Lorin G. (OT)

Working in a SNF, I recently encountered a man who had just hada Coronary-Artery Bypass Graft (CABG), Chronic Obstructive Pulmonary Disorder (COPD), and one or two other co-morbidities.  I was told I really needed to watch sternal precautions for this patient, but what could I do with him to help him with ADLs, basic light easy therapeutic exercises and functional transfers and mobility?  I remembered very little from school about sternal precautions.  I remembered something about avoiding bending, lifting and twisting (avoid those BLTs).  What could I do for getting this gentleman out of bed, getting him moving and making sure he didn’t push himself too much?

Another OT told me about this man’s heart pillow which he was to hold with both arms over his chest when he did his transfers out of bed to his wheelchair.  I did a little research on-line and learned that during a CABG or other heart surgery, surgeons break apart the sternum to access the heart, do their surgery and then wire the sternum back together (1).  During the first 4-8 weeks following surgery, a patient really has to watch their sternal precautions and not do any inappropriate exercises.  There is no lifting of weights of 10 lbs for the first 4-8 weeks.  A gallon of milk weighs around 8.5 pounds (2) and may be very difficult at first after a CABG or the placement of a pacemaker or other cardiac surgery.  An individual can lift a 1 or 1/2 pound weight while holding their other hand over their chest to start to strengthen their arms and build more endurance.

A quick summary of sternal precautions includes the following.  A patient needs to not push or pull with the arms when moving in bed and getting out of bed.  An individual needs to avoid twisting or deep bending (avoid those BLTs).  Advise the patient to avoid holding the breath during deep breathing.  An individual needs to always avoid reaching across the body or flex or extend the shoulders over ninety degrees.  It is vital, especially in the first two weeks to encourage a patient to brace their chest when coughing or sneezing.  Encourage reporting any popping or clicking noise in the chest to you, the nurse or other medical staff.  Someone recovering from heart surgery should not drive until cleared by their surgeon.  Overall, advise caution with most activities after heart surgery.  A heart patient should stop any activity that causes too much pain or discomfort with the use of the arms (3).

An individual can be encouraged to raise both arms over their head at the same time while sitting for about 5 seconds while sitting in order stretch.  About the best exercise following heat surgery is walking (functional ambulation for us OTs).  A patient can be encouraged to walk for about 10 minutes, then rest and then walk again, to build activity tolerance and endurance.  I was told to make surethis individual did not use his arms to push up from his chair (4).

Overall, as in all therapy, caution is the real key.  This patient’s recovery has been slow with the sternal precautions, the COPD and subsequent depression.  He states his recovery has been too slow. He has broken down with tears a few times.  A heart patient should be encouraged to exercise, so their muscles won’t atrophy and decline (4), but exercise with a patient with a lot of comorbidities can be strenuous and overwheling. I feel it is my mission to help this man recover through light exercise as he can tolerate it, functional ambulation and transfer practice and help with ADLs.

References:

1.  Linda Ray, “Arm Exercises with Sternal Precautions”, accessed at http://www.livestrong.com/article/362636-arm-exercises-with-sternal-precautions/ on 8/14/11.

2.  From www.Ask.com, accessed on 8/21/11 from  http://www.ask.com/questions-about/Weight-of-a-Gallon of-Milk

3. University of Wisconsin, Madison, “Sternal Precautions- After Cardiac Surgery” from  http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_INFORMATION-FlexMember-Show_Public_HFFY_1126652335881.html, accessed on 8/21/11.

4. Karla Gambrill, “Cardiac Precautions for Therapy”, accessed at http://www.livestrong.com/article/257357-cardiac-precautions-for-therapy/ on 8/21/11.