Exercise Program Implementation and Supervision
Phase-appropriate supervision
Inpatient phase I consists of low-level range of motion and ambulation on telemetry, with vital signs before, during, and after activity, watching for symptoms, and progressing through roughly 2-3 METs. Early outpatient phase II adds telemetry-monitored sessions two to three times weekly, 20-40 minutes, with gradual progression. Late outpatient phases III and IV shift toward self-management with less monitoring and more patient responsibility.
Monitoring and safety systems
Know your emergency action plan, the AED location, how often drills occur, crash cart contents, and how to activate EMS. Supervision ratio and monitoring intensity should match patient risk: those with ejection fraction under 30%, exercise-induced ischemia, arrhythmias, or a recent event need continuous ECG and closer supervision rather than a group walk.
Special considerations
ICD patients should keep peak heart rate 20-30 bpm below the therapy threshold and avoid isometric work and Valsalva. Transplant recipients have a denervated heart with blunted, delayed heart rate responses, so prescribe by RPE. Post-CABG patients observe sternal precautions, avoid heavy upper-body work for 6-8 weeks, and report sternal clicking. Post-MI patients need an adequate cool-down to avoid hypotension and arrhythmias. Document vital signs, symptoms, RPE, workload, and any adverse events every session.
Traps
Confusing phase I with phase II, forgetting to limit upper-body resistance after sternotomy, and assuming a monitored patient cannot also follow a home program.
Rule of thumb
Supervision should be proportional to risk. If you could not defend the chosen monitoring level in a progress note, it is too low.