Heart Failure Project

Rehabilitation Systems


Contents Introducing Heart Failure Rehabilitation ..............................................................................4 Heart Failure Rehabilitation Patient Assessment Form ...........................................................6 SF-36 Health Survey ........................................................................................................ 11 R P E / FT ....................................................................................................................... 13 DYSPNEA ........................................................................................................................ 14 6 - MINUTE WALK TEST (6MWT) ...................................................................................... 15 Lower Functioning MET Chart ........................................................................................... 16 Higher Functioning MET Chart .......................................................................................... 17 Metabolic Equivalents of Task ........................................................................................... 18 Heart Failure Patient Education ........................................................................................ 19 Early Warning Signs of an Exacerbation ............................................................................ 19 Five-Finger Fly-By Assessment ......................................................................................... 20 Exacerbation, Distress Interventions ................................................................................. 21 Energy Conservation ....................................................................................................... 24 Relaxation and Stress Management .................................................................................. 26 General Dietary Guidelines for Heart Failure Patients .......................................................... 28 Heart Failure Medications ................................................................................................. 30 Exercise Prescription and Progression ............................................................................... 37 General Aerobic Exercise Recommendations ...................................................................... 39 Gathering information from the 6MWT .............................................................................. 40 Incremental Increase in Aerobic Exercise & Strength Training ............................................. 41 Work-Rest Ratio .............................................................................................................. 42 Individual Therapeutic Session ......................................................................................... 43 SOAP NOTES .................................................................................................................. 45 Rehabilitation GOALS ....................................................................................................... 51 Heart Failure Rehabilitation Goals ..................................................................................... 52 (MET) to Functional Task Conversions .............................................................................. 53 Functional Capacity, Writing Functional Goals .................................................................... 54 The Compendium of Physical Activities Tracking Guide ....................................................... 56 Heart Failure Rehabilitation Progress Report ...................................................................... 66 About the Instructor ........................................................................................................ 69 Course Evaluation ........................................................................................................... 70 Congestive Heart Failure Glossary of Terms ....................................................................... 72


Introducing Heart Failure Rehabilitation What is Heart Failure Rehabilitation?

Heart failure, also called congestive heart failure (CHF), is a condition in which the heart cannot pump enough oxygenated blood to meet the needs of the body's other organs. The heart keeps pumping, but not as efficiently as a healthy heart. Usually, the loss in the heart's pumping action is a symptom of an underlying heart problem.

As the only major cardiovascular disease increasing in incidence and prevalence, congestive heart failure (CHF) is a major health threat. Progression of the disease often leads to severe disability and requires intensive medical and psychological management.

An estimated 5.7 million Americans are living with heart failure, and 670,000 new cases are diagnosed each year. Physical medicine professionals are having a positive impact by teaching and optimally restoring functional independence to heart failure patients within individual potentials. Professionals and patients working together are making necessary changes in diet, exercise and lifestyle modifications to prevent secondary complications in order to produce the highest possible quality of life.

Heart failure rehabilitation can improve a patient's functional ability, alleviate activity-related symptoms, improve quality of life, restore and maintain physiological, psychological, and social status. At Rehabilitation Systems, we have the combined expertise from our multidisciplinary team to lead the way in Heart Failure Rehabilitation program development and implementation for restorative professionals and their patients.

Key Features

Disease management training and education Signs and symptoms recognition with appropriate response patterns A continuum of restorative service from inpatient to outpatient to the home setting. Individualized treatment plans with online health coaching Webinars on medications, activity, weighing, nutrition, & stress management Lifestyle modification with secondary prevention planning


Program Outcomes

Improve cardiac output and myocardial contractility Achieve optimal fluid and sodium balance Education appropriate for understanding CHF pharmaceutical regimen Improve patient self-management through aggressive patient/family education and

Reduce cycle of hospital admissions and overall cost of care for patients with CHF Maximize functional independence Improve quality of life

Heart Failure Rehab Inclusion Criteria

Any patient with a diagnosis of heart failure and an ejection fraction of > 35% is a candidate for heart failure rehabilitation.


Heart Failure Rehabilitation Patient Assessment Form

Patient Information Name:________________________________________________ Date: __________ Address:______________________________________________ Phone:___________ Emergency Contact:_____________________________________ Phone: ___________ Age: ______ Sex: ____ Weight:_______ Height:______

_ Marital status: ____

Occupation:______________________________ Retired? ____ Disabled? ______ Insurance provider: ______________________________________ Number: ________ Address: ______________________________________________ Phone: __________ Diagnosis: _____________________________________________ Date of Dx: _______ Primary Care Provider: _____________________ Referring Physician: _________________

Health History Health Perception- Health Management Patterns Have you noticed an increase in cardiovascular symptoms such as chest pain or dyspnea (difficulty breathing)? * _________________________________________________________ Do you practice any preventive measures to decrease cardiac risk factors? * ___________________________________________________________________________ Do you foresee any potential self-care problems because of your cardiovascular health? * ___________________________________________________________________________ Nutritional- Metabolic Pattern Describe your daily dietary intake, including fat, sodium, and fluid. ___________________________________________________________________________ What is your present weight? _________ What was your weight one year ago? If different, explain. _____________________________________________________________________Does eating cause fatigue or shortness of breath? * __________________________________Elimination Pattern Do your feet or ankles swell? * __________________________________________________ Do you take medication to get rid of excess fluid? * __________________________________ Activity-Exercise Pattern Are your activities of daily living restricted because of your cardiovascular health? * ___________________________________________________________________________ Do you experience any discomfort or side effects as a result of exercise or activity? * ___________________________________________________________________________ Sleep-Rest Pattern How many pillows do you use to sleep at night? ____________________________________ How many times a night do you awaken to urinate? _________________________________ Do you ever wake up suddenly and feel as if you cannot catch your breath? * ___________________________________________________________________________ Cognitive-Perceptual Pattern Have you noticed any changes in your memory or level of awareness? * __________________________________________________________________________ Do you ever experience dizziness? * ____________________________________________


Do you find it difficult to express yourself verbally? * ________________________________ Do you experience any pain (e.g., chest pain, leg pain, with activity) as a result of your cardiovascular problem? * _____________________________________________________ Self-perception – Self-Concept Pattern Have your perceptions of yourself changed since you were diagnosed with a heart problem? * ___________________________________________________________________________ How has your cardiovascular problem affected your life and your self-esteem?* ___________________________________________________________________________ Role-Relationship Pattern Describe how this illness has affected the roles that you play in your daily life ___________________________________________________________________________ Describe how your heart condition has affected your relationships. ___________________________________________________________________________ How have your significant others been affected by your illness? ___________________________________________________________________________ Coping-Stress Tolerance Patterns Do you practice any stress reduction techniques? * ___________________________________________________________________________ Describe your normal coping mechanisms for stress. ___________________________________________________________________________ Who or where do you turn to during times of stress? Are these people or services helping you now? ______________________________________________________________________ Do you feel capable of handling your present health situation? Explain. ___________________________________________________________________________ Do you experience any cardiovascular symptoms such as chest pain or palpitations during times of stress? Explain. ___________________________________________________________________________ Present Temperament, check all that apply: Angry ____ Worried ____ Sad ____ Impatient ____ Frustrated ____ Depressed____ Anxious____ Calm____ Content ____ Cheerful ____ Happy ____ Explain: _______________________________________________________________ ______________________________________________________________________ Stressors / Fears /Concerns: _______________________________________________

*If yes, describe. Values-Belief Pattern What influence has your value-belief system had on your health during illness? ___________________________________________________________________________ Do you feel any conflicts between your value-belief system and your planned therapy? Explain. ___________________________________________________________________________ Describe any cultural or religious beliefs that may influence the treatment of your cardiovascular health? Explain. ______________________________________________________________


Heart Health History Have you ever been hospitalized for treatment of heart failure? No Yes, greater than 2 times in the last year Yes, less than or equal to 2 times in the last year # of days in hospital: _____________ Family history of heart disease: _____________________________________________ Family history of high blood pressure: ________________________________________ Do you have or have you ever had any of the following? If yes, give date of diagnosis, practitioner treating the condition, and the current treatment. Coronary Artery Disease (CAD) _________________________________________ Heart Valve Disease ______________________________________________________ Severe Lung Disease _________________________________________________ Severe anemia ______________________________________________________ Overactive thyroid ___________________________________________________ Abnormal heart rhythm _______________________________________________ Diabetes ___________________________________________________________ High Blood Pressure (Hypertension) _____________________________________ Heart Muscle Disease (cardiomyopathy) __________________________________ Congenital Heart Defects ______________________________________________ Do You Ever Have Chest Pain? _______Location: _______________ Frequency:______________ Type of Pain: _______________ Duration: ____________ Pain during activity? No Yes Pain during rest? No Yes Do you have any swelling? Where and how often? ______________________________


Associated Systems Health History Dyspnea rating for degree of breathlessness 1 = least severe, 5 = most severe #:_________ 1. Not troubled by breathlessness except during strenuous exercise 2. Short of breath when hurrying or walking up a slight hill 3. Walks slower than contemporaries on the level because of breathlessness 4. Stops for breath after about 100 yards or after a few minutes on the level 5. Too breathless to leave the house, or breathless when dressing or undressing Do you have a pulmonary diagnosis? Explain. ________________________________________ Have you been admitted to the hospital for breathing difficulty in the last year? # of days in hospital: _____________ Shortness of Breath Most Difficulty (circle one): Morning AM or PM Bedtime Oxygen Therapy Y/N FIO2:________When:_________ Home Respiratory Therapy Y/N What type of home respiratory therapy? _____________________________________ Have you been taught about any breathing techniques? Pursed Lip Breathing_____ Diaphragmatic Breathing_____ Accessory Muscle Use in Breathing_____ Sleep Hygiene #Hours: _______ # Pillows Used: ______ Reason for using pillows: ________________ Sleep Disturbances: ______What Kind: ______________________________________ Do you snore, or does your spouse say you snore? __________ Do you wake up to breathe? _____ Do you stop breathing during sleep? _________ Do you feel rested in the morning? ________ Do you need to take naps daily? ________ Do you take medication to help you sleep? ___________ Activities of Daily Living Are you able to care for yourself? _________ Are you able to care for your home? ________ Do you exercise? Y/N How often: ______________Type of exercise: ________________ Do you have exercise equipment? Y/N Type: _______________________________ Special interests & hobbies: ______________________________________________ Does breathing difficulty keep you from your activities? _____ Do you live alone? _____ Do you have transportation? ______ Do you need assistive devices? _____ If so, which devices? ______________________ Dietary History Do you have trouble eating? Y/N Why? ___________________________________ Do you have difficulty gaining or losing weight? _______________________________ Special diet? ___________________________________________________________ Appetite: ________Good________Fair________Poor_______ Is this usual for you? ________ Vitamins: Y/N Restaurants per week? __________ Do you consume alcohol? Y/N How much?__________________________________ Physical Assessment LAB DATA Date: ______________ LDL: ____________ HDL: ____________ TRIG: ___________ Total Cholesterol: __________ Ejection fraction: ______________


Skin Do you have red or darkened skin on any of your extremities that seems to last a long time?* ___________________________________________________________________________ Has this changed in the last year? * ______________________________________________ Is your skin ever tight and shiny? * _______________________________________________ How often does this happen? ___________________________________________________ Do your extremities ever feel more warm or cold to touch than normal? * ___________________________________________________________________________ Do your fingers, lips, ear lobes, or gums ever appear blue or purplish? * ___________________________________________________________________________ How motivated are you to achieve better health? ____________________________________

Therapist signature: _______________________________ Date: ___________________


SF-36 Health Survey Physical Functioning Score (PFS)

Example of processing a score of 21 from the question above: A Physical Functioning raw score of (21) is converted as follows: (21 – 10) ---------------- X 100 = 55 20 PRE PROGRAM: SF 36 PFScore:_________ POST PROGRAM: SF 36 PFScore:_________

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Please circle one number on each line.)

Activities Yes, limited a lot

Yes, limited a little

Not limited at all

1. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.

1 2 3

2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

1 2 3

3. Lifting or carrying groceries. 1 2 3 4. Climbing several flights of stairs. 1 2 3 5. Climbing one flight of stairs. 1 2 3 6. Bending, kneeling, or stooping. 1 2 3 7. Walking more than a mile. 1 2 3 8. Walking several blocks. 1 2 3 9. Walking one block. 1 2 3 10. Bathing or dressing yourself. 1 2 3


R P E / FT Ratings of Perceived Exertion / Ratings of Fatigue Threshold

How much are you (working / fatigued?) MODIFIED 10 POINT BORG SCALE

0 Nothing at all 0.5 Very, very slight

(just noticeable) 1 Very slight 2 Slight (light) 3 Moderate 4 Somewhat severe 5 Severe (heavy) 6 7 Very severe 8 9 10 Very, very severe

(maximal)


DYSPNEA SHORTNESS OF BREATH (SOBr)

How much are you breathing? MODIFIED 10 POINT BORG SCALE

0 Nothing at all 0.5 Very, very slight

(just noticeable) 1 Very slight 2 Slight (light) 3 Moderate 4 Somewhat severe 5 Severe (heavy) 6 7 Very severe 8 9 11 Very, very severe

(maximal)


6 - MINUTE WALK TEST (6MWT)

Therapist signature:____________________________________________________

Name: ______________________________________ Date: _________________________ Resting Data: HR RPE SOBr %

spO2 FiO2/ LPM

6MWT HR RPE SOBr %spO2

FiO2/LPM Distance Walked

1 MIN Tally mark

2 MIN Tally mark

3 MIN Tally mark

4 MIN Tally mark

5 MIN Tally mark

6 MIN Tally mark

TOTALS

Tally marks = 100ft, 100ft = one length. Total feet:

Comments: i.e., signs and symptoms, angina, dizziness, stopped/paused before 6 minutes, reason why, etc.


