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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
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Verlag, 1994.
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