Cardiovascular disease in Rehab/Nursing Home

By: Maged Taman

In Rehab the acute cardiovascular care is mainly to recognize the underlying condition and transfer the patient to appropriate hospital. However, patient was known angina and CHF who are not progressing can be managed in rehab. More commonly a rehab physician is faced with problems like low blood pressure, dehydration and mild CHF. These are the pearls related to this topic:

1- Identify cause of acute chest pain: EKG is done to look for EKG changes and compare with old EKG. MONA: morphine, oxygen, nitroglycerin and aspirin in patients with angina. Morphine may be held off give reaction to morphine may be unpredicted until rescue arrive unless deemed necessary.

2- Other causes of chest pain need to be identified if possible as dissecting aortic aneurysm and acute abdominal pain due to rupture AAA should be and transferred quickly.

3- Identify congestive heart failure findings as shortness of breath, JVD, lung crackles and leg edema. Treatment same as of in acute hospital for CHF: O2, IV lasix, NTG SL and Morphine. The latter may be used more cautiously with small doses of 3 mg in Rehab. Patient may have wheezing from CHF that is respond more quickly to Vent Neb than to lasix. Patient with known stable CHF can be treated in the Rehab severe CHF and new onset needs to be sent to acute hospital.

4- Low Blood pressure common in early admission in rehab secondary to deconditioning, pain meds, anemia and low oral intake. Commonly present as orthostatic hypotension. Be sure no sepsis: fever, high WBC's, patient looks sick...

5- Commonly patient would need to hold some of BP meds. A good way to do that is to hold BP meds for systolic BP <110. However patient with arrhythmia, low EF and bad CAD may need to continue their medications. It is commonly known from the discharge summary as patient comes to rehab facility. Patients close to discharge may be able to tolerate home medications of antihypertensive or need to hold one or more of blood pressure medicine. Commonly patients are followed by visiting nurse and if systolic BP increase to more than 140 patients restarts his home BP medicine that was held.

6- High thigh TEDS and a binder may help in orthostatic hypotension in early rehab as patient progress they commonly can be discontinued.

7- Encourage PO Fluids unless fluid overload, patient who cannot get enough oral fluid IV fluids may be needed commonly IV NS given.

8- Elderly patients may get easily dehydrated since thirst mechanism is diminished in elderly. Impaired cognition is a contributing cause. Thus offer regularly fluid to them. Some may need Iv hydration intermittently or hypodermyocalcysis.

9- Diuretics are common cause of dehydration. However stopping diuretics in patients with low LVEF or chronic renal failure may put patient in congestive heart failure so more close assessment if you would plan to hold diuretics. Weight measurement is easier and more accurate than measuring ins/os.

10- Elderly are particularly prone to get more washed out, fatigue, change of mental status or falls when dehydrated. Look for these signs of dehydration since patient may not express thirst.

11- Hypernatermia, non-ketotic hyperosmolar disease and increase BUN?creatinine occur in more advanced dehydration. IV hydration is commonly started and patient transferred to acute hospital if IV fluids as well treating and monitoring milder forms can be achieved in rehab.

12- Patient on thick diet honey and less so nectar may not be able to get enough fluid in their bodies. Overnight hydration about 750 to 1000 cc over night is commonly given, so IV pump does not interrupt morning rehab. Assess daily need of IV fluids. Do not write the order of hydration for more than 3 days in advance.

13- Avoid hypotonic fluids since patient commonly have pain, pain meds, thiazides and other factors that predispose to SIADH (increase antidiuertic hormone and water retention) and cause hyponatermia. Particularly those post surgery. However, patients with elevated sodium will need hypotonic fluids.

14- People who would need more urgent IV fluids are those usually lost fluids due to vomiting, diarrhea or over-diuresis and started to show symptoms and signs of dehydration (low BP, tachycardia, dry mouth, fatigued, washed out, high BUN/Cr ratio >20 .22.

15- Patient with quite low BP <80 or look in shock have to have IV normal saline wide open. Other measures like IV dopamine should be considered as well by rescue.

16- It is amazing how patients can differ some patient have a baseline line SBP about 95 thus SBP of 85 may not be considerable thus it is important to see how the patient looks. Besides the automatic BP machines are about 5-10 lower compared by the more accurate portable BP machines.

17- Write parameters routinely to therapists to hold therapy if systolic BP <110> 180 and heart rate <55>110 for most patients. Few patients will be functioning well at lower BP and heart rate. Check with patient during therapy for symptoms.

18- Use parameters to hold betablochers, digoxin, some calcium channels (cardizem and verapamil) hold for HR <60. However the patient cardiologist may accept lower heart rate down to 50 in patient with arrhythmia or CAD.

19- Do not role out MI in the floor if you think patient needs to be rolled out send back to hospital he came from. Unless your suspicion is very low and patient is watched well clinically and have cardiac enzymes repeated as well EKG if necessary.

20- Recognize dry weight and teach cardiac, hepatic and renal patients this concept. It is the weight at which patient has no shortness of breath and no leg or trace edema and no signs of being dry as thirsty, feeling dry, washed out or orthostatic. Patient usually can recognize at what weight he achieve this status. He has to try to keep it by increasing or decreasing lasix according to the deviation from dry weight. Many rehab patients can learn that. Some you have to go more objective by determining how comfortable their breathing, absent leg edema and no orthostatic hypotension.

21- Fluid challenge is a term used to describe given fluids to patients with low BP or elevated BUN/creatinine to see if it will improve the situation. It can be done either orally or IV fluids given.

22- Some patients may be found with high BP in home meds particularly in late afternoon or early morning since a controlled BP in mid day when patients see their doctor may reflect only the blood pressure at that time. These patient commonly will need adding BP in 4-10 PM according to the timing of rise of blood pressure. In some patients a presumed 24 hour BP medicine may cover only <12 hour and patient need the drug to be given twice a day or another BP medicine is added. Though for most patients BP tend to go down at night this is not the case with some patients who may have persistent hypertension overnight.