Lower Functioning MET Chart

Speed, Distance, Energy Conversion Chart. MPH Ft Per Min 6MWT / Ft (MET) kcal / min Notes:

0.1 8.8 52.8 1.07 5.35 0.2 17.6 105.6 1.15 5.75 0.3 26.4 158.4 1.22 6.1 0.4 35.2 211.2 1.3 6.5 0.5 44 264 1.38 6.9 0.6 52.8 316.8 1.45 7.25 0.7 61.6 369.6 1.53 7.65 0.8 70.4 422.4 1.61 8.05 0.9 79.2 475.2 1.68 8.4

1 88 528 1.76 8.8 1.1 96.8 580.8 1.84 9.2 1.2 105.6 633.6 1.91 9.55 1.3 114.4 686.4 1.99 9.95 1.4 123.2 739.2 2.07 10.35 1.5 132 792 2.14 10.7 1.6 140.8 844.8 2.22 11.1 1.7 149.6 897.6 2.3 11.5 1.8 158.4 950.4 2.37 11.85 1.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.6 2.1 184.8 1108.8 2.6 13 2.2 193.6 1161.6 2.68 13.4 2.3 202.4 1214.4 2.76 13.8 2.4 211.2 1267.2 2.83 14.15 2.5 220 1320 2.91 14.55 2.6 228.8 1372.8 2.99 14.95 2.7 237.6 1425.6 3.06 15.3 2.8 246.4 1478.4 3.14 15.7 2.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.45 MPH Ft Per Min 6MWT / Ft (MET) kcal / min

References:

Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O'Brien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO, Jacobs DR Jr, Leon AS. Compendium of Physical Activities: An update of activity codes and MET intensities. Medicine and Science in Sports and Exercise, 2000;32 (Suppl):S498-S516. http://prevention.sph.sc.edu/tools/docs/documents_compendium.pdf


Higher Functioning MET Chart

Quick Conversion Chart ( MPH ~ M E T ) MPH Ft PM 6MWT / Ft M E T kcal / min Legend:

1.5 132 792 2.14 10.7 1.6 140.8 844.8 2.22 11.1 1.7 149.6 897.6 2.3 11.5 1.8 158.4 950.4 2.37 11.85 1.9 167.2 1003.2 2.45 12.25

2 176 1056 2.52 12.6 2.1 184.8 1108.8 2.6 13 2.2 193.6 1161.6 2.68 13.4 2.3 202.4 1214.4 2.76 13.8 2.4 211.2 1267.2 2.83 14.15 2.5 220 1320 2.91 14.55 2.6 228.8 1372.8 2.99 14.95 2.7 237.6 1425.6 3.06 15.3 2.8 246.4 1478.4 3.14 15.7 2.9 255.2 1531.2 3.22 16.1

3 264 1584 3.29 16.45 3.1 272.8 1636.8 3.37 16.85

3.2 281.6 1689.6 3.45 17.25Walking = .1 to 3.7 MPH

3.3 290.4 1742.4 3.53 17.65 Running = 3.8 MPH UP

3.4 299.2 1795.2 3.6 18SEE=Standard Error of Estimation >10%

3.5 308 1848 3.68 18.4 MPH = Miles Per Hour

3.6 316.8 1900.8 3.75 18.75Ft PM = Feet Per Minute (Hallway Walk)

3.7 325.6 1953.6 3.83 19.156MWT = Six Minute Walk Test

SEE 3.8 334.4 2006.4 3.9 19.5 Ft = Feet

SEE 3.9 343.2 2059.2 3.97 19.85MET = Metabolic Equivalent of Task

SEE 4 352 2112 4.04 20.2Kcal / min = Kilocalorie Per Minute

MPH Ft PM 6MWT / Ft M E T kcal / min Legend: Ref: http://prevention.sph.sc.edu/tools/docs/documents_compendium.pdf

http://prevention.sph.sc.edu/tools/docs/documents_compendium.pdf�


Metabolic Equivalents of Task


Heart Failure Patient Education Patient education topics specific for heart failure are included in the patient’s workbook. Therapist topics are directed to exercise and activity education. Planning and preparing the patient for a Home Exercise Program should begin with the first therapeutic session.

Education Topic Exercise Topic One Goal Setting & Health History Evaluation & Start Exercise

Program

Two Reducing Modifiable Risk Factors

Introduction to Exercise is Medicine

Three Understanding Heart Medications

Using the 6 Minute Walk Test & Functional Goal Setting

Four Signs & Symptoms of Exacerbation

SOAP Notes & Personal Assessment

Five Understanding Cholesterol Warming Up Properly Six Signs of a Heart Attack Aerobic Exercise Seven Five-Finger-Fly-By Weight Training Eight Breathing Techniques &

Conservation of Energy Tracking Your Progress

Nine The Value of Sleep The Value of the Cool Down Ten Sleep Deprivation & Stress

Reduction Principles of Exercise &

Preparing for the HEP

Early Warning Signs of an Exacerbation Early detection of exacerbation can prevent or interrupt a serious bout of illness and or a hospital admission. A change or increase in the symptoms you often have may be the only early warning sign. You may notice one or more of the following:

1. Weight gain of 3 pounds in one day or 5 pounds in one week 2. Difficulty breathing/shortness of breath 3. Wheezing, coughing, coughing up blood 4. Feeling faint or dizzy 5. Increasing fatigue with no change in your activities 6. Waking from sleep with breathlessness 7. Swelling or pain in the abdomen 8. Loss of appetite 9. Chest pain 10. Fast or irregular heart beat 11. Swelling in legs or feet 12. Increased difficulty sleeping

If the patient reports any of these symptoms record them on the SOAP notes for the day, and instruct the patient to call their healthcare provider.


Five-Finger Fly-By Assessment

1 Body Position Tripod & Pillows

2 Rate of Respiration (1,2,3)Word Distress

3 Type of Cough Productive

4 Skin Color or Condition Central-Pulmonary Peripheral-Cardiac Central cyanosis is pulmonary dysfunction, tongue or lips. Peripheral cyanosis is cardiac dysfunction, nose or ears. Cyanosis is blue skin.

5 Mental Status Change


Exacerbation, Distress Interventions

Body Positioning: Severe distress. SOB SCALE 7-10

Excessive accessory muscle use. Tripod body position. The patient is unable to breathe unless maintaining a sitting position.

Orthopnea The number of pillows a patient uses to rest comfortably is another indicator of respiratory. Note whether the patient uses one-, two-, three-, or four-pillows to rest. An increase in the number of pillows to rest indicates an increase in dyspnea.

Interventions

1. Administer oxygen to keep oxygen saturation at 88% or higher. 2. Encourage the patient to employ energy conservation efforts. 3. Encourage the patient to employ more efficient breathing techniques.

Accessory muscle use

Employing accessory muscles to improve oxygenation can drain valuable energy reserves. Assisting the patient in using available resources effectively may decrease the possibility of exacerbation.

Interventions

1. Encourage pursed-lip breathing to slow rapid respiration and reduce collapse of airways during exhalation. See Breathing Retraining procedure.

2. Sit patient at the edge of the bed with arms folded and resting on a bedside table. This will promote expansion of the lungs and assist the accessory muscles to perform more efficiently.

3. If needed, encourage proper diaphragmatic breathing by pushing in on abdomen during exhalation. The belly should expand outward with inspiration.

4. Place hands on the trapezius muscles to encourage patient to drop the shoulders and expand the lungs in the correct direction for more efficient use.


Rate of Respirations: Severe distress. SOB SCALE 7-10.

This level is indicated if the patient can only speak a few words without a pause. This is identified as “two-word” or “three-word” distress. A change from a rapid rate to a slow rate in a patient with respiratory distress suggests extreme fatigue and the possibility of respiratory arrest.

Interventions

1. Administer oxygen to keep oxygen saturation at 88% or higher. 2. Encourage the patient to employ energy conservation efforts. If breathing

effort does not return to normal perform a more focused assessment to determine status of possible exacerbation.

3. Encourage the patient to employ more efficient breathing techniques.

Type of Cough: Ineffective cough, Severe distress. SOB SCALE 7-10.

The patient lies in bed with poor intake of air resulting in small ineffective coughs. The airway is not cleared and the patient begins to appear fatigued, and has increasing anxiety.

Interventions

1. Administer oxygen to keep oxygen saturation at 88% or higher. Humidify air if more than three liters per minute are administered.

2. Ensure adequate fluid intake of 2 to 3 liters per day to liquefy secretions. 3. Staged breathing.

i. The patient should assume a sitting position, or the head of the bed should be raised to 45 degrees, with head slightly flexed, shoulders relaxed, knee’s flexed, feet on the floor, if possible, and forearms supported by a pillow. The patient then drops the head and bends forward while using slow, pursed-lip breathing to exhale. Sitting up again, the patient uses diaphragmatic breathing to inhale slowly and deeply. Repeating this breathing pattern three to four times should facilitate mobilization of secretions.

4. Huff coughing. i. Before initiating a cough, the patient should take a deep abdominal breath,

bend slightly forward, and then huff cough (cough three to four times on exhalation). The patient may need to splint the thorax or abdomen to achieve a maximum cough.


Skin color or condition: Cyanosis. Severe distress. SOB SCALE 7-10.

Peripheral cyanosis is associated with cardiac dysfunction. Peripheral cyanosis is noted by a bluish or purplish tinge at the extremities or in the nose or ears. When assessing capillary refill time, there is no blanching of the nail bed. Central cyanosis is more closely associated with pulmonary function. Central cyanosis is noted by a bluish or purplish tinge to the central areas such as the tongue, conjunctivae, or inner surface of the lips. The nail beds may appear cyanotic, but blanch under pressure and refill time is normal. Pallor, mottled, or glossy skin indicates chronic decreased arterial perfusion.

Interventions

1. Administer oxygen to keep oxygen saturation at 88% or higher. 2. Encourage the patient to employ energy conservation efforts. If breathing

effort does not return to normal perform a more focused assessment to determine status of possible exacerbation.

3. Encourage the patient to employ more efficient breathing techniques, (see Breathing Retraining).

4. If peripheral cyanosis is evident transport the patient to the nearest Emergency Department and contact the physician.

Mental Status: Mild to severe. Severe distress. SOB SCALE 7-10.

Any changes in mental status such as agitation, combative behavior, confusion, or decreased level of consciousness require immediate intervention because this change may indicate the onset of rapid deterioration.

Interventions

1. Administer oxygen to keep oxygen saturation at 88% or higher. 2. Encourage the patient to employ energy conservation efforts, (see Energy

Conservation). 3. Encourage the patient to employ more efficient breathing techniques, (see

Breathing Retraining). 4. If mental status does not improve or continues to deteriorate, transport the

patient to the nearest Emergency Department and contact the physician.


Energy Conservation

Principle Energy conservation consists of tasks that are utilized to minimize energy expenditure in the patient with low or no reserves for maintaining basic life support. Conservation methods can be used with patients who struggle with daily tasks due to a chronic condition such as COPD or CHF. Methods can be used when a patient is unable to breathe within normal limits for that patient, and is using alternative breathing techniques that will further drain reserves and lead to distress or exacerbation.

Purpose Rehabilitation and nursing personnel can assist the patient in performing energy conservation tasks to relieve expenditure of reserves when a patient is working hard to breathe. Assisting the patient to conserve energy will bring control back to the patient, prevent exacerbation, and diminish the need for emergency care.

Procedure

Activity intolerance Decreased tolerance is evident when a patient is unable to complete ADL’s without assistance.

Interventions

1. Assist patients to avoid excessive tiring by combining activities when possible to shorten time involved to complete tasks.

2. Locate needed items for personal grooming within easy reach such as on a bedside table, to avoid standing for long periods of time.

3. Stop activities or exercise that produce excessive shortness of breath or tachycardia.

4. Allow for adequate rest periods between activities. 5. Make use of comfort measures that promote rest, such as massage,

encouraging personal items of comfort, changing locations away from drafts, improving lighting, etc.

6. Teach the patient to rate fatigue level on a scale of 0-10. See Modified 10 Point Borg Scale.

7. Save large tasks for when the patient has a low level of fatigue such as a score of 0-2.

8. Small tasks can be accomplished with monitoring during medium levels of fatigue such as from 3-6.

9. For greater fatigue levels rating 7 or higher, provide rest opportunities and monitor for potential breathing difficulties (see Five-Finger Fly-By Assessment and Exacerbation Interventions).

10. Continually identify priorities and eliminate non-essential activities. Anxiety and irritability


Low oxygen levels can cause a patient to become anxious and/or irritable. The change in disposition from calm to irritable increases energy expenditure and can lead to distress.

Interventions

1. Make an effort to reduce anxiety and irritability that can drain reserves. 2. Reduce stressors and respond promptly to patient’s concerns. 3. Accept irritability without provoking further aggressive responses. 4. Provide appropriate encouragement for progress.

Altered Body Positioning while effective for mild or moderate respiratory distress, tripod positions are not encouraged for severe respiratory distress. When the patient has to support the body in an upright position using arm strength, fatigue will occur quickly and the patient will lose valuable energy needed for basic survival.

Interventions Use a High Fowler’s position or dangle at the bedside with arms folded across a bedside table. Use of these positions will decrease the amount of work it takes to stay upright with the chest expanded for better lung efficiency.

Altered secretion clearance the elderly, and those with chronic respiratory conditions, have decreased ability to mobilize secretions. This can lead to infection and can quickly tire a person already struggling to breathe. Interventions Energy conservation methods can be applied to coughing, called stage-controlled coughing, (see Exacerbation Interventions). Teach the patient to use a huff-cough method, by huffing several times with exhalation to promote secretion movement and then one strong cough. (See Exacerbation Interventions and Breathing Retraining procedures for details.)

References Carpenito, L.J., (2002), Handbook of Nursing Diagnosis and Nursing Diagnosis, Application to Clinical Practice, J.B. Lippincott Co. Lewis, S.M., Heitkemper, M.M., Dirksen, S.R., (2004), Medical Surgical Nursing, Mosby Co. Linton, A. D., Matteson, Maebius, N. K., (2000), Nursing Care of Adults, W. B. Saunders Co.


Relaxation and Stress Management Principle Relaxation and stress management will help increase the quality of life. Stress can have negative effects on the body, such as decreased energy, hypertension, blood sugar imbalances, and impaired cognitive function. Purpose The purpose of this module is to help educate and incorporate stress and relaxation techniques into our patient’s lives. Procedure The word stress is derived from the Latin work stringer which means to “draw tight.” Long term or prolonged stress is a serious threat to a person’s emotional and physical health. As stress increases or the number of stressors increase a person’s ability to effectively adapt is decreases. Stress can be defined as any type of change that causes physical, emotional or psychological strain. Stress causes the body to release a hormone called cortisol. Prolonged high levels of cortisol can lead to heart disease and other health problems. Cortisol is an important hormone in the body, secreted by the adrenal glands and is involved in the following functions:

• Glucose metabolism • Regulation of blood pressure • Insulin release for blood sugar maintenance • Immune function • Inflammatory response

Cortisol normally is present in the body at higher levels in the morning and at its lowest at night. Although stress isn’t the only reason that cortisol is secreted into the bloodstream, it is termed “the stress hormone” because it’s also secreted in higher levels during the body’s ‘fight or flight’ response to stress. Cortisol is accountable for several stress-related changes in the body. While cortisol is important and a helpful part of the body’s response to stress, it’s important that the body’s relaxation response be activated so the body’s functions can return to homeostasis. Higher and more prolonged levels of cortisol in the bloodstream have been shown to have negative effects, such as:

• Impaired cognitive performance • Suppressed thyroid function • Blood sugar imbalances such as hyperglycemia • Decreased bone density • Decrease in muscle tissue • Higher blood pressure

Lowered immunity and inflammatory responses in the body


To keep cortisol levels healthy and under control, the body’s relaxation response should be activated after the fight or flight response occurs. You can learn to relax your body with various stress management techniques, and you can encourage lifestyle changes in order to keep the body from reacting to stress in the first place. The following have been found by many to be very helpful in relaxing the body and mind, aiding the body in maintaining healthy cortisol levels:

• Guided Imagery • Self-Hypnosis • Exercise • Yoga • Listening to Music • Breathing Exercises • Meditation • Anti-anxiety Medications

Relaxation is a form of control. Cortisol secretion varies among individuals. Studies have shown that people who secrete higher levels of cortisol in response to stress also tend to eat more food, and food that is higher in carbohydrates than people who secrete less cortisol. If you’re more sensitive to stress, it’s especially important for you to learn stress management techniques and maintain a low-stress lifestyle. References Linton, D. K., Matteson, M. A. & Maebuis, N. K. (2000). Introductory Nursing Care of Adults. (2nd Ed.). W.B. Saunders Company: Philadelphia. Lewis, S. K., Heitkemper, M. M. & Dirkesen, S.R. (2004). Medical Surgical Nursing. Assessment and Management of Clinical Problems.(6th ed.). Mosby, INC. St. Louis. Mountain Land Rehabilitation. (1996). Physical COPD Rehabilitation. Aspen Publishers Inc.


General Dietary Guidelines for Heart Failure Patients Eating healthy is necessary to improve your heart failure. Eating healthy often means making changes in your current eating habits. A registered dietitian can provide in-depth personalized nutrition education, tailor these general guidelines to meet your needs, and help you implement a personal action plan.

Here are some basic guidelines that will help you get started eating healthy.

Control the sodium in your diet. Decreasing the total amount of sodium you consume to no more than 2,000 mg (2 grams) per day is one of the most important ways to manage heart failure.

Learn to read food labels. Use the label information on food packages to help you to make the best low-sodium selections.

Eat a variety of foods to get all the nutrients you need.

