Post Operative Cardiac Rehabilitation
In the intensive care unit
This unit is staffed by highly experience nursing and medical staff who look after patients after cardiac surgery. After your operation, you will be closely monitored for 24-48 hours. This is an important part in the overall success of your heart operation.
Immediately after surgery, a doctor who assisted your surgery, and an anesthetist will bring you to the ICU. Tubes and monitoring devices inserted during surgery will monitor your blood pressure and pressure in chambers of your heart. Chest tubes are inserted through the skin to drain excess blood from around the heart into a bottle. A urinary catheter may be in place to accurately record urine output. Initially, all fluids will be given intravenously (through a needle). The electrodes placed on your chest will monitor heart rhythm (ECG).
While you are in the hospital, you may notice that your normal sleeping pattern is interrupted. This is because in the ICU monitoring will be done round the clock, lights will be on constantly, doctors and nurses will be entering and leaving the ICU frequently. It is natural for you to lose track of time. To help your heart heal, your body temperature will be kept cool. To accomplish this the temperature in your room will be cool and bed clothing will be light. Although you may be uncomfortable, low temperature is important for your recovery.
Lung Care
After heart surgery, the condition of the lungs is a primary concern. An endotracheal tube may be inserted in your nose or mouth in the operating room. This tube serves 3 purposes.
It guarantees adequate amount of oxygen to the heart muscles.
It helps clear secretion of mucus from your lungs.
It helps you breathe while you are asleep.
The endotracheal tube will be removed when you are able to cough up secretions and when blood tests show that there is enough oxygen in your blood.
When the endotracheal tube is removed, to assist in your recovery, you must cough and breathe deeply. The importance of coughing cannot be over emphasised because coughing helps to prevent congestion, a major complication of heart surgery.
Every two hours the nurses and the physiotherapists will work with you to encourage you to do this. A chest x-ray will be taken daily to monitor the progress of your lungs. Some types of movements may cause pain or discomfort. The chest incision will make coughing and deep breathing painful though coughing will not harm your incision. When your doctor believes your condition is stable, you will be transferred to the intermediate care area. The members of your family will not be permitted to visit you in the ICU for the first 24-36 hours.
Intermediate Care
Once the team is satisfied with your immediate post-operative recovery in the intensive care unit, you will be transferred to the intermediate care area. During your convalescing period in this area, the team will be concentrating on the following:
Breathing and bronchial hygiene. Deep Breathing and Coughing are advised. Postural drainage (changing the posture of the patient, if he cannot move, to relieve chest congestion)is given, if necessary.
Getting you started on eating and drinking again.
- Getting you mobilised.
Eating and drinking
After an operation most patients lose their appetite and also find that their stomach and digestive system are rather sluggish for a few days. Nurses will begin to give you small volumes of liquid. If you start taking adequate quantities of fluid, the intravenous drip lines will be removed. You will be given light food initially. Do not worry if you experience indigestion or a little abdominal swelling in the first few days. Bowel action is sluggish after anaesthesia and operation but this soon settles. If required, a mild laxative will be given by your nurse.
Mobilisation:
Your may be surprised to know that mobilisation begins soon after heart surgery. Early mobilisation aids recovery. The physiotherapist will first help you to walk around your bed, on the 2nd day after surgery. Gradually, you will be helped to walk longer distances and finally taken around the ward. During the initial mobilisation attempts you will find a good deal of stiffness around your shoulders and chest. This is the natural consequence of having a surgical incision on your breast bone. Also, patients who had a vein removed from the leg for coronary graft surgery may find the leg and ankle swollen up. For this, special stockings or crepe bandages encourage good circulation of blood through your leg. Nurses will advise you regarding the use and care of these stockings.
Wounds discharge:
It is very common for a small amount of fluid or blood-stained fluid to ooze from chest incision or leg wound during your recovery period. Small amount of discharge requires only application of dry dressing. If the discharge is excessive, the doctors and nurses will dress the wound.
You are encouraged to participate in:
Group Psysio therapy
Group sessions where you can share your thoughts with other patients
You may be advised to go in for pain management, if your doctor thinks it necessary. Pain management devices like ultrasound, shortwave diathermy, TENS (Transcutaneous Electrical Nerve Stimulation) may be used.
A body fat analyses and nutritional assessment are made. A dietician discusses with you and frames a diet plan.
