholesterol and is protective againstatherogenesis# .D. is reerred to as the QbadR cholesterolsince it is associated *ith the buildup o atty pla0ues *ithinthe arteries *hich reduce blood fo*# The body converts anycalories it does not need to use right a*ay into triglycerides,*hich are stored in adipose tissue# 2igh levels otriglycerides are seen in over*eight people, in thoseconsuming too many s*eets or too much alcohol, and inpeople *ith diabetes *ho have elevated blood sugar levels#

>omplete ;lood>ount (>;>) 1easures red blood cell count, *hite blood cell count, *hiteblood cell di6erential, platelets, hemoglobin, andhematocrit# A >;> is perormed to assess health, todiagnose and monitor a medical condition, and to monitorthe e6ects o medical treatment#

2ematocrit (2ct) 's the percentage o red blood cells in total blood volume# Alo* hematocirt may indicate anemia, blood loss, and vitaminor mineral deGciencies# A high hematocrit may indicatedehydration or polycythemia vera, a condition that causes

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an overproduction o red blood cells#9artial Thromboplastin Time(9TT) and9rothrombin Time(9T)

9TT and 9T tests measure ho* 0uicly the blood clots# Thetests are commonly used to monitor oral anticoagulanttherapy or to screen or selected bleeding disorders# Thetests e8amine all o the clotting actors o the intrinsicpath*ay *ith the e8ception o platelets# 9artialthromboplastin time is more sensitive than prothrombin timein detecting minor deGciencies#

*B0 $rterial blood (ases:

p2 F#? (F#-%F#?)9a>E (amount o carbon dio8ide*ithin arterial blood)

?3 mm 2g at sea level breathing ambient air(-%?mm 2g)

9aE NF mm 2g at sea level breathing ambient air(3%33 mm 2g)

2>E-% (amount o bicarbonate ions*ithin arterial blood)

? mC0+. (%@)

=aE N%N4L;y convention, A;" results are*ritten or spoen in the ollo*ingorder p29a>E9aE2>E-% (e#g#F#?+?3+NF+?)9artial Thromboplastin Time (9TT) @%-N secondsAcidemia Clevated acidity o blood (p2 F#-)Alalemia Decreased acidity o blood (p2 U F#?)

Cucapnia :ormal level o >E in arterial blood (-%?mm 2g)2ypercapnia Clevated level o >E in arterial blood( U ?

mm 2g)2yopcapnia .o* level o >E in arterial blood (- mm

2g)2ypo8emia .o* level o E in arterial blood (9aE  3

mm 2g)1ild hypo8emia 9aE @3%FN mm2g

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1oderate hypo8emia 9aE ?3%N mm2g=evere hypo8emia 9aE  ?3 mm2g2ypo8ia .o* level o E in the tissue despite

ade0uate perusion o the tissue#LAn increase in the 9a>E decreases the bodys p2# A decrease in the 9a>E raises the bodys p2##L=upplemental o8ygen is usually prescribed *hen the 9aE alls belo* mm2g#-#*20 Ot+er #alues:

Ihite ;lood >ells (I;>s)(.euocytes)

?-33%3,33

ells (s)(Crythrocytes)

1ale ?#@%@# /emale ?#%#N

Crethrosedimentation

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alpha%adrenergicreceptors# This actioncausesdilation oarterioles &veins and Y;9#

dro*siness sitting orlyingpositiondue to theris odi$$inessand+ororthostatichypotension#>loselymonitorpt duringe8ercise#

(tera$osin)

Angiotensin%>onvertingCn$yme(A>C)inhibitorAgents

Decreasebloodpressureandaterload bysuppressingthe en$ymethatconvertsangiotensin 'toangiotensin

''#

2T:,congestiveheart ailgure

2ypotension, di$$iness,dry cough,hyperalemia,hyponatremia

Avoidsuddenchangesin posturedue to theris odi$$iness& aintingromhypotension# 9ts *heart

ailureshouldavoidrapidincreasesinphysicalactivity#

>apoten(captorpril),Vasotec(enalapril),9rinivil(lisinopril),Altace(ramipril)

Angiotensin '' ;loc 2T:, Di$$iness, 1inimal >o$aar

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receptorantagonistangents

angiotensin'' receptors*hich limitvasoconstriction &stimulation

o vasculartissue

congestiveheart ailure

bac andleg pain,anginapectoris

implications or 9T

(losartan),Atacand(candesartan), Diovan(valsartan)

Antiarrhythmic Agents

Divided into? classes#>lass '(sodiumchannelblocers)%contorlcardiace8citation &conduction#>lass '' (betablocers)%inhibitsympatheticactivity byblocing ;%adrenergicreceptors#>lass '''%

prolongrepolari$ation byinhibitingbothpotassium &sodiumchannels &are oten

>ardiacarrhythmias

Hni0ue tothe speciGcantiarrhythmic agentKe8acerbation o cardiacarrhythmias, di$$iness,hypotension

Cncourage pts toadhere totheprescribed dosingscheduleandimmediately reportanyadversereactionsto ahealthcareproessional#

Sodiumc+annelblockers: 0uinidine(generic),Mylocaine(lidocaine)etablockers:  Tenormin(atenolol)Prolon(edre!olari)ation: >ordarone(amiodaroneCalciumc+annel

blockers: >ardi$em(diltia$em)