Eat foods high in potassium. As advised by your doctor, eat foods that are high in potassium such as: bananas; strawberries; oranges, other citrus fruits and citrus juices; cantaloupe; spinach; potatoes; dried fruits (such as prunes, dates and raisins); tomatoes; squash; avocados; broccoli; pinto beans; dry beans or peas; nuts and whole grains. Your potassium levels may drop if you are taking diuretics (also called "water pills") such as Lasix. Learn the signs of low potassium, such as fatigue, weakness, severe thirst, excessive urination, and heartbeat changes. Call your doctor if you notice these signs.

Include high-fiber foods in your diet. Fiber is the indigestible part of plant food that helps move food along the digestive tract, better controls blood glucose levels and may reduce the level of cholesterol in the blood. Vegetables, cooked dried peas and beans (legumes), whole-grain foods, bran and fresh fruit are high in fiber. The goal for everyone is to consume 25 to 35 grams of fiber per day.

Carefully follow your fluid management guidelines. Reduce your fluid intake if you have become more short of breath or notice swelling. General rule: limit fluids to 8 cups or less per day (which is equal to 64 ounces or less, or 2 quarts or less).

Maintain a healthy body weight. This includes losing weight if you are overweight. Limit your total daily calories, follow a low-fat diet and exercise regularly to achieve or maintain your ideal body weight.

Reduce alcohol consumption. Because alcohol can affect your heart rate and worsen your heart failure, your doctor may tell you to avoid or limit alcoholic beverages. Alcohol may also

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interact with the medications you are taking. Ask your doctor for specific guidelines regarding alcohol.

Food Labels Nutrition labels and an ingredient list are required on most foods so you can make the best selection for a healthy lifestyle. If you have trouble reading the food label, make an appointment to meet with a registered dietitian. He or she can review the label with you and help clear up any confusion.


Heart Failure Medications Principle

Patients with Congestive Heart Failure (CHF), or that have undergone Coronary Artery Bypass Graft (CABG) receive an array of medications to improve life expectancy. Dosage and types of medications may be adjusted depending upon the patient’s response to the medication. Expected outcomes and side effects should be understood prior to administering any medication. The type and dose of medications may change with infection, disease, stress, side effects or other factors. Observing and reporting response to medications increases the ability to determine effectiveness. Purpose

This procedure will identify common medications and their actions that are prescribed for the CHF and/or CABG patient. There are eight categories of medications that are commonly prescribed for CHF and CABG. Types and dosages may require adjustments to maintain or improve symptom control and improve outcomes. Accurate documentation and reporting of poor affect, or adverse side effects will enable physicians to prescribe medications according to the patient’s condition and needs. Medications are presented in categories with expected outcomes and examples. See the quick reference chart attached to the procedure for possible side effects. Procedure I. Medication type: Angiotensin converting enzyme (ACE) inhibitors. ACE inhibitors are a type of vasodilator that dilates the blood vessels to improve the amount of blood the heart pumps. ACE inhibitors block the effect of the renin-angiotensin-aldosterone system, which is thought to play a powerful role in heart failure. By preventing the formation of angiotensin II (an artery constricting substance), blood vessels widen and blood pressure drops, decreasing the workload of the heart.

ACE inhibitors are critical in the treatment of heart failure when systolic dysfunction is present. Systolic dysfunction occurs when the heart muscle doesn’t contract with enough force, so there is not enough oxygen-rich blood to be pumped throughout the body. ACE inhibitors may also be prescribed for the treatment of diastolic dysfunction; this occurs when the heart contracts normally, but the ventricle doesn’t relax properly so less blood enters the heart.

ACE inhibitors are now considered the first-choice treatment and are the cornerstone of therapy. Studies have shown that ACE inhibitors have been proven to significantly prolong the lives of people with heart failure by slowing the progression of heart failure and improving heart muscle function. If at all possible, every patient should be given ACE Inhibitors in combination with Beta Blockers for improvement of left ventricular function and prolongation of life.

A. Examples of ACE inhibitors are: 1. captopril (Capoten) 2. lisinopril (Prinivil, Zestril) 3. fosinopril (Monopril) 4. quinapril (Accupril) 5. trandolapril (Mavik) 6. enalapril (Vasotec) 7. benazapril (Lotensin) 8. ramipril (Altace)


9. perindopril (Aceon) 10. moexipril (Univasc)

B. Special Considerations: 1. These medications should be taken on an empty stomach one hour before meals. 2. Monitor blood pressure and kidney function while taking Ace inhibitors. 3. Patients taking Ace inhibitors should not use salt substitutes: they contain potassium and Ace inhibitors cause the body to retain potassium. 4. Over the counter non-steroidal anti-inflammatory medications and aspirin may cause the body to retain sodium and potassium, and decrease the effect of an ACE inhibitor.

C. Adverse Reactions: 1. Red itchy skin rash 2. Dizziness, lightheadedness, or fainting 3. Salty or metallic taste, decreased ability to taste 4. Cough 5. Sore throat; fever; mouth sores; unusual bruising, palpitations, chest pain, swelling in extremities 6. Hyperkalemia 7. Dehydration

II. Medication type: Angiotensin II receptor blocker (ARB). ARBs are used to decrease blood pressure in people with heart failure. Rather than lowering levels of angiotensin II (as ACE inhibitors do), angiotensin II receptor blockers prevent this chemical from working on the heart and blood vessels, which keeps blood pressure from rising. ARBs also prevent the fluid retention and shortness of breath that can accompany heart failure. ARBs are generally prescribed only when ACE inhibitors cannot be tolerated.

A. Examples of ARBs are: 1. losartan (Cozaar) 2. valsartan (Diovan) 3. irbesartan (Avapro) 4. candesartan (Atacand) 5. eprosartan mesylate (Teveten) 6. telemisartan (Micardis)

B. Special considerations: 1. Monitor blood pressure and kidney function of patients taking ARBs.

C. Adverse Reactions: 1. Dizziness, lightheadedness, or fainting when getting out of bed or rising from a chair. 2. Diarrhea, muscle cramps or weakness 3. Insomnia 4. Sinusitis or upper respiratory infection 5. Confusion 6. Dehydration

III. Medication type: Antiarrhythmics. Antiarrhythmics control irregular heartbeats and maintain a normal heart rate and rhythm.

A. Examples of antiarrhythmics are: 1. amiodarone (Cordarone) 2. disopyramide phosphate (Norpace)


3. procainamide (Procan, Pronestyl) 4. propafenone (Rhythmol) 5. quinadine sulfate (Quinidex) 6. sotalol (Betapace) 7. tocainide HCl (Tonocard)

B. Special Considerations: 1. These drugs are contraindicated in patients with second or third degree heart block. 2. Lidocaine is contraindicated in patients with CHF.

C. Adverse Reactions: 1. Dizziness, headache, hypotension 2. Blurred vision 3. Bradycardia 4. Palpitations 5. Nausea, vomiting, constipation 6. Hypotension 7. Photosensitivity 8. Ringing of ears, hearing loss

IV. Medication type: Anticoagulants and Platelet inhibitors. A. Anticoagulants are used to prevent the formation and extension of blood clots. Anticoagulants increase the time it takes for blood to clot. They are often used to reduce the risk of strokes and heart attacks that occur when blood clots get stuck in small blood vessels. Initial anticoagulation therapy is usually begun with heparin because of its rapid onset of action. Warfarin is used for maintenance therapy and takes several days to reach a therapeutic effect. Warfarin is the oral anticoagulant most commonly used for patients requiring long-term anticoagulation therapy. Warfarin interferes with the manufacturing of vitamin K dependent clotting factors by the liver. This results in the depletion of prothrombin clotting factors so PT and INR need to be monitored often to reduce risk of severe bleeding. Warfarin is used for prevention and treatment of deep vein thrombosis, treatment of atrial fibrillation, prevention and treatment of pulmonary embolus, as part of treatment of coronary occlusion, and prevention of thrombus formation after valve replacement.

1. Examples of anticoagulants are: a) enoxaparin (Lovenox) b) Heparin sodium c) warfarin (Coumadin)

2. Special Considerations: a) Monitor PT and INR for Coumadin and PTT for heparin use

3. Adverse Reactions: a) Severe bleeding b) Nausea, vomiting, diarrhea c) Skin rash d) Abdominal cramping

B. Platelet inhibitors inhibit platelets from sticking together therefore reducing the risk of blood clots.

1. Examples of platelet inhibitors are: a) aspirin (Ecotrin, Bayer) b) clopidogril bisulfate (Plavix) c) dipyramidamole (Persantine)


d) ticlopidine (ticlid) V. Medication type: Antihypertensives. Antihypertensives are commonly used to treat high blood pressure by relaxing and widening (vasodilating) blood vessels.

A. Examples of Antihypertensives are: 1. clonidine HCl (Catapress, Dixarit) 2. doxazosin mesylate (Cardura) 3. guanabenz acetate (Wytensin) 4. methyldopa (Aldomet) 5. phenoxybenzamine (Dibenzyline) 6. prazosin HCl (Minipress) 7. terazosin HCl (Hytrin)

B. Special considerations: 1. Monitor blood pressure before administering medication

C. Adverse Reactions: 1. Postural hypotension and Orthostatic hypotension 2. Dry mouth, 3. Sedation, weakness, headache 4. Arrhythmias 5. Bradycardia 6. Nausea, vomiting 7. Dyspnea, palpitations, chest pain 8. Constipation

VI. Medication type: Beta-Blockers. Beta Blockers are commonly prescribed for the treatment of angina, hypertension, and irregular heart rhythms. In CHF, the heart tries to compensate for its weakened pumping action by beating faster, which puts more strain on the heart. Beta-blockers reduce the heart’s tendency to beat faster by blocking beta-receptor cells on the heart, reducing the effects of chemical messengers that increase heart rate. This allows the heart to maintain a slower rate and pressure. Over time, beta-blockers improve the heart’s pumping ability. Since beta-blockers reduce the heart rate, they also decrease the amount of oxygen that circulates through the body. When patients take these, they may become less able to handle strenuous physical activity. They might feel nauseated and weak after lifting or walking long distances. Studies have shown that certain beta-blockers may have significant benefits for heart failure patients, and in fact may be responsible for a dramatic drop in mortality rates. Beta-blockers should be used in combination ACE inhibitors, diuretics, or both to obtain optimal treatment.

A. Examples of Beta blockers are: 1. acebutolol HCl (Sectral) 2. atenolol (Tenormin) 3. betaxolol (Kerlone) 4. bisoprolol (Zebeta) 5. carvedilol (Coreg) 6. dofetilide (Tikosyn) 7. labetalol (Normodyne, Trandate) 8. metoprolol (Lopressor, Toprol-XL) 9. nadolol (Corgard) 10. propranalol HCl (Inderal) 11. sotalol (Betapace)

B. Special considerations:


1. These medications should be taken with meals or right after meals. Food delays how fast beta-blockers are absorbed and should reduce side effects. 2. Beta-blockers should not be used if a patient has severe lung congestion, hypotension, or bradycardia. The doctor should set guidelines for holding the medication if pulse or blood pressure drop below set parameters.

C. Adverse Reactions: 1. Dizziness or lightheadedness. 2. Tiredness or insomnia 3. Sudden weight gain 4. Increased shortness of breath, wheezing, difficulty breathing 5. Chest pain

VII. Medication type: Calcium Channel Blockers. Calcium Channel Blockers produce their antiarrhythmic effect by inhibiting the movement of calcium through channels across the myocardial cell membranes and vascular smooth muscle, which discourages smaller vessels from narrowing and going into spasm. Calcium channel blockers also relax blood vessels and increase the supply of blood and oxygen to the heart, while reducing its workload. Calcium channel blockers should not be used for patients who have heart failure due to systolic dysfunction.

A. Examples of Calcium channel blockers are: 1. amlodipine (Norvasc) 2. diltiazem HCl (Cardizem, Dilacor, Tiazac) 3. felodipine (Plendil) 4. nicardipine HCl (Cardene) 5. nifedipine (Adalat, Procardia) 6. verapamil HCl ( Calan, Covera, Isoptin)

B. Special Considerations: 1. This medication should be given with food or milk. 2. Patients should not eat grapefruit or drink grapefruit juice while taking calcium channel blockers 3. Alcohol interferes with the effects of calcium channel blockers and increases the side effects.

C. Adverse Reactions: 1. Drowsiness, increased appetite 2. Weight gain 3. Breathing difficulty, wheezing 4. Irregular or slow heart beat 5. Skin rash

VIII. Medication type: Diuretics. Diuretics act on the kidneys to remove more sodium and water from the bloodstream than usual and convert it into urine. This helps to relieve the heart’s workload by decreasing the amount of fluid to be pumped throughout the body. Diuretics also decrease the buildup of fluid in the lungs and tissues throughout the body. Three primary types of diuretics exist:

A. Potassium-Sparing agents. Potassium-sparing diuretics may work in two ways. They can depress the reabsorption of sodium in the kidney tubules, therefore increasing sodium and water excretion and depress the excretion of potassium. Potassium sparing diuretics such as Aldactone, antagonizes the action of aldosterone (a hormone produced by the adrenal cortex that enhances the reabsorbtion of sodium in the distal convoluted tubule of the kidney). When aldosterone is blocked, sodium and water are secreted, but potassium remains.


1. Examples of potassium-sparing diuretics are: a) spironolactone(aldactone) b) amiloride (Midamor) c) triamterene (Dyrenium)

B. Thiazides. Thiazides inhibit the reabsorption of sodium and chloride ions in the ascending portion of the loop of Henle and distal tubule of the nephron. This action results in the excretion of sodium, chloride, and water. Thiazides often serve as the basis for high blood pressure treatment.

1. Examples of thiazides are: a) chlorothiazide (Diuril) b) chlorthalidone (Hygroton) c) indapamide (Loszol) d) hydrochlorothiazide (Esidrix, HydroDiuril)

C. Loop Diuretics. Loop diuretics increase the excretion of sodium and chloride by inhibiting reabsorption of these ions in the distal and proximal tubules and in the loop of Henle. It is important to monitor for dehydration and potassium loss. Loop diuretics are generally used for severe heart failure, especially when kidney function is impaired.

1. Examples of loop diuretics are: a) bumetanide (Bumex) b) furosemide (Lasix) c) ethacrynic acid (Edecrin)

2. Special Considerations: a) Monitor electrolytes and kidney function b) Weigh patients taking diuretics daily and notify doctor if patient gains 2 pounds in one day or 5 pounds in one week c) Alcohol and sleep aids may increase the side effects of diuretics

3. Adverse Reactions: a) Extreme tiredness or weakness b) Muscle cramps c) Dehydration and thirst d) Dizziness, lightheadedness e) Ringing in ears, f) Fever, sore throat g) Rapid and excessive weight loss

IX. Medication type: Digitalis. Digitalis is an inotropic drug that increases the strength of the heart’s contraction, decreases the heart size, reduces arrhythmias, & improves exercise tolerance. Digitalis is often used in heart failure patients with atrial fibrillation. Digitalis may be harmful to patients with right-sided heart failure. Patients who stop taking Digoxin after using it in combination with ACE inhibitors are at risk for worsening heart failure.

1. An example of Digitalis is: a) digoxin (Lanoxin)

2. Special Considerations: a) Try to administer digoxin to patient at the same time every day b) Monitor patient’s pulse prior to administering and hold if pulse is lower than recommended by physician.

3. Adverse reactions: a) Nausea, vomiting, b) Changes in vision, photosensitivity, blurred vision c) Headache, confusion, fatigue, muscle weakness


d) Bradycardia X. Medication type: Nitrates. Nitrates are vasodilators that open the veins and arteries. Nitrates increase the supply of blood and oxygen to the heart while reducing the blood pressure that the heart has to pump against.

