Pediatric Cardiology Rehabilitation in an Adult World

Janet Duval, RN, BSN, Manager of Noninvasive Cardiovascular Diagnostics Advocate Lutheran General Hospital Park Ridge, Illinois
Janet Duval, RN, BSN, Manager of Noninvasive Cardiovascular Diagnostics Advocate Lutheran General Hospital Park Ridge, Illinois
This article outlines Advocate Lutheran General Hospital’s innovative Pediatric Cardiac Rehabilitation Program, which is among only a few in the country. Computer games, music, cell phones, movies, friends, lip gloss and homework: all things in a typical 10-year-old girl’s life that may be perceived as priorities or challenges. However, in one specific 10-year-old girl’s life, surviving a myocardial infarction and undergoing reconditioning was her priority and her challenge. In the cardiac rehab department at Advocate Lutheran General Hospital, this little girl’s challenge became our challenge. A pediatric cardiologist asked us to provide Mikayla Kutil with a structured, monitored program of education, exercise, risk reduction and reconditioning. This is the Phase II Cardiac Rehab service we typically provide for adults that have undergone cardiac surgery or angioplasty or have had a myocardial infarction. Mikayla had suffered a myocardial infarction while undergoing a cardiac ablation for a dysrhythmia and required the assistance of our program to continue her recovery. Our team consisted of Theresa Drummond, RN, BSN, MA, nurse clinician III, Carolyn Ruiz, RN, BSN, nurse clinician II, Shawn Schueman, MS, exercise physiologist, Michelle Torri, MS, exercise physiologist, Fay Matsinopoulos, administrative assistant, and myself. After researching other cardiac rehab programs in our area, our team discovered that no other facility offered a pediatric program. In fact, we could only identify two pediatric programs nationally that provided this service. With the assistance of a nurse practitioner working with Jonathon Rhodes, MD, at Children’s Hospital Boston, we committed to developing an age-appropriate program that focused on exercise, nutrition, risk reduction and stress management. Patient safety is always our number one priority. The cardiac rehab department has a crash cart, medications, respiratory equipment and processes in place to respond to emergency situations; however, all are geared toward adults. If we were to provide our services to a high-risk child, we needed to modify many things, including our emergency response. Because of the height and weight of this patient, the pediatric cardiologist recommended that we use the adult crash cart. We obtained a pediatric respiratory box and emergency medications that were appropriate for the clinical situation, including a pediatric dosing chart. A clinical specialist did a refresher course in pediatric basic life support and we notified the hospital’s code blue team, rapid response team and emergency department that we were going to be treating a pediatric patient. Exercise was the next issue to address. We knew we had to make this entire experience fun in order to keep a 10-year-old girl interested so she would benefit from the program. We developed age-appropriate physical activities that would assist our patient in recovering from her physical condition, hoping to give her the confidence needed to succeed emotionally and psychologically as well. In addition to the treadmills and exercise bikes, we integrated a hoola hoop, a Skip-It, a basketball, a punching bag, and an electronic dance mat into the program to provide a variety of activities to maintain interest. Our search for resources to assist us with nutritional education produced the website, www.mypyramid.gov.1 A great deal of importance needed to be placed on a heart healthy diet for weight loss and weight management. Lessons in the treatment plan included: recording food choices for three days in order for the cardiac rehab staff to evaluate and discuss with the patient and family; trips to favorite fast-food restaurants to find out the amounts of calories and fat in the foods ordered; a tutorial on how to evaluate nutritional contents by reading food labels; a survey of foods available in the school’s vending machines; and an interactive game on the website that reinforced heart healthy food choices and exercise. Once we developed our plan to address the safety and physical needs of our patient, we turned our focus to psychological issues. In this fast-paced, high-speed world, children are faced with many stressors in their lives more than ever before. Imagine adding the fear of having a life-threatening dysrhythmia and then a myocardial infarction on top of everything else. According to Erik Erikson, a 10-year-old is in the School-Aged Child (Industry versus Inferiority) stage, approaching the Adolescent (Identity versus Confusion) stage.2 At this age, a child might be very dependent on the parent while also starting to integrate many roles such as child, sibling, student and athlete into a self-image. We knew the parents and family would be an integral part of the process, and prepared to develop a therapeutic relationship with them as well. Mikayla’s mother attended the exercise and educational sessions so that she was aware of Mikayla’s progress, could assist with homework assignments, and have the information to reinforce nutrition and exercise lifestyle changes. Social interactions are also particularly important at this time, with the child beginning to develop a sense of pride in accomplishments and explore independence. Since Mikayla was going to miss some school, and therefore, the social interactions from her peer group, it was important that she felt comfortable with the adult patients in our program. At first, Mikayla was hesitant to exercise in an atmosphere of adult patients, ranging in age from 40 to mid-70s. She was not accustomed to the type of music playing or the conversations taking place. Our team worked very hard to get her to engage with the adult patients, and we explained to our other participants why we needed to introduce a 10-year-old child into their cardiac rehab experience. Once everyone understood what was going on, the situation was not so tense. Mikayla and the adult patients began to converse and encourage each other, and by the end of the program, Mikayla had developed bonds with some of the adults, whom she then referred to as her “grandmas and grandpas.” The experience also was beneficial for our adult patients, allowing them to see that people can have heart problems at any age. Mikayla has since undergone a second ablation that was successful. She has returned to playing softball and is enjoying a healthier lifestyle. As for the cardiac rehab team, we found this to be a very positive and educational challenge. The exercise physiologists partnered with the nurses to develop a creative program that would be comprehensive, educational, fun and safe. We felt a sense of accomplishment and learned that, together, our team is able to provide care to any person at any age. We look forward to our next challenge. For more information, please visit: http://www.advocatehealth.com/luth/