If you are unable to deal with stress, you can discuss the issue with a psychologist.
For most adults, after a cardiac surgery, the patient is encouraged to climb stairs. If all the heamodynamic parameters are normal at this time the patient is briefed on Home care and discharged.
It is important for you and your family to accept that you would not have been discharged unless you are fit to go home. Without this confidence a nagging and unjustified worry will remain. It is important for you and your family to get your doubts clarified.
Rehab at Home
Rehabilitation for post operative patients should focus on cardiac health keeping in mind the fact that the patient has undergone a major surgery.
Your Outlook
You have survived a health crisis. You have been on medication and special care. Survival from a life crisis releases euphoria. However, depression is a common sequel this euphoria.You have to make a personal effort to adopt a mental attitude of expectation of full recovery, rather than resignation to ill health. No one can do this for you. Others can help by support but it is essentially your personal contribution to your recovery.
Another frequent worry is concerned with being left alone in the house when the others have to be out. There is no reason why you should have an attack or any other problem just because you are alone. You will soon come to realise that you are safe alone. During the first few days at home, continue the same routine as during the last few days in the hospital. You will probably have been dressing yourself and walking around quite freely. Within a day or two start taking short walks in the house lasting about five minutes, 5 or 6 times a day. You can take the stairs slowly if you do not feel pain or become breathless. In case you feel any discomfort stay on one floor level for a few days and then try again. Take a nap when you feel like it. By the end of the first week you should be out in the garden and during the second week you should start taking short walks.
Family/ Caregiver support
Your family members (or friends) are understandably, worried about you. They are all concerned to do the best for you but are often unsure what this is or how to do it. This can lead to misunderstandings which can hurt you and them. The best way to avoid this is to talk freely together about it. Silence puts up barriers. At times you may be depressed and irritable and even quite difficult to get on with. It is important for them to realise that this is just a stage in your convalescence and that their part is to be patient and supportive.
Their help will be very important for you than perhaps you are able to realise and also more difficult to give than you appreciate. It is also important for you and the family to understand that it is very easy for them, in their concern for you, to be over-protective. This is comfortable for you but unhelpful in the long-term. They have to resist this temptation for your own good. The ultimate goal for you is to stand on your own feet and control your own life. You and your family often want guidance on how much you should do. A doctor will give you advice on this. But generally speaking, during recovery you should be encouraged to do as much as you feel inclined but not pushed beyond your inclination. This applies to all aspect of your life including social activities, exercise, leisure and work.
(A CHD patient is often middle-aged and has a number of financial and family commitments and uncertainty about future. It is often important for a patient's spouse or business partner to visit the patient to explain how family and business affairs can be tackled and give the patient the peace of mind and instil self-confidence in him.)
Daily Routine
You should not expect to resume total responsibility for household duties until 6 weeks after you are discharged from hospital. Do not lift anything heavy (especially more than 10 lbs). Do not try to open jammed doors, windows or push heavy furniture.
Hobbies:
If you have any special hobby, which you would like to resume during your convalescence at home, please inquire as to when you may begin.
Stairs:
You may climb stairs at home provided you take your own time and go slowly. Climbing stairs does require more energy than walking. If you become tired, short of breath or dizzy, sit down on the stairs, and rest a while.
Bathing:
Showers are permitted when the incision is healed. Use warm water and soap. Wash your incision gently with soap but do not scrub it. Sit on a bath stool if necessary. Do not attempt climbing into a bath tub at first. Getting out may be very difficult. Avoid extremely hot or cold showers.
Incisions:
A few weeks after surgery your incision will look better. Tingling sensation, numbness, itching and redness near the incision sites are normally experienced after open-heart surgery. This will gradually decrease with time. If there is excessive swelling, tenderness or drainage, let your doctor know.
Support stockings:
This is used to improve the circulation of the leg and to prevent leg swelling. You are advised to wear this for a period of six months.
Weight:
Weigh yourself daily if you have had a problem with fluid retention. Keep a daily record of your weight.
Driving and Travel
Avoid driving a car or scooter for approximately 8 to 12 weeks after surgery, since your reaction time will to sluggish due to weakness, fatigue and medication. It takes 8 to 12 weeks for the breast bone to completely heal. While travelling by car, stop every 1 or 2 hours and walk around. This will improve circulation of blood and prevent swelling of legs. Air travel as well as journey by train and safe and can undertaken two weeks after surgery. Carrying things like suitcases, brief cases and children should be avoided for 8 to 12 weeks.