A. Examples of Nitrates are: 1. oral nitroglycerine (Dilatrate-SR, Imdur, ISMO, Isordil, Monoket) 2. nitroglycerine ointment (Nitro-Bid Ointment, Nitrol) 3. Nitroglycerine skin patches (Deponit, Minitran, Nitro-Dur, Transderm-Nitro) 4. Nitroglycerine sublingual tablets (Isordil, Nitrostat, Nitrogard, Sorbitrate)

B. Special Considerations: 1. Monitor blood pressure before administering medication

C. Adverse reactions: 1. Headache, loss of appetite, diarrhea 2. Irregular heart rate 3. Numbness or tingling of the fingers or toes 4. Weight gain, swelling of ankles 5. Fever, joint pain, sore throat, skin rash

References

General Medications Guidelines. (2004). Retrieved October 19, 2005, from http://www.cchs.net/health/health-info/docs/1800/1821.asp?index=8120

Heart Failure Medications. (2004). Retrieved October 19, 2005, from http://www.cchs.net/health/health-info/docs/1800/1822.asp?index=8122

Medications Commonly Used to Treat Heart Failure. (2005). Retrieved October 19, 2005, from http://americanheart.org/presenter.jhtml?identifier=118

Roach, S.S, & Scherer, J. C. (2000). Introductory clinical pharmacology 6th ed. New York: Lippincott.


Exercise Prescription and Progression

Principle In patients with COPD, disability is primarily a result of progressive deconditioning. As the disease progresses, limited ventilatory capacity makes exertion unpleasant and leads to an increasingly sedentary lifestyle. Shortness of breath (breathlessness) and exercise intolerance are the most incapacitating symptoms patients develop. A counter-measure to progressive functional decline in patients with COPD is exercise training.

For cancer patients undergoing chemotherapy or radiation treatments, moderate-intensity aerobic exercise training should be performed to maintain endurance, strength, and function. The goal of exercise at this time is to maintain function and prevent the loss of endurance and strength. Cancer treatments exhaust physical and emotional reserves, so the goal of moderate-intensity aerobic exercise training is to maintain these resources. Persons undergoing intensive chemotherapy or radiation may benefit from routine physical therapy, occupational therapy, and ambulation, as well as strength and flexibility exercises. These people are easily fatigued but appear to benefit from moderate-intensity aerobic activities. Moderate-intensity aerobic exercise during this time improves strength and endurance and assists in countering signs and symptoms associated with the cancer and its treatments, such as fatigue and nausea. Moderate-intensity aerobic exercise training may also offer profound psychological benefits for persons in cancer therapy, particularly with regard to depression. Additionally, special modifications in the type of exercise performed may be required if orthopedic limitations, such as range of motion deficits, occur as a result of cancer surgery or cancer treatments.

For “Lung Cancer” patients, irreversible destruction of the lungs is the hallmark of COPD which accompanies or precedes lung cancer. Significant ventilation-perfusion mismatch occurs, impairing maximal gas exchange. Additionally, the work of breathing is increased secondary to increased airway resistance and hyperinflation. Increased muscle mass and a better vascular system will help improve peripheral extraction of oxygen, which will lead to better physical activity. Evaluate the patients need for bronchodilator therapy, mucolytics or supplemental oxygen during exercise. Therapists will find that frequent follow-up, encouragement and reassurance are integral to the success of the rehabilitation process. Progress in exercise tolerance may be minimal in this population, however diligent participation can reduce respiratory symptoms, reverse anxiety and depression, and increase the ability to perform activities of daily living. Purpose It has clearly been demonstrated that exercise is beneficial for patients who have COPD. Structured exercise protocols and less demanding protocols alike produced significant improvement in exercise tolerance, decreased minute ventilation and improved dyspnea. Although exercise may not lengthen life expectancy, it has been shown to improve the quality of life and therefore should be an integral adjunctive treatment for all pulmonary patients. Components of an exercise prescription An exercise prescription generally includes the following specific recommendations:

• Type of exercise or activity (i.e. strength training, walking, cycling, swimming, chopping wood, fishing, showering, cleaning house)


• Specific workloads (i.e. MPH, MET, FPM-walking speed, Kcal/min, ) • Duration-(variable) and frequency-(fixed:3 X Wk) of the activity or exercise session • Intensity guidelines – Target heart rate (THR) range and estimated rate of (RPE),

(SOBr), (Fatigue). Precautions or contraindications regarding oxygen saturation such as: Keep oxygen saturation > 88% Sp02 at all times during the therapeutic exercise session or an orthopedic, cardiac or co-morbidity concern. The 6 Minute Walk Test (6MWT) is used to establish the exercise prescription of the patient in both the in & out patient setting. Many COPD patients will not likely complete the full (6MWT). However, the information collected from the test is valuable. Special attention should be paid to Oxygen Saturation (%Sp02), Ratings of Perceived Exertion (RPE), Dyspnea (SOBr), Heart Rate (HR), and Fraction of Inspired Oxygen or Liters Per Minute (Fi02/ LPM) when identifying exercise intensity. Subjective V. Objective Measurements. Subjective measurements are (RPE), (SOBr) (Fatigue) Objective measurements are (HR), (%Sp02), (Fi02/LPM). Low stress threshold V. High stress threshold. Low stress threshold is categorized by high subjective ratings with low objective measurements. High stress threshold is categorized by low subjective ratings with high objective measurements. If the Heart Rate remains low 80 to 100 and RPR-FT/SOBr are high between 6 and 7, one may conclude that the patient has a lower stress threshold or deconditioned functional capacity and is appropriate to start at a lower intensity level of RPR/SOBr of 2 to 3. Conversely, if the patient achieves a Heart Rate of 100 to 120 and reports an RPE-FT/SOBr of 3 to 4, this patient has a higher stress threshold and is appropriate to start at a moderate intensity level of RPE-FT/SOBr of 3 to 4. Procedure Sure and safe progression is consistently achieved in the COPD diseased population with incremental increases in prescriptive exercise intensity, type, and duration. Start Low and Go Slow

Moderate Intensity Low Intensity Exercise to promote functional independence Activity to maintain function or prevent deconditioning

Accumulate 30 minutes three to five days per week. RPE 4-6 on 10 point scale.

Accumulate 10 minutes of activity that is well-tolerated three times a week and gradually increase exercise time and intensity, RPE 2-4 on 10 point scale.


General Aerobic Exercise Recommendations

Parameter Recommendation and Comment Mode

Most exercises involving large muscle groups are appropriate, but walking, cycling, and NuStep, are especially recommended. The key is to modify exercise mode based on acute or chronic treatment effects of pulmonary exacerbations.

Frequency At least 3 times/wk, but daily exercise may be preferable for severely deconditioned inpatients performing lighter-intensity and shorter-duration exercises.

Intensity Moderate intensity, depending on patient's current fitness level and severity of side effects from treatments. Guidelines include 50%-75% VO2max or HRreserve, 60%-70% HRmax, or an RPE of 4-6. HRreserve is the best guideline if HRmax is estimated rather than measured.*

Duration At least 20-30 min of continuous activity, but this goal may require multiple intermittent shorter bouts (eg, 5-10 min) with rest intervals in deconditioned patients or those experiencing severe side effects of treatment.

Progression Initial progression should be in frequency and duration. Only when these goals are met should intensity be increased. Progression should be slower and more gradual for deconditioned patients or those with severe side effects of treatment.


Gathering information from the 6MWT The amount of time completed on the 6 Minute Walk Test (6MWT) sets the starting point for exercise duration for the first session and to progress through interval training onto continuous exercise with multiple types of exercise equipment as an exercise progression methodology. The patient completed 3 minutes on the (6MWT), this patient starts with an exercise duration of 3 minutes the first session, then as soon as the patient can tolerate it, work to perform 3 minutes of low intensity work, with a 3 minute rest period followed by 3 more minutes of exercise, this is “interval training” and is a standard starting method for patients with low functional levels. Below is an example of incremental exercise progression. Each patient will progress differently depending on type, stage and grade of disease or exacerbation; therefore, therapist must individualize prescriptive exercise based on the individual’s adaptability, resiliency, tolerance, knowledge, skills, abilities, and eagerness to perform therapeutic exercise.


Incremental Increase in Aerobic Exercise & Strength Training Session WORK REST INTERVAL WORK 50-70% - 1RM Session 1 3 MIN Tread Mill 1 x 8 Session 2 3 MIN 3:00 3 MIN 1 x 8 Session 3 3 MIN 2:30 3 MIN 1 x 8 Session 4 3 MIN 2:00 3 MIN 1 x 10 Session 5 3 MIN 1:30 3 MIN 1 x 10 Session 6 3 MIN 1:00 3 MIN 1 x 10 Session 7 3 MIN 0:30 3 MIN 1 X 12

Session 8 6 MIN End of Rest Inter 0:00 0 MIN 1 X 12

Session 9 7 MIN Tread Mill 1 X 12 Session 10 8 MIN Tread Mill 2 x 8 Session 11 6 MIN ADD: CE, NS, UBE 3 MIN 2 x 8 Session 12 6 MIN CE or NS or UBE 4 MIN 2 x 8 Session 13 7 MIN CE or NS or UBE 4 MIN 2 x 10 Session 14 7 MIN CE or NS or UBE 5 MIN 2 x 10 Session 15 7 MIN CE or NS or UBE 6 MIN 2 x 10 Session 16 7 MIN CE or NS or UBE 7 MIN 2 X 12 Session 17 8 MIN CE or NS or UBE 7 MIN 2 X 12 Session 18 8 MIN CE or NS or UBE 8 MIN 2 X 12 Session 19 9 MIN CE or NS or UBE 8 MIN 3 X 8 Session 20 9 MIN CE or NS or UBE 9 MIN 3 X 8 Session 21 10 MIN CE or NS or UBE 9 MIN 3 X 10 Session 22 10 MIN CE or NS or UBE 10 MIN 3 X 10 Session 23 11 MIN CE or NS or UBE 10 MIN 3 X 12 Session 24 11 MIN CE or NS or UBE 11 MIN 3 X 12 Legend: CE: Cycle Ergometer NS: NuStep UBE: Upper Body Ergometer


Work-Rest Ratio The Work-Rest-Ratio (WRR) as a method of interval training serves best at the beginning of the low level patients program and should follow the One-to-One (1:1) (WRR) rule, i.e., Work 3 minutes: Rest 3 minutes: Work 3 minutes. The Work-Rest-Ratio-Interval (WRRI) should decrease in 30 second increments from threptic session to therapeutic session or as the patient tolerates without fatigue hangovers. Once the (WRRI) has been closed, the therapist may add one (1) minute of exercise duration per exercise session or as the patient tolerates without fatigue hangovers. (Causing a “Fatigue Hangover” is a cardinal sin) The optimal aerobic activity segment should seek to reach the following “Best Case Scenario”. GOAL: Best Case Scenario; 15 minutes walking/treadmill, 15 minutes cycling, with 20 minutes of upper and lower extremity strength training exercises. Prescribing exercise in the chronic diseased population requires a significant amount of planning and encouragement. The exercise prescription should proceed gradually since most individuals are extremely limited in the amount of exercise tolerated secondary to deconditioning, dyspnea, exertional distress or hypersensitivity to exertion.

References United States Army Center for Health Promotion and Preventive Medicine 5158 Blackhawk Road. Aberdeen Proving Ground, Maryland 21010-5403 MAJ Robert L. Gauer, MD, FACSM LTC Francis G. O.Connor, MD, FACSM F. Edward Hébert School of Medicine Uniformed Services University of the Health Sciences Department of Family, Sports and Preventative Medicine 4301 Jones Bridge Road Bethesda, Maryland 20814 COL Willis B. Campbell, MD, Ph.D., MPH, FACSM Larry W. Laughlin, M.D., Ph.D. FCCP


Individual Therapeutic Session Principle Each therapeutic session is an opportunity to provide exercise in a controlled and monitored environment, and education that not only enhances exercise, but also improves all aspects of function. Each session will build on the previous session in both fitness and knowledge. Purpose Exercise sessions should focus on individual needs and aim to progress the patient to a higher level of functioning. Patient goals should be discussed and reviewed at various points throughout the sessions to assist in measuring progress. Documentation during each session also helps both therapists and patients measure success.

Procedure

Subjective Record subjective information that the patient reports, such how they are feeling or sleeping.

Objective Record a productive chough, or sleep disturbance such as waking up to breathe.

Measurements • HR (Heart Rate) • BP (Blood Pressure) • % spO2 • RPE/SOBr/Fatigue

Physiological Changes During Exercise

What do these measurements mean? You expect the heart rate to increase with exertion. You should also see an increase in blood pressure with exercise. Oxygen usage will increase, but the % sp O2 should remain above 88% at all times during exercise. Any sudden change in any of the baseline measurements or subjective reporting indicates a need to decrease or even stop the exercise. Monitoring changes will allow you to determine whether to increase or decrease the intensity of the therapeutic session or seek medical attention from the patient’s physician.

Aerobic Exercise

There are various modes that can be used for aerobic exercise. Ideally two modes of aerobic exercise will provide variety if the patient can tolerate the exercise duration. The treadmill is the most important mode of aerobic training as it easily translates into ADL's and functional independence.

• All aerobic exercise must begin with a 3 min warm up and conclude with a 3 min cool down at minimal loads.

• Aerobic training requires only one warm up and one cool down. Transitioning between equipment is exempt from WU & CD workloads.


• COPD patients often have balance and falls-risk issues so they must be monitored for safety while on exercise equipment. As a rule, most COPD patients will require balance and gait training to counter the lean tissue waisting that occurs from chronic corticoid steroid use.

Resistance Exercise

Resistance exercise is patient dependent; therefore, adjusting intensity, and volume should be considered based on patient needs, ability, and history.

• Resistance exercise is very important for LE & UE as it translates into ADL's.

• Resistance exercise is an emerging research focus for COPD patients as it’s revealing functional outcomes equivalent to aerobic exercise training.

• Resistance exercise progression is outlined in the following guidelines: o Sets & Reps:

1x8, 1x10, 1x12, 2x8, 2x10, 2x12, 3x8, 3x10, 3x12.

• ROM exercise may be “medically necessary”, thus, ROM therapy should be carefully attended to.

Patient Education

Exercise sessions will include education associated with your condition. Successive education will build on previous education. You will be asked to read about the benefits of exercise and proper exercise, and you will be given tips for making everyday tasks easier.

• 8 sessions should be taught and documented. • Patient education is a partnership, ask the patient to pre-read, and then

cover the section & answer questions once a week in a 15-minute lesson session.

Follow-up Complete SOAP notes and documentation.

Assessment

Document how the patient tolerated the exercise session using intensity, duration, frequency, and mode (IDFM).

Plan Document goals and/or changes for the next session using IDFM.

Measurements

Allow the patient to cool down, and then collect final measurements and compare to baseline measurements. The resting heart rate should be within 8 beats of the baseline.


SOAP NOTES

Session #

Patient Name:

Date:

Subjective: Patient feels (check one) О Good О Fair О Poor

Objective: Weight ____________,

Resting Measurements Aerobic Exercise

Start Tx End Tx Requirement Type Duration Int HR BP %

spO2 FiO2

HR HR <100 to DC

Warm up (3 Min)

BP BP <200/110

%spO2 %spO2 >88%

FiO2 FiO2 Keep % spO2 >88

Education: Notes:

Cool Down (3 Min)

RPE/DYSP/Fatigue (1-10) Strength Training

Sets (1-3) Reps (8-12) Load (lbs)

Leg Press Chest Press Overhead Press Pull Downs Rowing

Assessment:

Planning:

Therapist


Session #

Patient Name:

Date:





spO2 FiO2

HR HR <100 to DC

Warm up (3 Min)

BP BP <200/110

%spO2 %spO2 >88%


Education: Notes:

Cool Down (3 Min)




Assessment:

Planning:

Therapist


Rehabilitation GOALS Functional capacity and the writing of functional goals must relate to activities of daily living for rehabilitation outcome relevance. Goal setting must be a partnership, where the therapist and the patient work together to establish functional short-term and outcome goals. Goal setting is identifying realistic functional expectations with your patient. This process takes place during the initial evaluation and is documented on the 700/701. Each therapist needs to identify how they will reach the patients’ goals in measurable, objective, and functional terms. Ask yourself, “Are the goals measurable, objective, and functional?


