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Management of the Critically Ill Aging Client with a CHF Exacerbation

presented by Jennifer Ryan

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The physical therapist management of aging patients with a heart failure (HF) exacerbation is complex, and requires ongoing clinical reasoning to determine the patient’s readiness to participate, as well as their ability to progress versus their need to rest. The considerations that need to be weighed are related to the patient’s cardiovascular function and hemodynamic stability, their pulmonary function and dependence on ventilatory support, positive pressure ventilation (or supplemental oxygen), renal function, and their neuromuscular function and overall muscular weakness that can be a result of a prolonged critical illness and immobility. Medications and interventions required to manage their critical illness must also be considered. Participants will learn the pathophysiology of HF related to the prolonged illness as well as the sequelae of an exacerbation, the evaluative components necessary to weigh into the clinical reasoning of when a patient is ready to participate, as well as when an individual demonstrates that they have exceeded their capacity. Through a case-based presentation, the learner will gain insights into the many possible clinical scenarios that can present with an aging patient with a HF exacerbation who is critically ill.

Meet Your Instructor

  • Jennifer Ryan, PT, DPT, MS, CCS

    Jennifer Marie Ryan, PT, DPT, MS, CCS, graduated from the Physical Therapy program at the University of Illinois in 1990 and went on to complete both a Master of Science in Physical Therapy and a Transitional Doctor of Physical Therapy degree at Rosalind Franklin University of Medicine and Science. In July 2006, she was awarded board certification as a Cardiovascular and Pulmonary Clinical Specialist by the American Board of Physical Therapy Specialties. In 2012 she was awarded the Mary Sinnott Award for Excellence in Acute Care and she was awarded the Acute Care Section Lecture for 2014. Throughout her physical therapy career, she has specialized in physical therapy care for critically ill patients. In her current position at the University of Chicago Medical Center she mentors staff and students about management of acutely ill patients along with her patient care. Her teaching in the area of cardiovascular and pulmonary physical therapy includes several continuing education seminars, and as a contract faculty member in the Department of Physical Therapy and Human Movement Sciences, Northwestern University, Feinberg School of Medicine.
    She serves as: a delegate from the Illinois Chapter of the American Physical Therapy Association, the Education Chair for the Cardiovascular and Pulmonary Section of APTA, and as a member of the Subject Matters Expert Task Force of the Acute Care Section of APTA. She founded Rehab Education Formula, an online resource for therapist-focused education.

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Chapters & Learning Objectives

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  1. The Pathophysiology Of the Cardiovascular System Related to Aging

    1. The Pathophysiology Of the Cardiovascular System Related to Aging

    The cardiovascular system undergoes changes in the system structure and subsequent function as a result of aging. How much a system changes as it ages in terms of structure and function is impacted by many modifiable risk factors. The changes to the myocardium that often present are an elevated intrinsic heart rate, myocardial hypertrophy with reduced compliance and reduced responsiveness to sympathetic stimuli. The vascular system may undergo changes in the muscle integrity that reduces it’s distensibility and ability to dilate in response to changes in demand related to exercise.

  2. The Pathophysiological Impact of Heart Failure on Other Body Systems

    2. The Pathophysiological Impact of Heart Failure on Other Body Systems

    The anticipated changes in other body systems as a result of heart failure compound a patient’s ability to recover from a HF exacerbation due to the changes in aerobic capacity, and impaired renal function. An individual with HF presents with chronic changes in multiple systems, namely the renein-angiotensin-aldosterone system as well as the musculoskeletal system, due to prolonged reduced perfusion related to HF that also compound a patient’s ability to recover from an acute bout of HF. In the musculoskeletal system, the shift to type II muscle fibers changes their exercise tolerance/aerobic capacity at baseline and limits their capacity to do work. When the patient is in a HF exacerbation the increased volume creates more work for their system. Their intolerance of fluid volume changes due to their impaired cardiac function during an exacerbation is also due to their limited renal function as a result of the likelihood that their prolonged cardiac dysfunction led to prolonged hypoperfusion of the renal vasculature which collectively impact their management of intravascular volume as well as their exercise tolerance.

  3. The Medical Interventions to Manage the Aging Client in a Heart Failure Exacerbation

    3. The Medical Interventions to Manage the Aging Client in a Heart Failure Exacerbation

    In the most critical phases of a patient’s recovery from a HF exacerbation, they often are unable to maintain their blood pressure so significantly that they present with a reduced ejection fraction from their baseline. To manage this, they often require the support of inotropic and vasoactive medications that may not sufficiently support them to allow participation in exercise and can subsequently impair their mental status, breathing mechanics and their peripheral muscle strength.

  4. Physical Therapist Evaluation of the Readiness of an Aging Client with a Heart Failure Exacerbation to Participate in Therapy

    4. Physical Therapist Evaluation of the Readiness of an Aging Client with a Heart Failure Exacerbation to Participate in Therapy

    Through a thorough systems evaluation the physical therapist will determine the patient’s readiness to participate in an initial examination and intervention as well as for each subsequent intervention. A process of weighing the impact of the patient’s pharmacological support, the oxygenation support and the hemodynamic response in addition to employing the input of members of the interprofessional team by conferring with nursing and the primary service, the therapist will determine the patient’s readiness to participate.

  5. Dealing with the “What If’s”

    5. Dealing with the “What If’s”

    Throughout the patient’s progression in care there are always many possible scenarios. The course will take you through a case to understand the patient’s response to care to help you to gain an understanding of the physical therapist’s clinical reasoning to determine the patient’s ability to progress versus rest during the session. The course will also discuss other possible scenarios of hemodynamic changes or changes in oxygenation, beyond what presented in the case, that could present and how they would be managed.