Day in the Life (Part II): Physical Therapist with Board Certification in Cardiovascular and Pulmonary Physical Therapy
Sonya L. Irons, PT, DPT, CCS
Posted 11/ 2/23
In Part I of the “Day in the Life: Physical Therapist with Board Certification in Cardiovascular and Pulmonary Physical Therapy”, I discussed how a typical day was structured in an acute care setting and inpatient rehabilitation facility (IRF). For Part II, I want to dive into typical evaluation and intervention strategies for the cardiovascular and pulmonary physical therapy population.
Importance of Functional Mobility
Whether a patient just had a total hip arthroplasty (THA) or a coronary artery bypass graft (CABG) surgery, functional mobility is the focus. The need to safely perform bed mobility, transfers, gait, stairs, or wheelchair mobility translates across diagnoses. The differences occur with the surgical limitations imposed on these different patient populations to ensure the integrity of the surgical repair. A patient post-operative CABG may have sternal precautions, which are a set of physician orders limiting certain aspects of shoulder range of motion, amount of weight lifted with their upper extremities, and/or certain types of functional movements. A patient post-operative with a THA with a posterolateral approach might have hip precautions that include limiting hip flexion past 90 degrees, limiting hip adduction past midline, and/or limiting hip internal rotation. Encouraging a patient to use a log roll technique after a CABG surgery for bed mobility will follow sternal precautions orders, whereas having the patient perform bed mobility via a long sitting approach would be more appropriate for a patient with post-operative hip precautions. The bottom line is that both patients need to be able to get in and out of bed, but how it will be performed will look different.
Vital Signs are Vital
Whether you are working with patients in an inpatient or outpatient setting, this could involve patients before and/or after surgery, and/or patients with diagnoses such as congestive heart failure, pneumonia, chronic obstructive pulmonary disease, COVID and/or post-COVID. Even our patients in outpatient physical therapy present with multiple risk factors for cardiovascular disease, consisting of hypertension, obesity, diabetes, or a sedentary lifestyle. At evaluation, all patients should have their cardiovascular and pulmonary system screened with a set of vital signs at rest and with activity. These patients with cardiovascular and pulmonary diagnoses may need more consistent vital sign monitoring at rest, vital signs with activity, and vital signs post-activity at ongoing visits to ensure appropriate hemodynamic response to activity.
Vital sign response during activity provides insight into exercise tolerance. A patient’s systolic blood pressure value should increase proportionally with workload, and diastolic blood pressure value should stay the same. Heart rate should increase with activity, although patients may have a blunted response with medication such as beta blockers. I teach patients to self-monitor exercise intensity on a Rating of Perceived Exertion (RPE) scale, and/or self-monitor their dyspnea with a Rating of Dyspnea (RPD) scale. Additionally, I may check oxygen saturation (especially if the patient is on supplemental oxygen), respiratory rate, lung sounds and/or heart sounds via auscultation.
Electrocardiogram (ECG or EKG)
Depending on the facility, I might have the ability to monitor heartrate via EKG, which is a bonus. If I have access to an EKG, this provides an excellent opportunity to watch heart rate and rhythm, both at rest and with activity. Patients may have continuous EKG, or EKG only during therapy.
Monitoring vital signs is just one aspect of the assessment for this patient population. Evaluations will have similarities across diagnoses, and will include components related to functional mobility, range of motion, strength, sensation, cognition, postural assessment, pain management, safety awareness and balance. Evaluations for patients with cardiovascular and pulmonary conditions may include added tests and measures, such as chest wall excursion, breathing pattern assessment, cough assessment, and/or quality of phonation. The Six Minute Walk Test or Two Minute Walk Test are commonly utilized tests to assess distance walked and gait speed. The value reached on the selected test is compared to an age-normative value.
Pain is common after any surgery, including those patients trying to take a deep breath after a sternotomy or thoracotomy incision. If the patient has an impairment that is negatively impacting functional mobility, then I need to address that impairment while also focusing on functional mobility. The table introduces common impairments, followed by interventions with this patient population.
I also enjoy the health promotion and wellness aspect of teaching patients and their caregivers. There is so much education to provide with a range of topics including sternal precautions, importance of upright posture, assistive device management, decreasing risk of falls, wound care, energy conservation, and/or the benefits of a walking program. It takes a multidisciplinary team to assure coverage for all these educational topics.
Short-term and long-term goals for the patient are patient-centered, while also incorporating functional goals related to bed mobility, transfers, gait, standing, stairs, balance, and wheelchair mobility. If applicable for the patient, I am likely to consider adding a goal related to self-monitoring exercise intensity with RPE, or a goal related to achieving a certain metabolic equivalent (MET) level to prepare for the home environment. For example, if the patient has a flight of stairs at home to access their bathroom, can the patient negotiate a flight of stairs with stable vital signs in the hospital environment first before they go home?
I love working in the hospital on a collaborative team, and I especially enjoy learning about new surgical procedures and diagnoses. Two of my favorite memories include being part of the team that mobilized a patient after the first Transcutaneous Aortic Valve Replacement (TAVR) or the first Left Ventricular Assistive Device (LVAD) was performed at that hospital. Working with patients to ensure they meet their goals is rewarding.
About the author: Sonya L. Irons, PT, DPT, CCS is a Board Certified Cardiovascular and Pulmonary Clinical Specialist and a course instructor for Scorebuilders.