Heart Failure Rehabilitation Goals Building Blocks for Functional Goals

1. pt will be independent with pursed lip breathing to prevent anxiety attacks while

maintaining blood oxygen saturations above 90 % Sp02 2. pt will be independent ambulation 400 feet in order to take the trash out. 3. pt will increase LE Strength from 3/5 to 4/5 to stand up from commode. 4. pt will increase UE strength from 2/5 to 3/5 in order to reach shower head for

adjustment. 5. pt will increase ambulation from 200 feet to 400 feet to increase pt’s walking capability

to reach the garage. 6. pt shall strengthen LE from 2/5 to 4/5 from a seated to standing position that results in

pt’s ability to navigate stairs in home. 7. pt seeks LE & UE strength increase from 1/5 to 3/5 to pick up laundry basket and set it

on table. 8. pt seeks UE strength increase from 1/5 to 2/5 to enable hair dressing, an over the head

strength requirement. 9. pt seeks an ambulation functional increase from 200 feet to 500 feet that produces the

capacity to use public transportation for grocery shipping. 10. pt shall increase walking and standing capacity from 1.5 MET to 3.0 MET in order to

clean kitchen and cook meals. 11. pt shall seek UE & LE strength and balance gains from 3/5 to 4+/5 to safely walk to and

operate the riding snow blower. 12. pt shall increase function from 1.5 MET to 2.0 MET to restore self care tasks of toileting,

bathing, & dressing. 13. pt will increase abdominal strength from 1/5 to 3/5 to support abdominal breathing

patterns for increased control of shortness of breath and oxygenation. 14. pt seeks balance increases lost to corticosteroid-induced muscle wasting to reduce falls

risk and to safely navigate stairs. 15. pt seeks strength gains lost to corticosteroid-induced muscle wasting to reduce falls risk

and stand up from chairs. 16. pt shall gain UE ROM over head from 20 degrees to 30 degrees to reach food items

from upper shelves. 17. pt shall obtain UE & LE strength gains from 1/5 to 3/5 to reduce falls & osteoporosis

fractures resulting from corticosteroid-induced bone mineral wasting. 18. pt shall increase functional capacity from 1.5 MET to 3.3 MET in order to mop kitchen

floors. 19. pt seeks a functional increase from 2.0 MET to 3.5 MET which will enable the bathing of

his dog. 20. pt seeks a functional increase from 2.0 MET to 3.8 MET which will enable him to scrub

the bathtub, his most difficult home chore.


(MET) to Functional Task Conversions 3.0 home activities; cleaning, wash car, wash windows, clean garage 3.5 home activities; mopping 3.0 home activities; cleaning, house or cabin, genera 3.5 home activities; vacuuming 3.8 home activities; scrubbing floors, on hands and knees, bathtub 3.5 home activities; standing - packing/unpacking boxes 3.0 home activities; implied walking - putting away household items 3.0 home activities; walking - light, non-cleaning shut/lock doors 3.5 home activities; standing - bathing dog, and cat –small animals 3.0 home repair; automobile repair, general 3.0 home repair; carpentry, general, workshop 3.0 home repair; painting, papering, plastering, scraping 3.0 home repair; put on and or removal of tarp 3.0 lawn and garden; riding snow blower 2.0 self care; standing - getting ready for bed, in general 2.0 self care; dressing, undressing (standing or sitting) 2.0 self care; talking and eating (standing) 2.0 self care; grooming, shaving, brushing teeth, washing hands 2.5 self care; hairstyling 2.0 self care; showering, toweling off (standing) 2.5 music playing; conducting 2.5 music playing; piano or organ 2.5 music playing; violin 2.5 home activities; multiple household tasks in general, light effort 2.5 home activities; cleaning, dusting, changing linen 2.3 home activities; wash dishes - standing 2.5 home activities; wash dishes; clearing dishes from table – walking 2.0 home activities; cooking or food preparation - general 2.5 home activities; serving food, setting table - walking or standing 2.5 home activities; cooking or food preparation – walking 2.5 home activities; feeding family pet, cat, dog, small animals 2.5 home activities; putting away groceries, carrying groceries 2.3 home activities; food shopping, standing or walking 2.3 home activities; ironing 2.0 home activities; implied standing - laundry, fold or hang clothes 2.0 home activities; making bed 2.5 home activities; watering plants 2.5 home activities; building a fire inside 2.0 home activities; standing-light (pump gas, change light bulb, etc.)


Functional Capacity, Writing Functional Goals Purpose Physical and Occupational Therapists are required to document patient outcomes on the Department of Health and Human Services Plan of Treatment, 700 & 701, etc. Human physiological outcomes at rest and during activity are well known, translating measurements (MET) allows therapists to apply scientific principles to the assessment of everyday functional capacity. The validity of metabolic equivalents (MET) and it’s relationship to functional capacity or physical activity is central to the Compendium of Physical Activities Tracking Guide. The compendium was developed for use in epidemiologic studies to standardize the assignment of MET intensities in physical activity. The compendium has been used in studies worldwide to assign intensity units MET to physical activity, and to develop innovative ways to assess energy expenditure in physical activity.

Procedure Knowing where to find MET provides the therapist with validated information for this MET to functional capacity translation method.

Most aerobic exercise equipment includes an instrument panel for test, measurement and control. This panel will be the source of MET or Kcal measurement during therapeutic exercise. Take the time to locate the MET/Kcal read out display. The conversion method consists of taking the MET data from the instrument panel just before ending steady state exercise. Use the MET value and compare it to the physical activity tracking guide to reveal equivalent “every day” functional tasks or Activities of Daily Living (ADL).


If a patient can walk on the tread mill for 15 minutes at 3.0 METs, they can reasonably perform any 3.0 MET task, listed in The Compendium of Physical Activities Tracking Guide for 15 minutes.


The Compendium of Physical Activities Tracking Guide MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 1 to 2 MET LEVEL 0.9; inactivity; quiet sleeping 1.5; home activities; reclining with baby 1.0; inactivity; lying quietly, watching television 1.0; inactivity; lying quietly, doing nothing, lying in bed awake 1.0; inactivity; sitting quietly and watching television 1.0; inactivity; sitting quietly, sitting smoking, listening to music 1.2; inactivity; standing quietly (standing in a line) 1.0; inactivity; reclining in a chair - talking or talking on phone 1.0; inactivity; reclining in a chair – reading 1.0; inactivity; meditating 1.5; lawn and garden; watering lawn or garden, standing or walking 1.5; miscellaneous; sitting - card playing, playing board games 1.8; miscellaneous; sitting - writing, desk work, typing 1.8; miscellaneous; standing - talking or talking on the phone 1.5; miscellaneous; sitting - talking or talking on the phone 1.8; miscellaneous; sitting - studying, general, including reading - writing 1.8; miscellaneous; sitting - class, note-taking or class discussion 1.8; miscellaneous; standing – reading new paper waiting for bus 1.5; miscellaneous; sitting - arts and crafts, light effort 1.8; miscellaneous; standing - arts and crafts, light effort 1.5; miscellaneous; family reunion, genealogy, sitting, talking, eating 1.8; music playing; accordion 1.5; occupation; farming, milking by machine, light effort 1.3; occupation; police, riding in a squad car (sitting) 1.5; occupation; sitting - light office work, general 1.5; occupation; sitting meetings, general, and/or with talking involved 1.5; occupation; typing, electric, manual or computer 1.0; self care; sitting on toilet 1.5; self care; bathing (sitting) 1.5; self care; eating (sitting) 1.0; self care; taking medication, sitting or standing


MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 1.0; self care; having hair or nails done by someone else, sitting 1.5; sexual activity; active, vigorous effort 1.3; sexual activity; general, moderate effort 1.0; sexual activity; passive, light effort, kissing, hugging 1.0; transportation; riding in a car or truck 1.0; transportation; riding in a bus 1.0; religious activities; sitting in church, attending a ceremony 1.5; religious activities; sitting in church, talking or singing 1.3; religious activities; sitting, reading religious materials at home 1.2; religious activities; standing in church (quietly), standing quietly 1.0; religious activities; kneeling in church/at home (praying) 1.8; religious activities; standing, talking in church 1.5; religious activities; eating at church 1.5; religious activities; typing, electric, manual, or computer 1.5; volunteer activities; sitting - meeting, general 1.5; volunteer activities; sitting - light office work, in general 1.5; volunteer activities; typing, electric, manual, or computer 2 to 3 MET LEVEL

2.5; conditioning exercise; stretching, hatha yoga 2.5; conditioning exercise; mild stretching 2.5; fishing and hunting; fishing from boat, sitting 2.0; fishing and hunting; fishing, ice, sitting 2.5; fishing and hunting; hunting, bow and arrow or crossbow 2.5; fishing and hunting; hunting, duck, wading 2.5; fishing and hunting; pistol shooting or trap shooting, standing 2.5; home activities; multiple household tasks in general, light effort 2.5; home activities; cleaning, dusting, changing linen, taking out trash 2.3; home activities; wash dishes - standing 2.5; home activities; wash dishes; clearing dishes from table – walking 2.0; home activities; cooking or food preparation - general 2.5; home activities; serving food, setting table - walking or standing 2.5; home activities; cooking or food preparation – walking MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 2.5; home activities; feeding family pet, cat, dog, small animals 2.5; home activities; putting away groceries, carrying groceries 2.3; home activities; food shopping, standing or walking 2.3; home activities; non-food shopping, standing or walking 2.3; home activities; ironing 2.0; home activities; implied standing - laundry, fold or hang clothes 2.0; home activities; making bed 2.5; home activities; watering plants 2.5; home activities; building a fire inside


2.0; home activities; standing - light (pump gas, change light bulb, etc.) 2.5; home activities; sitting-playing with children–light, only active periods 2.8; home activities; standing - playing with children – light, active periods 2.5; home activities; child care: sitting/kneeling - dressing, bathing 2.5; home activities; sit, playing with animals, light, only active periods 2.8; home activities; stand, playing with animals, light, only active periods 2.8; home activities; walk/run, playing w/animals, light, only active periods 2.5; lawn and garden; mowing lawn, riding mower 2.5; lawn and garden; walking, applying fertilizer or seeding a lawn 2.3; miscellaneous; standing - drawing (writing), casino gambling 2.0; miscellaneous; standing, with movement – miscellaneous 2.0; miscellaneous; sitting - arts and crafts, moderate effort 2.0; miscellaneous; touring/traveling/vacation involving walking and riding 2.5; miscellaneous; camping involving standing, walking, sitting 2.0; music playing; cello 2.5; music playing; conducting 2.0; music playing; flute (sitting) 2.0; music playing; horn 2.5; music playing; piano or organ 2.5; music playing; trumpet 2.5; music playing; violin 2.0; music playing; woodwind 2.0; music playing; guitar, classical, folk (sitting) 2.5; occupation; bakery, light effort 2.3; occupation; bookbinding 2.0; occupation; directing traffic (standing) MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 2.5; occupation; chambermaid, making bed (nursing) 2.5; occupation; custodial work - cleaning sink and toilet, light effort 2.5; occupation; custodial work - dusting, light effort 2.5; occupation; custodial work - vacuuming, light effort 2.0; occupation; farming, moving animals, driving, light effort 2.5; occupation; farming, driving harvester, cutting hay, open irrigation 2.5; occupation; farming, driving tractor 2.6; occupation; horse racing, walking speed 2.3; occupation; printing (standing) 2.5; occupation; police, directing traffic, shouting commands (standing) 2.0; occupation; police, driving a squad car (sitting) 2.5; occupation; shoe repair, general 2.5; occupation; sitting; moderate (riding mower/forklift, crane operation) 2.5; occupation; tailoring, cutting 2.5; occupation; tailoring, general 2.0; occupation; tailoring, hand sewing 2.5; occupation; tailoring, machine sewing 2.0; occupation; walking on job, less than 2.0 mph, very slow 2.0; self care; standing - getting ready for bed, in general 2.0; self care; dressing, undressing (standing or sitting)


2.0; self care; talking and eating (standing) 2.0; self care; grooming, shaving, brushing teeth, washing hands 2.5; self care; hairstyling 2.0; self care; showering, toweling off (standing) 2.5; sports; billiards 2.5; sports; croquet 2.5; sports; darts, wall or lawn 2.5; sports; football or baseball, playing catch 2.5; sports; horseback riding, walking 2.0; transportation; automobile or light truck (not a semi) driving 2.0; transportation; flying airplane 2.5; transportation; motor scooter, motorcycle 2.5; walking; bird watching 2.5; walking; pushing or pulling stroller with child or walking with children 2.0; walking; household walking from room to room MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 2.0; walking; walking, less than 2.0 mph, level ground, strolling, very slow 2.5; walking; walking, 2.0 mph, level, slow pace, firm surface 2.5; walking; walking from house to car or bus, from car or bus to go places 2.5; walking; walking to neighbor’s house to socialize, visit, or teach 2.8; walking; walking, 2.5 mph, downhill 2.5; water activities; boating, power 2.5; religious activities; sitting, playing an instrument at church 2.0; religious activities; standing, singing in church, active participation 2.0; religious activities; walk/stand to usher for religious purposes 2.5; religious activities; serving food at church 2.0; religious activities; preparing food at church 2.3; religious activities; washing dishes/cleaning kitchen at church 2.5; religious activities; standing - moderate (lifting 50 lbs) 2.5; volunteer activities; sitting - moderate work 2.3; volunteer activities; standing - light work (filing, talking, assembling) 3 to 4 MET LEVEL 3.0; conditioning exercise; bicycling, stationary, 50 watts, very light effort 3.5; conditioning exercise; calisthenics, home exercise, general 3.5; conditioning exercise; rowing, stationary, 50 watts, light effort 3.0; conditioning exercise; weight lifting 3.0; dancing; ballroom, slow (e.g. waltz, foxtrot, slow dancing) 3.0; fishing and hunting; fishing, general 3.5; fishing and hunting; fishing from river bank, standing 3.3; home activities; carpet sweeping, sweeping floors 3.0; home activities; cleaning, wash car, wash windows, clean garage 3.5; home activities; mopping 3.0; home activities; cleaning, house or cabin, genera 3.5; home activities; vacuuming 3.0; home activities; cooking Indian bread on an outside stove