Visitors:
Visitors mean well. They want to see how you are doing. However, too much "visiting" can be exhausting and interfere with your recovery. Discourage visits from your friends and relatives. Let them know that rest is an important part of your recovery.
Walking:
Bed rest can cause low back pain, shoulder pain, stiffness and depression. Walking can help you get rid of these feelings by improving blood circulation, walking should be done daily with gradual increase in distance and speed.
Rest:
During initial recovery period you need more rest. Try to get 8 to 10 hours of sleep at night. Space your activities and rest periods to avoid extreme fatigue.The need for mental rest after a heart attack is often over looked. It often happens that the attack recurs during mental stress and physical exhaustion.
Returning to work:
This decision depends upon the type of work and your level of physical fitness.Usually, this decision is made after a 4 - 6 weeks review.
Diet
It is normal for your appetite to be poor after surgery. It will pick up as you begin to recover. The dietician and the nurses will help you to understand your dietary plan. Each day you should eat a combination of vegetables, whole grain, bread, meat and dairy products. Balanced eating quickens healing and lessens fatigue. Body weight is important in reducing the work of your heart. Avoid food containing large amounts of fat, sugar and salt. Avoid large heavy meals. Avoid rushing through meals. Remember your heart must increase it's work after meals in order to digest the food. So after meals, plan on some walking (not rigorous exercise).
Caffeine:
For some people, caffeine in coffee, tea, chocolate and cola type beverages causes the heart to beat faster and sometimes irregularly. If you experience this, change to a brand of caffeine-free beverages. You may drink these as often as you would normally drink any type of regular coffee, tea, chocolate or cola.
Drinking:
Alcoholic beverages including beer are allowed in moderation, unless otherwise indicated by the doctor. Alcohol increases the effect of tranquillisers and sleeping pills. So if you are on these type of medication, do not drink.
Exercise
Strengthening and toning of your muscles is necessary.
By exercising twice a day, you'll find it easier to carry out your day-to-day activities.
Important: If you feel severe pain when performing any of these exercises, stop immediately. If pain persists, notify your doctor. Never force or over-stretch a muscle, as you may cause further damage.
And remember to get maximum benefit out of this program, perform each exercise slowly and gently. Work the exercise into your daily routine; for example, exercise as you bathe, or while sitting in a chair watching T.V.
Exercise Guide:
Neck Exercises:
Keeping your shoulders level, touch you chin to your right shoulder, or as close to it as possible. Then touch your chin to your left shoulder, or as close to it as possible. Do not raise your shoulder to your chin. Return to the starting position.
Next, maintaining the same position, move your hand toward your body as close to it as possible. Then move your hand away from your body, as far from it as possible. Return to starting position and repeat the exercise with your left hand.
Elbow exercises:
For this exercise, you can sit in a chair or stand, whichever is most comfortable. Let your arms hang loosely at your side. Then, bending your right elbow, bring your fingertips to your right shoulder, or as close to it as possible. Return your right arm to starting position and repeat the exercise with your left arm.
Forearm exercises:
Keeping your upper right arm at your side, bend your elbow so your forearm's at a 90 "angle to your upper arm and your palm is facing the ceiling. Turn your palm down, then up. Repeat the exercise with your left hand.
Knee exercises:
For this exercise, you can sit on the bed with your legs straight ahead of your or lie on your abdomen with your legs extended. Bend your right knee as much as possible. Return to starting position, and repeat the exercise with your left knee.
Hip exercises:
Lie on your back and bend your right knee. Bring your knee toward your chest, or as close to it as possible. Return your knee to starting position, and repeat the exercise with your left knee.
Next, keeping your knee and hip straight, and toes pointed upwards, move your right leg to the right as far as possible. Return to starting position and repeat the exercise with your left leg.
Bend your hip and knee so the bottom of your right foot is flat on the bed. Roll your leg inward as far as possible. Return to starting position, and repeat the exercise with the left leg.
Maintaining the same position with your back and hips flat on the bed, raise your right leg upward as far as possible. Return your right leg to starting position and repeat the exercise with your left leg.
Trunk exercises:
Sit on a chair so your legs are straight and your arms hang loosely at your side. Bend forward as far as possible. Return to starting position.
