i bc27f85be50b71b1 (130 page)

has vascular or hematOlogic dysfunction include the following:

•

Patients with peripheral vascular disease commonly have

concurrent coronary artery disease and diabetes mellitus; there·

fore, being watchful for signs and symptoms of angina in conjunction with monitOring vital signs and blood glucose levels is essential.

•

Patients with peripheral vascular disease may also have concurrent chronic obstructive pulmonary disease; therefore, activity tol·

crance may have pulmonary limitations as well.

• Patients with peripheral vascular disease may have impaired

sensation from arterial insufficiency, comorbid diagnosis of diabetes mellitus, or peripheral edema; therefore, sensation testing is an important component of the physical therapy evaluation.

•

Peripheral edema can result from a variery of disorders, including venous insufficiency, liver disease, rena) insufficiency or rena) failure, and heart failure; rherefore, rhe physical therapist should

perform a thorough review of the patient's medical history before

VASCULAR SYSTEM AND HEMATOLOGY

429

performing any edema management techniques. For example, limb

elevation may be helpful in chronic venous insufficiency but may

be detrimental in acute congestive heart failure.

•

The physical therapist should monitor a patient's CBC and

coagulation profile on a daily basis to determine the potential risk

for bruising or bleeding, thrombus formation, and for altered oxygen-carrying capacity with exertion.

•

To gain insight into the hemostatic condition of the patient,

determine (1) whether the abnormal blood laboratory values are

expected or consistent with patients medical-surgical status, (2) the

reiative severity (mild, moderate, or severe) of the abnormal laboratory values, and (3) wherher the patient has a medical history or predisposing condition that could be exacerbated by the abnormal

laboratoty values.

•

The physical therapist must determine the need to modify or

defer physical therapy intervention in the serring of abnormal

blood laboratory values, most commonly alterations in Hct, Pit,

and PTITNR. Often, there is no specific numeric protocol for this

purpose; thus, the decision to modify or defer physical therapy

must be based on the clinical picture as well as the quantitative

data. For example, a patient may have a low Pit count but is hemodynamically stable without signs of active bleeding. The physical therapist may therefore decide to continue to mobilize the patient

out of bed. Conversely, if a patient with a low Pit count has new

hemoptysis, the physical therapist may then defer manual chest

physical therapy techniques, such as percussion.

•

Exercise guidelines for patients with thrombocytopenia vary

among hospitals. A general rule of thumb regarding exercises that

should be performed is the following: activities of daily living;

active range of motion, and ambulation with physician approval

for Pit count of less than 20,000 mm3; active range of motion and

walking as tolerated for Pit count of 20,000-30,000 mm3; active

range of motion, ambulation, or stationary bicycling for Pit count

of 30,000-50,000 mm3; and, progressive resisrive exercise, ambulation,:, or stationary bicycling for a Pit count of 50,000-150,000

mm3,

• For an INR greater than 3.5 (the standard highest level for anticoagulation), consult with the nurse or physician before physical

430 ActITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

therapy intervention and modify treatment accordingly. There is no

common protocol for activiry guidelines for the patient with an

INR greater than 3.5; however, most patients continue out-of-bed

activities and activities of daily living with caution or supervision

with an INR slightly greater than 3.5. Generally, physical therapy

intervention is deferred, and the patient may be on bed rest if the

INR is greater than 6.0.

•

The monitoring of blood pressure, heart rate, and respiratory

rate is recommended at rest and with activity, because the hemodynamic sequelae of alterations in blood volume or viscosity may be subtle or insidious in onset and first noticed in response to exercise

by the physical therapist.

•

Observe the patient for the signs and symptoms of thrombus

formation or bleeding during physical therapy intervention. Immediately report any abnormalities to the nurse.

•

Progression of activity tolerance in patients with hematologic

disorders does not occur at the same rate as in patients with normal blood composition; therefore, the time frame for goal achievement rna y need to be lengthened.

References

1. Black JM, Matassarin-Jacobs E (cds). Luckmann and Sorensen's Medical-Surgical Nursing: A Psychophysiologic Approach (4th cd). Philadelphia: Saunders, 1993;1286.

2. Marieb EN. Blood. In EN Marieb (cd), Human Anatomy and Physiology (3rd cd). Redwood City, CA: Benjamin-Cummings, 1995;584-611.

3. Knight CA. Peripheral Vascular Disease and Wound Care. In SB O'Sullivan, TJ Schmirz (cds), Physical Rehabilitation: Assessmenr and Trearment (4th cd). Philadelphia: FA Davis, 2001;583-608.

4. Lanzer P, Rosch J (cds). Vascular Diagnosrics: Noninvasive and Invasive Techniques, Peri-Intervenrional Evaluarions. Berlin: Springer

Verlag, 1994.

5. Fahey VA (cd). Vascular Nursing (3rd cd). Philadelphia: Saunders, 1999.

6. Hallet JW, Brewster DC, Darling RC (cds). Handbook of Patient Care in

Vascular Surgery (3rd cd). Bosran: Litrle, Brown, 1995.

7. Hillman RS, Aulr KA (cds). Hemarology in Clinical Practice: A Guide co

Diagnosis and Management. New York: McGraw-Hili, J 995; 17.

8. Goodman ec, Snyder TK. Overview of Hemarology: Signs and Symproms. In ec Goodman, TK Snyder (cds), Differential Diagnosis in Physical Therapy: Musculoskeletal and Sysremic Conditions. Philadelphia: Saunders, 1990;114.