3.8; home activities; scrubbing floors, on hands and knees, bathtub 3.5; home activities; standing - packing/unpacking boxes 3.0; home activities; implied walking - putting away household items 3.0; home activities; walking - light, non-cleaning shut/lock doors MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 3.0; home activities; carrying small children 3.0; home activities; child care: standing - dressing, bathing, grooming 3.5; home activities; standing - bathing dog, and cat –small animals 3.0; home repair; automobile repair, general 3.0; home repair; carpentry, general, workshop 3.0; home repair; painting, papering, plastering, scraping 3.0; home repair; put on and or removal of tarp 3.0; home repair; wiring, plumbing 3.0; lawn and garden; riding snow blower 3.5; lawn and garden; trimming shrubs or trees, power cutter 3.0; lawn and garden; picking fruit off trees, picking fruits/vegetables 3.0; lawn and garden; walking/standing - picking up yard, light 3.0; lawn and garden; walking, gathering gardening tools 3.0; miscellaneous; standing - arts and crafts, moderate effort 3.5; miscellaneous; standing - arts and crafts, vigorous effort 3.5; music playing; trombone 3.0; music playing; guitar, rock and roll band (standing) 3.5; music playing; marching band, drum major (walking) 3.5; occupation; carpentry, general 3.0; occupation; custodial work - buffing the floor with electric buffer 3.5; occupation; custodial work - general cleaning, moderate effort 3.5; occupation; custodial work - mopping, moderate effort 3.0; occupation; custodial work - take out trash, moderate effort 3.0; occupation; custodial work - vacuuming, moderate effort 3.5; occupation; electrical work, plumbing work 3.5; occupation; farming, chasing cattle, non-strenuous (walking) 3.0; occupation; farming, milking by hand, moderate effort 3.5; occupation; locksmith 3.0; occupation; machine tooling, welding 3.0; occupation; standing; light/moderate, assemble/repair heavy parts 3.5; occupation; standing; moderate, assembling at fast rate, lifting 50 lbs 3.5; occupation; tailoring, weaving 3.3; occupation; walking on job, 3.0 mph, in office, moderate speed 3.8; occupation; walking on job, 3.5 mph, in office, brisk speed 3.0; occupation; walking, 2.5 mph, slowly and carrying 25 pounds MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 3.0; occupation; walking, gathering things at work, ready to leave 3.0; occupation; working in scene shop, theater actor, backstage employee 3.5; sports; archery (non-hunting) 3.0; sports; frisbee playing, general


3.0; sports; golf, miniature, driving range 3.5; sports; golf, using power cart 3.5; sports; horseback riding, saddling horse 3.0; sports; horseshoe pitching, quoits 3.0; sports; shuffleboard, lawn bowling 3.5; sports; trampoline 3.0; sports; volleyball, non-competitive 3.0; transportation; driving heavy truck, tractor, bus 3.5; walking; carrying infant or 15 pound load 3.0; walking; loading /unloading a car 3.0; walking; downstairs 3.0; walking; loading /unloading a car 3.0; walking; walking, 2.5 mph, firm surface 3.3; walking; walking, 3.0 mph, level, moderate pace, 3.8; walking; walking, 3.5 mph, level, brisk, firm surface 3.0; water activities; sailing, boat sailing, windsurfing, ice sailing, general 3.0; water activities; surfing, body or board 3.0; water activities; water volleyball 3.5; winter activities; snowmobiling 3.3; religious activities; walking, 3.0 mph, moderate speed 3.8; religious activities; walking, 3.5 mph, not carrying anything 3.0; religious activities; cleaning church 4 to 5 MET LEVEL 4.0; bicycling; bicycling, <10 mph, leisure, to work or for pleasure 4.8; dancing; ballet or modern, twist, jazz, tap, jitterbug 4.5; dancing; general 4.5; dancing; ballroom, fast (disco, folk, square), line dancing 4.0; fishing and hunting; digging worms, with shovel 4.0; fishing and hunting; fishing from river bank and walking MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 4.0; home activities; multiple household tasks all at once, vigorous effort 4.0; home activities; sweeping garage, sidewalk or outside of house 4.0; home activities; walk/run - playing with children – moderate 4.0; home activities; elder care, disabled adult, only active periods 4.0; home activities; walk/run, playing with animals, moderate 4.0; home repair; automobile body work 4.5; home repair; carpentry, finishing or refinishing cabinets or furniture 4.5; home repair; caulking, except log cabin 4.5; home repair; laying or removing carpet 4.5; home repair; laying tile or linoleum, repairing appliances 4.5; home repair; painting 4.5; home repair; sanding floors with a power sander 4.5; home repair; scraping and painting 4.5; home repair; washing fence, painting fence 4.5; lawn and garden; mowing lawn, power mower


4.5; lawn and garden; operating snow blower, walking 4.5; lawn and garden; planting seedlings, shrubs 4.5; lawn and garden; planting trees 4.3; lawn and garden; raking lawn 4.0; lawn and garden; raking roof with snow rake 4.0; lawn and garden; sacking grass, leaves 4.5; lawn and garden; trimming shrubs or trees, manual cutter 4.5; lawn and garden; weeding, cultivating garden 4.0; lawn and garden; gardening, general 4.0; music playing; drums 4.0; music playing; marching band, playing an instrument (walking) 4.0; occupation; bakery, general, moderate effort 4.0; occupation; custodial work – feathering arena floor, moderate effort 4.0; occupation; farming, chasing cattle or other livestock on horseback 4.0; occupation; farming, feeding small animals, milk bottle for calf, goat 4.5; occupation; farming, feeding cattle, horses 4.5; occupation; farming, hauling water for animals, general hauling water 4.5; occupation; forestry, sawing, power 4.0; occupation; forestry, weeding 4.5; occupation; furriery – raise mink for fur coats MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 4.0; occupation; machine tooling, tapping and drilling 4.0; occupation; masseur, masseuse, manual therapy (standing) 4.5; occupation; orange grove work 4.0; occupation; police, making an arrest, taking command (standing) 4.0; occupation; lifting items continuously, 10 – 20 lbs, with limited walking 4.0; occupation; tailoring, pressing, starching 4.0; occupation; walking, 3.0 mph, moderately and carrying 25 lbs 4.0; occupation; walking, pushing a wheelchair 4.5; occupation; walking, 3.5 mph, briskly and carrying 25 pounds 4.5; running; jogging on a mini-tramp 4.5; sports; badminton, social singles and doubles, general 4.5; sports; basketball, shooting baskets 4.0; sports; coaching: football, soccer, basketball, baseball, swimming, etc. 4.0; sports; curling 4.5; sports; golf, general 4.5; sports; golf, walking and carrying clubs 4.3; sports; golf, walking and pulling clubs 4.0; sports; gymnastics, general 4.0; sports; softball, officiating 4.0; sports; table tennis, ping pong 4.0; sports; tai chi 4.0; walking; pushing a wheelchair, non-occupational setting 4.0; water activities; swimming, treading water, moderate effort, general 5 to 6 MET LEVEL


5.5; conditioning exercise; health club exercise, general 5.0; dancing; aerobic, low impact 5.5; dancing; ballroom, dancing fast 5.0; fishing and hunting; hunting, general 5.0; home activities; maple syruping/sugar bushing 5.0; home activities; walk/run-playing with children–vigorous 5.0; home activities; walk/run, playing with animals, vigorous 5.0; home repair; caulking, chinking log cabin 5.0; home repair; cleaning gutters MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 5.0; home repair; hanging storm windows 5.0; home repair; painting the outside of the house 5.0; home repair; spreading dirt with a shovel 5.0; lawn and garden; carrying, loading or stacking wood 5.0; lawn and garden; clearing land, hauling branches 5.0; lawn and garden; digging sandbox 5.0; lawn and garden; digging, spading, filling garden with compost 5.0; lawn and garden; laying sod 5.5; lawn and garden; mowing lawn, general 5.5; lawn and garden; mowing lawn, walk, power mower 5.5; occupation; construction, outside, remodeling 5.5; occupation; farming, shoveling grain 5.0; occupation; forestry, ax chopping, (SLOW) 5.0; occupation; forestry, hoeing 5.0; occupation; walking, carrying objects about 25 to 49 pounds 5.0; sports; cricket (batting, bowling) 5.0; sports; softball or baseball, fast or slow pitch, general 5.0; sports; tennis, doubles 5.0; walking; using crutches 5.0; walking; walking, 4.0 mph, level, firm surface 5.0; walking; walking, grass track 5.0; water activities; snorkeling 5.5; winter activities; ice skating, moderate effort 5.0; winter activities; skiing, downhill, light effort 6 to 7 MET LEVEL 6.0; bicycling; 10-12 mph 6.0; fishing and hunting; fishing in stream, in waders 6.0; fishing and hunting; hunting, deer, elk, large game 6.0; fishing and hunting; hunting, pheasants or grouse 6.0; home activities; butchering animals 6.0; home activities; moving furniture, household items 6.0; home repair; carpentry, outside house, installing rain gutters 6.0; lawn and garden; chopping wood, splitting logs MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT


6.0; lawn and garden; gardening with heavy power tools, tilling a garden 6.0; lawn and garden; mowing lawn, walk, hand mower 6.0; lawn and garden; shoveling snow, by hand 6.0; occupation; coal mining, general 6.0; occupation; farming, care of animals (grooming, brushing, shearing) 6.0; occupation; forestry, planting by hand 6.0; occupation; horse grooming 6.5; occupation; horse racing, trotting 6.5; occupation; truck driving, loading and unloading truck 6.0; occupation; using heavy power tools such jackhammers 6.0; sports; boxing, punching bag 6.0; walking; carrying 16 to 24 lb load, upstairs 6.0; walking; hiking, cross country 6.5; walking; marching, rapidly, military 6.0; walking; walking, 3.5 mph, uphill 6.3; walking; walking, 4.5 mph, level, firm surface 6.0; water activities; swimming, leisurely, not lap swimming, general 7 to 8 MET LEVEL 7.5; home activities; carrying groceries upstairs 7.5; home repair; carpentry, sawing hardwood 7.0; occupation; forestry, sawing by hand 7.0; occupation; masonry, concrete 7.0; running; jogging, general 7.0; sports; basketball, officiating 7.0; sports; racquetball, casual, general 7.0; sports; tennis, general 7.0; walking; backpacking 8 to 9 MET LEVEL 8.0; walking; up stairs 8.0; bicycling; bicycling, general 8.0; occupation; carrying heavy loads, such as bricks MET LEVEL / CATAGORY / FUNCTIONAL TASK EQUIVALENT 8.0; occupation; farming, baling hay, cleaning barn, vigorous effort 8.0; occupation; fire fighter, hauling hoses on ground 8.5; occupation; shoveling, digging ditches 8.0; running; running, 5 mph (12 min/mile) 8.0; sports; basketball, game 9 to 10 MET LEVEL 9.0; walking; carrying load upstairs, general 9.0; home activities; moving household items upstairs, carrying furniture 9.0; sports; football, competitive


10.0; walking; carrying 50 to 74 lb load, upstairs References

1. Barbara Ainsworth, William Haskell, Arthur Leon, David Jacobs, Jr., Henry Montoye, James Sallis & Ralph Paffenbarger, Jr. Compendium of physical activities: classification of energy costs of human physical activities. Medicine and Science in Sports and Exercise 25: 71-80, 1993.

2. Wasserman K, Hansen JE, Sue DY, Whipp BJ, Casaburi R. Principles of exercise testing and interpretation, 3rd ed. Baltimore: Lippincott Williams & Wilkins; 1999.

3. Wasserman K. Cardiopulmonary exercise testing and cardiovascular health. Armonk, NY: Futura; 2002.

4. Principles of Exercise Testing and Interpretation; Including Pathophysiology. Karlman Wasserman, James E. Hansen, Darryl Y. Sue, Brian J. Whipp, William W. Stringer, M.D. - 2005 - 585 pages.

5. 5. Sue DY. Integrative cardiopulmonary testing: basis and application. Medicine, Exercise, Nutrition and Health 1994;3:32-35.

6. Whipp BJ, Davis JA, Torres F, et al. A test to determine parameters of aerobic function during exercise. J Appl Physiol: Resp Environ Exerc Physiol 1981;50:217-221

7. Beaver WL, Wasserman K, Whipp BJ. A new method for detecting anaerobic threshold by gas exchange. J Appl Physiol 1986;60:2020-2027

8. Cohen-Solal A. Cardiopulmonary exercise testing in chronic heart failure. In: Wasserman K, ed. Exercise gas exchange in heart disease. Armonk, NY: Futura Publishing Co, 1996:17-35.

http://books.google.com/books?vid=ISBN0781748763&id=-3yIUQazb7cC&pg=RA3-PA241&lpg=RA3-PA241&ots=hpklWLrplp&dq=Wasserman+K,+++Casaburi+R.&sig=uqbMj2NCaUCKlBvgM99iYjJ4624�


Heart Failure Rehabilitation Progress Report Dear Dr. XXXX Patient: XXXX Age:63 Date: April 22, 2005 Admitting Diagnosis: CHF Baseline Data Completion Data Date 20/08/05 04/15/05 Resting HR, BP, SaO2%, FiO2 94 89 RA 72 94 RA Exercising HR, BP, SaO2%, FiO2 117 88 RA 109 90 RA Exercise Duration & Intensity – Cycle 3 min Level 1 5 min Level 2

Exercise Duration & Intensity - Treadmill 1 min 1 mph 7 min 2 mph

Rating of Perceived Exertion (1-10)

5 = working hard 3 = working moderately

Rating of Perceived Dyspnea (1-10)

5 = very SOB 3 = moderately SOB

6 Minute Walk Test Note Pt terminated test at 4 min and 27 sec

Pt completed walk test

6MWT – Distance 738 feet 1,342 feet Comments on Training and Compliance: XXX is strong willed; she worked diligently in almost every exercise session. The greatest gain was seen in muscular strength. Compliance was an issue as XXX refused to use supplemental oxygen for exercise training. This refusal was ultimately a barrier to further progress in the program; hence, XXX was discharged early (26 visits V. 36 visits) due to non compliance to oxygen saturation guidelines. Signs, Symptoms and Changes: Ratings of Perceived Exertion improved from 6 to 3. Ratings of Dyspnea improved from 6 to 3 as well. Oxygen de saturation was a continual battle. We used interval training to provide an exercise stimulus resulting in physiological adaptation to increased work. Patient Education: XXX took part in learning about the following: Medication and Equipment for self care, Physical fitness, Chest Physical Therapy, Airway Management, Stress Management, Relaxation, Nutrition for COPD Patients, Disorders of the Respiratory System. Current Home Activity Guidelines: XXX has purchased a Tread Mill and will continue this program at home. She may come back to Pulmonary Physical Therapy to join a phase three program at no cost. Thank you, for this referral. Sincerely, John Doe

118 7270

68 64 128

112 122


DATE: October 14, 2009. TO: J. Doe M.D. RE: John Doe

Heart Failure Rehabilitation Discharge Summary

OVERALL PROGRESS: POOR FAIR GOOD EXCELLENT Compliance: Good. Mr Doe was in attendance three times a week and we committed to improving his health. Six minute walk test: Pt able to make improvements with 6 min walk test improving from 350 ft and terminating test at 2 min 37 sec to 740 ft and completing test. Pt required no supplemental oxygen and was able to maintain %SPO2 at 97 and above. Patient Education: Pt received education on medications and equipment for self-care, physical fitness, chest physical therapy, airway management, stress management, relaxation, nutrition for COPD patients, and disorders of the respiratory system. Home Exercise Program: Pt needs further instructions and pictures to understand his home exercise program. Pt instructed to walk 3-5 times per week Additional Comments: Pt took encouragement during treatment to push him self. Pt motivation was at first poor, but really took off after session 9 which resulted in good overall progress. Thank you for this referral, John Doe


Part A Part B Other

Physical Therapy

PLAN Skilled Services Required:GOALS (Short Term) Gait Training ROM/Contracture Mgmt.