Now, maintaining the same position, bend to the right side, making sure your bend from the waist. Then bend to the left. Return to starting position.
Next, stand with your feet 2" (5.1cm) apart. Let your arms hang loosely at your sides - and without bending your knees - bend backward, as far as possible. Return to starting position.
Keeping your hips facing straight ahead, twist your upper body to the right as far as possible. Then, twist your body to the left as far as possible. Then, twist your body to the left as far as possible. Return to starting position.
Shoulder exercises:
Standing straight with your arms at your sides, raise your right arm forward and upward (over you hear), as far as possible. Return to starting position, and repeat the exercise with your left arm.
Now, standing with your arms at your sides, raise your right arm sideways and upward, over your head, or as far as possible. Return your right arm to starting position and repeat the exercise with your left arm.
Maintaining the same position, raise your right arm to shoulder level. Then bring your arm across your body towards your left shoulder, or as close to it as possible. Return your arm to starting position, and repeat the exercise with your left arm.
Sexual Activity for Cardiac Patients
The patient's happiness and successful re-entry into family life depends upon his/her sexual adjustment.
It is perfectly normal to expect that your sex life will be as healthy and enjoyable as it ever was.
There are many adjustments to make after cardiac surgery. Many people are concerned about how their illness and recovery may affect their sexuality.
- Acknowledge that sexual needs are normal.
- Acknowledge that having questions and concerns about resuming sexual realisation are normal.
- Share concerns about sexual activity with your partner.
- Discuss ways to gradually prepare for sexual intercourse.
- List several measures, which will decrease the stress on your heart with sexual activity.
Impotence from fear and anxiety or as a side effect of drug therapy is fairly common.
Your best indicator is how you feel physically and mentally. For the first eight weeks, avoid positions that cause pressure on the breast bone or tension on arms and chest.
Pick time when you are rested and relaxed.
Wait two hours after eating a meal or drinking alcohol.
The demands placed on your heart during sexual relations are equal to walking briskly on the street, or climbing one or two flights of stairs. With sexual inter-course, as with these activities, you may notice an increase in your heart rate and in your breath. Your blood pressure also rises. To make sex as comfortable as possible, and less stressful on your heart, resume relations with your regular partner in the usual setting. If your discharge day is approaching and you have not had the opportunity to discuss this with your doctor, bring the subject up yourself. Your doctor realises sexuality is important and welcomes the chance to discuss this matter with you and your spouse.
The exercise programme that you will be following when you go home may improve your heart function. This will allow you to do and enjoy more work without having your heart work so hard. Improvement in cardiac conditioning has been shown to also increase the quality of sexual activity. Sexual intercourse is similar to exercise because it places the same demands on your heart.
Resume sexual relations slowly as you have resumed your other activities. Engage in sexual activity that was comfortable for you and your partner before hospitalisation. Continue to discuss your feelings with each other as you resume sexual activities. Don't be surprised if you experience a temporary increase or decrease in sexual desire after major illness. Medications and the interference in your body's normal function may cause these changes to occur. If you have any questions or concerns about these, please do not hesitate to consult your doctor. When you are ready for sexual relations, choose times of day when you are most rested. For many this will be in the morning after a good night's sleep. Since sexual relations are exercise, it is advised that you rest as you do after other activities.
A very hot or a very cold room not the best setting for sex. Because emotions have an effect on heart's working load, sex should not immediately follow and argument or an emotional outburst.
Use your medication to full advantage. Ask your doctor if he would advise you to take nitroglycerin before having sexual relations. You can prevent angina from occurring by taking nitroglycerin before lovemaking.
If at any point during your lovemaking you do experience angina or chest pain, slow down or stop. Use your nitroglycerin as prescribed then rest for a while.
Symptoms such as palpitations, irregular heart-beats or extreme shortness of breath during inter-course should also suggest to you to either slow down or modify your activity. If you have any questions or concerns about this aspect of your rehabilitation, please let your rehabilitation team know.
Visiting your physician:
See your local physician/cardiologist when you get home. An appointment may be made to see your surgeon or cardiologist in 12 weeks. If any symptoms return that concern you, call your local physician.
Source: The above material was prepared with the help of the Cardiac Rehabilitation unit at the Institute of Cardio Vascular Diseases, Chennai.