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consideredthe moste6ectiveantiarrhytmic agent#>lass 'V%

(calciumchannelblocers)%depressdepolari$ation & slo*conductionthrough theAV node#

Anticoagulant Agents

'nhibitplateletaggregation& thrombusormation

9ostpercutaneoustransluminalcoronaryangioplasty &coronaryartery bypassgrat surgery,prevention o venousthromboembolim &

cardioembolic events inpts *ith atrialGbrillation &prostheticheart valves

2emorrhage, X ris obleeding,gastrointestinal distress*ith oralmedication

Atherapistmust becareul toavoidinjurysecondary to theris oe8cessivebleedingor

bruising#9teducationregardingcommonsidee6ects isalsoindicated

2eparin,>oumadin(*ararin),.oveno8(eno8aparin)

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to protectthe pts#

AntihyperlipidemiaAgents

 There are categorieso lipid%modiyingagents# Themostcommonlyused drugs,the statins,inhibiten$ymeaction incholesterolsynthesis,brea do*n.D., Ytriglyceridelevels, andX 2D.levels# Theothercategoriesare bile acidse0uestrants, nicotinic

acid,cholesterolabsorptioninhibitors, &Gbric acidderivatieves

2yperlipidemia,atherosclerosis, preventcoronaryevents in pts*ith e8istingcoronarydisease,diabetes or9VD

2eadache,"' distress,myalgia,rash

Aerobice8ercisecanincreasehighdensitylipoproteins andma8imi$ethee6ects odrugtherapy

.ipitor(atorvastatin), Zocor(simvastatin), Tricor(enobibrate)

Antithrombotic(antiplatelet)

Antithrombotic agentsinhibit

9ost%myocardialinarction, a%

2emorrhage,thrombocyt

1ust becareul toavoid

;ayer(aspirin),9lavi8

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agents plateletaggregationand clotormation

Gb, preventarterialthrombusormation

openia,potentialliver to8icity*ith theuse oaspirin, "'

distress

injurysecondary to theris obleeding#

(clopidogrel),9ersantine(dipyridamole)

;eta ;locerAgents (;eta%Adrenergic;locingAgents)

Decreasethemyocardialo8ygendemand bydecreasingheart rateandcontractilityby blocing;%adrenergicreceptors

2T:, agina,arrhythmias,heart ailure,migraines,essentialtremor

;radycardia, cardiacarrhythmias, atigue,depression,di$$iness,*eaness,blurredvision

2< & ;9responsetoe8ercise*ill bediminished# loselymonitorpts duringpositionalchangesdue to an

X ris ororthostatichypotension#

 Tenormin(atenolol),.opressor(metoprolol), 'nderal(propanolol)

>alcium>hannel;locerAgents

Decreasethe entry ocalcium intovascular

2T:, anginapectoris,arrhythmias,congestive

Di$$iness,headache,hypotension,

2< & ;9responsetoe8ercise

:orvasc(amlodidine), 9rocardia(niedipine)

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smoothmuscle cellsresulting indiminishedmyocardialcontraction,

vasodilation,and Yo8ygendemand othe heart

heart ailure peripheraledema

*ill bediminished# 1onitorpt closely*henmoving to

anuprightpositionsecondary todi$$inessand+ororthostatichypotension#Ebservethe 9t orsigns &symptoms ocongestive heartailuresuch as*orseningperipheraledema,dyspneaor *eightgain#

, >alan(verapamil)>ardi$em(dilita$em)

DiureticAgents

X thee8cretion osodium &urine# This

2T:, edemaassociated*ith heartailure,

Dehydration,hypotension,

9ositioning changescanincrease

.+ia)ide: Diuril(chlorothia$ide)

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causes areduction inplasmavolume*hich Yblood

pressure#>lassiGcations includethia$ide,loop, andpotassiumsparingagents#

pulmonaryedema,glaucoma

electrolyteimbalance,polyuria,X.D.,arrhythmias

the ris o di$$inessand allsdue to Y;9#1onitor

ptsclosely orsigns &symptoms oelectrolyteimbalance andmuscle*eanessorcramping#

6oo!: .asi8(urosemide)Potassiums!arin(: 

Dyrenium(triamterene)

:itrateAgents

Y ischemiathroughsmoothmusclerela8ationand dilationo peripheralvessels

Anginapectoris

2eadache,di$$iness,orthostatichypotension, refe8tachycardia, nausea,vomiting#

9ts mustbeeducatedto cometo astandingpositionslo*ly#

=ublingualadministration onitroglycerin is thepreerredmethodto treat

:itrostat(nitroglycerin), 'sordil(isosorbidedinitrate),Amyl nitritesolution orinhalation#

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an acuteanginaattac#

9ositive'notrophicAgents

Xthe orceand velocityo

myocardialcontraction,slo* the 2ardiacarrthytmias,"' distress,

di$$iness,blurredvision

 Therapists shouldmonitor

2< duringactivity,teach thept andam totae thepts pulse,and seehealthcareprovidersadvice orrates lessthan @3bpm ormorethan 33bpm#

.ano8in(digo8in)

 ThrombolyticAgents

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