Balance Re-ed Home ProgramOutcome (Long Term) Therapeutic ex. Pt/Caregiver Training

Muscle Re-Ed Safety SkillsEnergy Cons. Equipment Needs

Other

N/A

20. INITIAL ASSESSMENT 19. PRIOR HOSPITALIZATION FROM to

Age M / F Rehab Potential

Hx and level of function at start of care:

Min tolerated DistanceHR%SPO2RPEDyspneaFIO2

Min tolerated DistanceHR%SPO2RPEDyspneaFIO2

22. SERVICE DATES FROM THROUGH

FORM HCFA-700 (11-91)

2)

Tx Justification:

15. PHYSICIAN SIGNATURE 16. DATE

N/A

DISCONTINUE SERVICESORCONTINUE SERVICES

18. ON FILE (Print/type physician's name)

N/A

5)

21. FUNCTIONAL LEVEL(end of billing period) PROGRESS REPORT:

3. HICN

10. TREATMENT DIAGNOSIS

6. ONSET DATE 7. SOC DATE

FIRST NAME M.I. 2. PROVIDER NUMBER

4. PROVIDER NAME MEDICAL RECORD NO. (Optional)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH CARE FINANCING ADMINISTRATION

(professional establishing POC including professional designation)13. Signature

12. PLAN OF TREATMENT FUNCTIONAL GOALS

PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION (COMPLETE FOR INITIAL CLAIMS ONLY)1. PATIENT'S LAST NAME

14. FREQ/DURATION (e.g. 3/wk x wk.)

11. VISITS FROM SOC

1)

8.TYPE: 9. PRIMARY DIAGNOSIS

2)

1)

From17. Certification

I CERTIFY THE NEED FOR THESE SERVICES FURNISHED UNDER THIS PLAN OF TREATMENT AND WHILE UNDER MY CARE

3)

4)

THROUGH

__

Assessment

____

6 minute walk test

6 minute walk test Assessment

______


About the Instructor

Roger K. Campbell, M.S., CET, MFT-c.

Program Developer / Director Rehabilitation Systems

[email protected] www.rehabsys.com

Mr. Campbell started his exercise science career in 1985 as an Army Master Fitness Trainer, where he physically prepared troops for combat deployments. With the GI Bill, Campbell obtained his Bachelor of Science Degree in Exercise Science from Utah State University, followed by a Master of Science Degree from the University of Utah, in Clinical Exercise Physiology. Campbell's greatest passion is working for the physical restoration of pulmonary and cancer diseased individuals. While involved with the University of Utah's Lung Transplant program, Campbell realized that greater restorative measures could, and should, be implemented to improve functional abilities of lung and cancer patients, and has set his focus on their rehabilitation pathway. Campbell spends his best energies devoted to duplicating and maintaining pulmonary and cancer rehabilitation programs. Additionally, Campbell is committed to the development of health care professionals as a serving panel member of the industries-first, accredited Cancer Specialist certification prepared by the American College of Sports Medicine (ACSM) and the American Cancer Society (ACS).

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Course Evaluation

The purpose of this evaluation is to gather input so that we may improve this course and how it is taught and therefore help you improve your learning. We are the only ones looking at your responses, and we will report back to you on the feedback received if you desire, you may email us at: [email protected] 1. What are the strongest features of this course and of our teaching? In other words, what contributes most to your learning experience? 2. What specific suggestions do you have for changes that we can make to improve the course or how it is taught? 3. Is the pace of the course: (Too Fast) (Just Right) (Too Slow)

mailto:[email protected]�


Congestive Heart Failure Glossary of Terms

Abdominal: Relating to the abdomen, the belly , that part of the body that contains all of the structures between the chest and the pelvis . The abdomen is separated anatomically from the chest by the diaphragm , the powerful muscle spanning the body cavity below the lungs .

Abdominal pain: Pain in the belly (the abdomen). Abdominal pain can come from conditions affecting a variety of organs. The abdomen is an anatomical area that is bounded by the lower margin of the ribs above, the pelvic bone (pubic ramus) below, and the flanks on each side. Although abdominal pain can arise from the tissues of the abdominal wall that surround the abdominal cavity (the skin and abdominal wall muscles), the term abdominal pain generally is used to describe pain originating from organs within the abdominal cavity (from beneath the skin and muscles). These organs include the stomach, small intestine, colon, liver, gallbladder, and pancreas.

Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior. In referring to a growth, abnormal may mean that it is cancerous or premalignant (likely to become cancer ).

Absorb: 1. To take something in, as through the skin or the intestine. 2. To react with radiation and reduce it in intensity, as with a dose of radiation or transmitted light.

Abstinence: The voluntary self-denial of food, drink, or sex. Today, abstinence is commonly taken to mean no sexual activity.

ACE inhibitor: A drug that inhibits ACE (angiotensin converting enzyme) which is important to the formation of angiotensin II. Angiotensin II causes arteries in the body to constrict and thereby raises the blood pressure. ACE inhibitors lower the blood pressure by inhibiting the formation of angiotensin II. This relaxes the arteries. Relaxing the arteries not only lowers blood pressure, but also improves the pumping efficiency of a failing heart and improves cardiac output in patients with heart failure. ACE inhibitors are therefore used for blood pressure control and congestive heart failure .

Adrenaline: A substance produced by the medulla (inside) of the adrenal gland, adrenaline (the official name in the British Pharmacopoeia) is synonymous with epinephrine. Technically speaking, adrenaline is a sympathomimetic catecholamine. It causes quickening of the heart beat, strengthens the force of the heart's contraction, opens up the bronchioles in the lungs and has numerous other effects. The secretion of adrenaline by the adrenal is part of the "fight-or-flight" reaction that we have in response to being frightened.

Aerobic: Oxygen-requiring. Aerobic bacteria need oxygen to grow. Aerobic exercise requires the heart and lungs to work harder to meet the body's increased oxygen demand.


Aerobic exercise: Brisk physical activity that requires the heart and lungs to work harder to meet the body's increased oxygen demand. Aerobic exercise promotes the circulation of oxygen through the blood.

Aggressive: In oncology, quickly growing, tending to spread rapidly. As, for example, an aggressive tumor.

Alcohol: An organic chemical in which one or more hydroxyl (OH) groups are attached to carbon (C) atoms in place of hydrogen (H) atoms. Common alcohols include ethyl alcohol or ethanol (found in alcoholic beverages), methyl alcohol or methanol (can cause blindness) and propyl alcohol or propanol (used as a solvent and antiseptic ). Rubbing alcohol is a mixture of acetone , methyl isobutyl ketone, and ethyl alcohol. In everyday talk, alcohol usually refers to ethanol as, for example, in wine, beer, and liquor. It can cause changes in behavior and be addictive.

Alcohol abuse: Use of alcoholic beverages to excess, either on individual occasions ("binge drinking") or as a regular practice. For some individuals-children or pregnant women, for example-almost any amount of alcohol use may be legally considered "alcohol abuse," depending on local laws. Heavy alcohol abuse can cause physical damage and death.

Aldosterone: A hormone made by the outer portion (cortex) of the adrenal gland that regulates the balance of salt and water in the body. Pronounced AL·do·ste·rone.

Angiography: A procedure performed to view blood vessels after injecting them with a radioopaque dye that outlines them on x-ray. This technique can be usefully used to look at arteries in many areas of the body, including the brain, neck (carotids), heart, aorta, chest, pulmonary circuit, kidneys, gastrointestinal tract, and limbs.

Angioplasty: Procedure with a balloon-tipped catheter to enlarge a narrowing in a coronary artery. Also called Percutaneous Transluminal Coronary Angioplasty (PTCA).

Angiotensin: A family of peptides (smaller than proteins) that act as vasoconstrictors to narrow blood vessels.

Angiotensin converting enzyme: Usually abbreviated ACE.

Arrhythmia: An abnormal heart rhythm.

Artery: A vessel that carries blood high in oxygen content away from the heart to the farthest reaches of the body. Since blood in arteries is usually full of oxygen, the hemoglobin in the red blood cells is oxygenated. The resultant form of hemoglobin (oxyhemoglobin) is what makes

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arterial blood look bright red.

Asthma : A common disorder in which chronic inflammation of the bronchial tubes (bronchi) makes them swell, narrowing the airways. Asthma involves only the bronchial tubes and does not affect the air sacs ( alveoli ) or the lung tissue (the parenchyma of the lung) itself.

Attention: The ability to focus selectively on a selected stimulus, sustaining that focus and shifting it at will. The ability to concentrate.

Balance: A biological system that enables us to know where our bodies are in the environment and to maintain a desired position. Normal balance depends on information from the inner ear, other senses (such as sight and touch) and muscle movement.

Biopsy: The removal of a sample of tissue for purposes of diagnosis. (Many definitions of "biopsy" stipulate that the sample of tissue is removed for examination under a microscope. This may or may not be the case. The diagnosis may be achieved by other means such as by analysis of chromosomes or genes.)

Blood: The familiar red fluid in the body that contains white and red blood cells, platelets, proteins, and other elements. The blood is transported throughout the body by the circulatory system. Blood functions in two directions: arterial and venous. Arterial blood is the means by which oxygen and nutrients are transported to tissues while venous blood is the means by which carbon dioxide and metabolic by-products are transported to the lungs and kidneys, respectively, for removal from the body.

Blood pressure: The blood pressure is the pressure of the blood within the arteries. It is produced primarily by the contraction of the heart muscle. It's measurement is recorded by two numbers. The first (systolic pressure) is measured after the heart contracts and is highest. The second (diastolic pressure) is measured before the heart contracts and lowest. A blood pressure cuff is used to measure the pressure. Elevation of blood pressure is called "hypertension".

Breast : The breast refers to the front of the chest or, more specifically, to the mammary gland. The mammary gland is a milk producing gland. It is composed largely of fat. Within the mammary gland is a complex network of branching ducts. These ducts exit from sac-like structures called lobules, which can produce milk in females. The ducts exit the breast at the nipple.

Calcium: A mineral found mainly in the hard part of bones, where it is stored. Calcium is added to bones by cells called osteoblasts and is removed from bones by cells called osteoclasts. Calcium is essential for healthy bones. It is also important for muscle contraction, heart action, nervous system maintenance, and normal blood clotting. Food sources of calcium include dairy foods, some leafy green vegetables such as broccoli and collards, canned



















salmon, clams, oysters, calcium-fortified foods, and tofu. According to the National Academy of Sciences, adequate intake of calcium is 1,200 milligrams a day (four glasses of milk) for men and women 51 and older, 1,000 milligrams a day for adults 19 through 50, and 1,300 milligrams a day for children 9 through 18. The upper limit for calcium intake is 2.5 grams daily.

Catheter: A thin, flexible tube . For example, a catheter placed in a vein provides a pathway for giving drugs, nutrients, fluids, or blood products. Samples of blood can also be withdrawn through the catheter.

Chest: The area of the body located between the neck and the abdomen . The chest contains the lungs , the heart and part of the aorta . The walls of the chest are supported by the dorsal vertebrae , the ribs , and the sternum .

Chest X-ray: Commonly used to detect abnormalities in the lungs, but can also detect abnormalities in the heart, aorta, and the bones of the thoracic area. Metallic objects, such as jewelry are removed from the chest and neck areas for a chest x-ray to avoid interference with x-ray penetration and improve accuracy of the interpretation.

Chronic: This important term in medicine comes from the Greek chronos, time and means lasting a long time.

Circulation: The movement of fluid in a regular or circuitous course. Although the noun "circulation" does not necessarily refer to the circulation of the blood, for all practical purposes today it does. Heart failure is an example of a problem with the circulation.

Circulatory: Having to do with the circulation, the movement of fluid in a regular or circuitous course. Although the adjective "circulatory" need not necessarily refer to the circulation of the blood, for all practical purposes today it does. A circulatory problem is taken usually to be a problem with the blood circulation, for example with heart failure.

Clinical: 1. Having to do with the examination and treatment of patients. 2. Applicable to patients. A laboratory test may be of clinical value (of use to patients).

Clinical trials: Trials to evaluate the effectiveness and safety of medications or medical devices by monitoring their effects on large groups of people.

Condition: The term "condition" has a number of biomedical meanings including the following:

1. An unhealthy state, such as in "this is a progressive condition." 2. A state of fitness, such as "getting into condition." 3. Something that is essential to the occurrence of something else; essentially a

"precondition."



4. As a verb: to cause a change in something so that a response that was previously associated with a certain stimulus becomes associated with another stimulus; to condition a person, as in behavioral conditioning.

Congestive heart failure : Inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver and kidneys. Heart failure may be due to failure of the right or left or both ventricles. The signs and symptoms depend upon which side of the heart is failing. They can include shortness of breath (dyspnea), asthma due to the heart (cardiac asthma), pooling of blood (stasis) in the general body (systemic) circulation or in the liver's (portal) circulation, swelling ( edema ), blueness or duskiness (cyanosis), and enlargement (hypertrophy) of the heart.

Contraction: The tightening and shortening of a muscle.

Coronary artery disease: A major cause of illness and death, coronary artery disease (CAD) begins when hard cholesterol substances (plaques) are deposited within a coronary artery.

Cough: A rapid expulsion of air from the lungs typically in order to clear the lung airways of fluids, mucus, or material. Also called tussis.

Dehydration : Excessive loss of body water. Diseases of the gastrointestinal tract that cause vomiting or diarrhea may, for example, lead to dehydration. There are a number of other causes of dehydration including heat exposure, prolonged vigorous exercise (e.g., in a marathon), kidney disease, and medications (diuretics).

Diabetes: Refers to diabetes mellitus or, less often, to diabetes insipidus . Diabetes mellitus and diabetes insipidus share the name "diabetes" because they are both conditions characterized by excessive urination (polyuria).

Diagnosis: 1 The nature of a disease ; the identification of an illness. 2 A conclusion or decision reached by diagnosis. The diagnosis is rabies . 3 The identification of any problem. The diagnosis was a plugged IV.

Disease: Illness or sickness often characterized by typical patient problems (symptoms) and physical findings (signs). Disruption sequence: The events that occur when a fetus that is developing normally is subjected to a destructive agent such as the rubella (German measles) virus.

Diuretic: Anything that promotes the formation of urine by the kidney. (The word "diuretic" comes from a combination of the Greek "dia-", thoroughly + "ourein", to urinate = to urinate



thoroughly).

Donor: The giver of a tissue or organ, for example, of blood or a kidney.

Dysfunction: Difficult function or abnormal function.

ECG: Abbreviation for electrocardiogram or EKG. The K is from "kardio" (in German).

Echocardiography: Echocardiography is a diagnostic test which uses ultrasound waves to make images of the heart chambers, valves and surrounding structures. It can measure cardiac output and is a sensitive test for inflammation around the heart (pericarditis). It can also be used to detect abnormal anatomy or infections of the heart valves.

Edema: The swelling of soft tissues as a result of excess water accumulation.

Electrocardiogram : A recording of the electrical activity of the heart. An electrocardiogram is a simple, non-invasive procedure. Electrodes are placed on the skin of the chest and connected in a specific order to a machine that, when turned on, measures electrical activity all overaround the heart. Output is usually in the form of a long scroll of paper displaying a printed graph of activity. Newer models output the data directly to a computer and screen, although a print-out may still be made.

Electrolyte: An electrolyte is a substance that will dissociate into ions in solution and acquire the capacity to conduct electricity. The electrolytes include sodium, potassium, chloride, calcium and phosphate. Informally, called lytes. (The clue to the word electrolyte is in the lyte which comes from the Greek lytos meaning that may be dissolved.)

Emphysema: 1) A lung condition featuring an abnormal accumulation of air in the lung's many tiny air sacs, a tissue called alveoli. As air continues to collect in these sacs, they become enlarged, and may break, or be damaged and form scar tissue. Emphysema is strongly associated with smoking cigarettes, a practice that causes lung irritation. It can also be associated with or worsened by repeated infection of the lungs, such as is seen in chronic bronchitis. The best response to the early warning signs of emphysema is prevention: stop smoking and get immediate treatment for incipient lung infections. Curing established emphysema is not yet possible. Because patients don't have an adequate amount of space in the lungs to breathe, they gasp for breath, and may not be able to obtain enough oxygen. Those with severe emphysema usually end up using an oxygen machine to breathe. In some cases, medication may be helpful to ease symptoms or to treat infection in already-damaged lungs.

Enzyme: A protein (or protein-based molecule) that speeds up a chemical reaction in a living organism. An enzyme acts as catalyst for specific chemical reactions , converting a specific set of reactants (called substrates) into specific products. Without enzymes, life as we know it




would not exist.

Epinephrine: A substance produced by the medulla (inside) of the adrenal gland. The name epinephrine was coined in 1898 by the American pharmacologist and physiologic chemist (biochemist) John Jacob Abel who isolated it from the adrenal gland which is located above (epi-) the kidney ("nephros" in Greek). (Abel also crystallized insulin). Technically speaking, epinephrine is a sympathomimetic catecholamine. It causes quickening of the heart beat, strengthens the force of the heart's contraction, opens up the airways (bronchioles) in the lungs and has numerous other effects. The secretion of epinephrine by the adrenal is part of the fight-or-flight reaction. Adrenaline is a synonym of epinephrine and is the official name in the British Pharmacopoeia.

Essential: 1. Something that cannot be done without. 2. Required in the diet, because the body cannot make it. As in an essential amino acid or an essential fatty acid. 3. Idiopathic. As in essential hypertension. "Essential" is a hallowed term meaning "We don't know the cause."

Fatigue: A condition characterized by a lessened capacity for work and reduced efficiency of accomplishment, usually accompanied by a feeling of weariness and tiredness. Fatigue can be acute and come on suddenly or chronic and persist.

FDA: The Food and Drug Administration, an agency within the U.S. Public Health Service, which is a part of the Department of Health and Human Services.

Gene: The basic biological unit of heredity . A segment of deoxyribonucleic acid (DNA) needed to contribute to a function.

Genes: The basic biological units of heredity . Segments of deoxyribonucleic acid (DNA) needed to contribute to a function.

Gynecomastia: Excessive development of the male breasts. Temporary enlargement of the breasts is not unusual or abnormal in boys during adolescence or during recovery from malnutrition. Gynecomastia may be abnormal as, for example, in Klinefelter's syndrome.

Heart: The muscle that pumps blood received from veins into arteries throughout the body. It is positioned in the chest behind the sternum (breastbone; in front of the trachea, esophagus, and aorta; and above the diaphragm muscle that separates the chest and abdominal cavities. The normal heart is about the size of a closed fist, and weighs about 10.5 ounces. It is cone-shaped, with the point of the cone pointing down to the left. Two-thirds of the heart lies in the left side of the chest with the balance in the right chest.



Heart attack: The death of heart muscle due to the loss of blood supply. The loss of blood supply is usually caused by a complete blockage of a coronary artery, one of the arteries that supplies blood to the heart muscle. Death of the heart muscle, in turn, causes chest pain and electrical instability of the heart muscle tissue.

Heart disease: Any disorder that affects the heart. Sometimes the term "heart disease" is used narrowly and incorrectly as a synonym for coronary artery disease. Heart disease is synonymous with cardiac disease but not with cardiovascular disease which is any disease of the heart or blood vessels. Among the many types of heart disease, see, for example: Angina; Arrhythmia; Congenital heart disease; Coronary artery disease (CAD); Dilated cardiomyopathy; Heart attack (myocardial infarction); Heart failure; Hypertrophic cardiomyopathy; Mitral regurgitation; Mitral valve prolapse; and Pulmonary stenosis.

Heart failure : Inability of the heart to keep up with the demands on it and, specifically, failure of the heart to pump blood with normal efficiency. When this occurs, the heart is unable to provide adequate blood flow to other organs such as the brain, liver and kidneys. Heart failure may be due to failure of the right or left or both ventricles. The signs and symptoms depend upon which side of the heart is failing. They can include shortness of breath (dyspnea), asthma due to the heart (cardiac asthma), pooling of blood (stasis) in the general body (systemic) circulation or in the liver's (portal) circulation, swelling ( edema ), blueness or duskiness (cyanosis), and enlargement (hypertrophy) of the heart.

Heart muscle: A type of muscle with unique features only found in the heart. The heart muscle, or cardiac muscle, is medically called the myocardium ("myo-" being the prefix denoting muscle).

Heart transplant: A surgical procedure in which a diseased heart is replaced with a healthy heart from a deceased person.

Heart valves: There are four heart valves. All are one-way valves. Blood entering the heart first passes through the tricuspid valve and then the pulmonary valve. After returning from the lungs, the blood passes through the mitral (bicuspid) valve and exits via the aortic valve.

High blood pressure : Also known as hypertension, high blood pressure is, by definition, a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above 140 with a diastolic pressure above 90.

Hormone: A chemical substance produced in the body that controls and regulates the activity of certain cells or organs.

Hypertension: High blood pressure , defined as a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above 140 with a diastolic pressure above 90.

















Ibuprofen: A non-steroidal anti-inflammatory drug (NSAID) commonly used to treat pain, swelling, and fever. Common brand names for Ibuprofen include Advil, Motrin, and Nuprin.

Immune: Protected against infection. The Latin immunis means free, exempt.

Immune system: A complex system that is responsible for distinguishing us from everything foreign to us, and for protecting us against infections and foreign substances. The immune system works to seek and kill invaders.

Infection: The growth of a parasitic organism within the body. (A parasitic organism is one that lives on or in another organism and draws its nourishment therefrom.) A person with an infection has another organism (a "germ") growing within him, drawing its nourishment from the person.

Kidney: One of a pair of organs located in the right and left side of the abdomen which clear "poisons" from the blood, regulate acid concentration and maintain water balance in the body by excreting urine. The kidneys are part of the urinary tract. The urine then passes through connecting tubes called "ureters" into the bladder. The bladder stores the urine until it is released during urination.

Laboratory: A place for doing tests and research procedures and preparing chemicals, etc. Although "laboratory" looks very like the Latin "laboratorium" (a place to labor, a work place), the word "laboratory" came from the Latin "elaborare" (to work out, as a problem, and with great pains), as evidenced by the Old English spelling "elaboratory" designating "a place where learned effort was applied to the solution of scientific problems."

Leg: In popular usage, the leg extends from the top of the thigh down to the foot. However, in medical terminology, the leg refers to the portion of the lower extremity from the knee to the ankle.

Liver: An organ in the upper abdomen that aids in digestion and removes waste products and worn-out cells from the blood. The liver is the largest solid organ in the body. The liver weighs about three and a half pounds (1.6 kilograms). It measures about 8 inches (20 cm) horizontally (across) and 6.5 inches (17 cm) vertically (down) and is 4.5 inches (12 cm) thick.

Low blood pressure : Any blood pressure that is below the normal expected for an individual in a given environment. Low blood pressure is also referred to as hypotension.

Lungs: The lungs are a pair of breathing organs located with the chest which remove carbon dioxide from and bring oxygen to the blood. There is a right and left lung.




Medical history: 1. In clinical medicine, the patient's past and present which may contain clues bearing on their health past, present, and future. The medical history, being an account of all medical events and problems a person has experienced, including psychiatric illness, is especially helpful when a differential diagnosis is needed. 2. The history of medicine.

Mortality: A fatal outcome or, in one word, death. The word "mortality" is derived from "mortal" which came from the Latin "mors" (death). The opposite of mortality is, of course, immortality. Mortality is also quite distinct from morbidity (illness).

Muscle: Muscle is the tissue of the body which primarily functions as a source of power. There are three types of muscle in the body. Muscle which is responsible for moving extremities and external areas of the body is called "skeletal muscle." Heart muscle is called "cardiac muscle." Muscle that is in the walls of arteries and bowel is called "smooth muscle."

Naproxen : A non-steroidal anti-inflammatory drug (NSAID) used for the management of mild to moderate pain, fever, and inflammation . Naproxen blocks the enzyme cyclooxygenase that makes prostaglandins, resulting in lower concentrations of prostaglandins. As a consequence, inflammation, pain and fever are reduced. Brand names for naproxen include Anaprox, Naprelan, Naprosyn, and Aleve.

Natriuretic: Causing natriuresis, the excretion of an excessively large amount of sodium in the urine.

Nausea: Nausea is the urge to vomit. It can be brought by many causes including, systemic illnesses, such as influenza, medications, pain, and inner ear disease.

Neck: The part of the body joining the head to the shoulders. Also, any narrow or constricted part of a bone or organ that joins its parts as, for example, the neck of the femur bone.

Nuclear medicine: The branch of medicine concerned with the use of radioisotopes in the diagnosis, management, and treatment of disease. Nuclear medicine uses small amounts of radioactive materials or radiopharmaceuticals, substances that are attracted to specific organs, bones, or tissues. The radiopharmaceuticals used in nuclear medicine emit gamma rays that can be detected externally by special types of cameras: gamma or PET cameras. These cameras work in conjunction with computers used to form images that provide data and information about the area of body being imaged. The amount of radiation from a nuclear medicine procedure is comparable to that received during a diagnostic x-ray.

Organ: A relatively independent part of the body that carries out one or more special functions. The organs of the human body include the eye, ear, heart, lungs, and liver.















Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. The physical part of pain results from nerve stimulation. Pain may be contained to a discrete area, as in an injury, or it can be more diffuse, as in disorders like fibromyalgia . Pain is mediated by specific nerve fibers that carry the pain impulses to the brain where their conscious appreciation may be modified by many factors.

Pill: In pharmacy, a medicinal substance in a small round or oval mass meant to be swallowed. Pills often contain a filler and a plastic substance such as lactose that permits the pill to be rolled by hand or machine into the desired form. The pill may then be coated with a varnishlike substance.

Potassium: The major positive ion (cation) found inside of cells. The chemical notation for potassium is K+.

Prognosis: 1. The expected course of a disease . 2. The patient's chance of recovery. The prognosis predicts the outcome of a disease and therefore the future for the patient . His prognosis is grim, for example, while hers is good.

Progressive: Increasing in scope or severity. Advancing. Going forward. In medicine, a disease that is progressive is going from bad to worse.

Proteins: Large molecules composed of one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein.

Pulmonary: Having to do with the lungs. (The word comes from the Latin pulmo for lung).

Pulse: The rhythmic contraction and expansion of an artery due to the surge of blood from the beat of the heart. The pulse is most often measured by feeling the arteries of the wrist. There is also a pulse, although far weaker, in veins.

Quality of life: An important consideration in medical care, quality of life refers to the patient's ability to enjoy normal life activities. Some medical treatments can seriously impair quality of life without providing appreciable benefit, while others greatly enhance quality of life.

Randomized: The use of chance alone to assign the participants in an experiment or trial to different groups in order to fairly compare the outcomes with different treatments. Randomization is an important feature of experimental design.

Range: In medicine and statistics, the difference between the lowest and highest numerical values. For example, if five premature infants are born weighing two, three, four, four, and five pounds respectively, the range of their birth weights is two to five pounds.


Receptor: 1. In cell biology, a structure on the surface of a cell (or inside a cell) that selectively receives and binds a specific substance. There are many receptors. There is a receptor for ( insulin ; there is a receptor for low-density lipoproteins ( LDL ); etc. To take an example, the receptor for substance P, a molecule that acts as a messenger for the sensation of pain , is a unique harbor on the cell surface where substance P docks. Without this receptor, substance P cannot dock and cannot deliver its message of pain. Variant forms of nuclear hormone receptors mediate processes such as cholesterol metabolism and fatty acid production. Some hormone receptors are implicated in diseases such as diabetes and certain types of cancer. A receptor called PXR appears to jump-start the body's response to unfamiliar chemicals and may be involved in drug-drug interactions. 2. In neurology, a terminal of a sensory nerve that receives and responds to stimuli.

Rejection: In transplantation biology, the refusal by the body to accept transplanted cells, tissues or organs. For example, a kidney transplanted may be rejected.

Rest: 1. Repose. Relaxation. 2. A fragment of embryonic tissue that has been retained after the period of embryonic development. Also called an embryonic rest.

Salt: In medicine, salt usually refers to sodium chloride, table salt, used for seasoning food, for the preservation of meat, etc. Salt is found in the earth and in sea water and is isolated by evaporation and crystallization from sea water and other water impregnated with particles of salt.

Sense: In biology and medicine, the faculty of sensory reception. The ability to convey specific types of external or internal stimuli to the brain and perceive them. Sensory reception occurs through a process known as transduction in which stimuli are converted into nerve impulses which are relayed to the brain.

Side effects: Problems that occur when treatment goes beyond the desired effect. Or problems that occur in addition to the desired therapeutic effect.

Sign: Any objective evidence of disease. Gross blood in the stool is a sign of disease. It can be recognized by the patient, doctor, nurse, or others. In contrast, a symptom is, by its nature, subjective. Abdominal pain is a symptom. It is something only the patient can know.

Skin: The skin is the body's outer covering. It protects us against heat and light, injury, and infection. It regulates body temperature and stores water, fat, and vitamin D. Weighing about 6 pounds, the skin is the body's largest organ. It is made up of two main layers; the outer epidermis and the inner dermis.


Sleep : The body's rest cycle.

Sodium: The major positive ion (cation) in fluid outside of cells. The chemical notation for sodium is Na+. When combined with chloride, the resulting substance is table salt.

Surgery: The word "surgery" has multiple meanings. It is the branch of medicine concerned with diseases and conditions which require or are amenable to operative procedures. Surgery is the work done by a surgeon. By analogy, the work of an editor wielding his pen as a scalpel is s form of surgery. A surgery in England (and some other countries) is a physician's or dentist's office.

Symptom: Any subjective evidence of disease. Anxiety, lower back pain, and fatigue are all symptoms. They are sensations only the patient can perceive. In contrast, a sign is objective evidence of disease. A bloody nose is a sign. It is evident to the patient, doctor, nurse and other observers.

Systolic: The blood pressure when the heart is contracting. It is specifically the maximum arterial pressure during contraction of the left ventricle of the heart. The time at which ventricular contraction occurs is called systole.

Therapy: The treatment of disease .

Thyroid: 1. The thyroid gland. Also, pertaining to the thyroid gland. 2. A preparation of the thyroid gland used to treat hypothyroidism. 3. Shaped like a shield. (The thyroid gland was so-named by Thomas Wharton in 1656 because it was shaped like an ancient Greek shield.)

Tissue: A tissue in medicine is not like a piece of tissue paper. It is a broad term that is applied to any group of cells that perform specific functions. A tissue in medicine need not form a layer. Thus,

• The bone marrow is a tissue; • Connective tissue consists of cells that make up fibers in the framework supporting

other body tissues; and • Lymphoid tissue is the part of the body's immune system that helps protect it from

bacteria and other foreign entities.

Transplant: The grafting of a tissue from one place to another, just as in botany a bud from one plant might be grafted onto the stem of another. The transplanting of tissue can be from one part of the patient to another (autologous transplantation), as in the case of a skin graft using the patient's own skin; or from one patient to another (allogenic transplantation), as in the case of transplanting a donor kidney into a recipient.

Ultrasound : High-frequency sound waves. Ultrasound waves can be bounced off of tissues using special devices. The echoes are then converted into a picture called a sonogram.





Ultrasound imaging, referred to as ultrasonography, allows physicians and patients to get an inside view of soft tissues and body cavities, without using invasive techniques. Ultrasound is often used to examine a fetus during pregnancy. There is no convincing evidence for any danger from ultrasound during pregnancy.

Vein: A blood vessel that carries blood low in oxygen content from the body back to the heart. The deoxygenated form of hemoglobin (deoxyhemoglobin) in venous blood makes it appear dark. Veins are part of the afferent wing of the circulatory system which returns blood to the heart.

Ventricular: Pertaining to the ventricles, the lower chambers of the heart, as in ventricular fibrillation and ventricular septal defect.

Viable: Capable of life. For example, a viable premature baby is one who is able to survive outside the womb.

Viral: Of or pertaining to a virus. For example, "My daughter has a viral rash ."

X-ray: 1. High-energy radiation with waves shorter than those of visible light. X-rays possess the properties of penetrating most substances (to varying extents), of acting on a photographic film or plate (permitting radiography), and of causing a fluorescent screen to give off light (permitting fluoroscopy). In low doses X-rays are used for making images that help to diagnose disease, and in high doses to treat cancer . Formerly called a Roentgen ray. 2. An image obtained by means of X-rays.





Heart Failure Project

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