Day 2 After Sternotomy
Mr. T, 64, is day 2 post three-vessel CABG via median sternotomy. Orders: sternal precautions, no lifting over 5 lb, avoid pushing or pulling with the arms; 2 L O2 by nasal cannula; activity as tolerated with assistance. Pre-session vitals: HR 104 (his documented baseline is 72), BP 102/64, SpO2 92%, RR 24, temp 100.8 F. He is diaphoretic and says he "feels a little off," then asks to walk to the bathroom "like the doctor said." The bathroom is 15 feet away. Pain was 3/10 an hour ago. Most recent hemoglobin is 8.6 g/dL.
1. Should the COTA proceed with ambulation, modify the session, or hold it? Defend the decision with the specific data.
Read the worked answer
Hold the ambulation and escalate. The decision is not "activity as tolerated" in the abstract; it is a match of today's numbers against this patient's own baseline and against common inpatient hold parameters.
Findings that individually warrant stopping and collectively make ambulation unsafe:
- HR 104 vs baseline 72 - more than 20 bpm above his baseline, and resting.
- SpO2 92% on supplemental O2 - borderline at rest; it will drop with exertion.
- Temp 100.8 F and new diaphoresis - possible infection or early complication; diaphoresis with tachycardia is a classic warning sign.
- Hgb 8.6 g/dL - reduced oxygen-carrying capacity; orthostatic intolerance and falls risk are elevated.
- RR 24 and "feels off" - patient self-report of not feeling right is a legitimate data point, not noise.
Action: seat or return him to bed, do not ambulate, take a full set of vitals, and notify the nurse and covering provider now rather than "after my next patient." Document the vitals, the patient's statement, the decision, and who was notified. Communicate to the OT so the plan of care reflects the hold.
2. Two days later he is cleared and still needs a walker to reach the bathroom. How should the COTA grade the session so that sternal precautions and the goal are both satisfied?
Read the worked answer
The apparent conflict - he needs upper-extremity support to walk, but he cannot push or pull with his arms - is resolved by controlling the amount and direction of force through the arms rather than banning the device.
Plan:
- Confirm with the OT/nursing that walker use with sternal precautions is permitted at this facility; practice varies, and the COTA follows the supervising OT's and surgeon's parameters rather than a personal preference.
- Teach him to splint the sternum with a folded towel or pillow held against the incision during transitions and any coughing.
- Coach him to rest forearms on the walker for balance with minimal weight bearing through the hands, keeping elbows bent and shoulders relaxed, and to avoid pushing the walker ahead and hauling himself forward.
- Use a gait belt and one-person assist; the therapist pulls on the belt, not on his arms.
- Pre-medicate, sit at the edge of bed with a vitals check, then walk the 15 feet with a chair staged halfway.
- Teach the log roll and the "nose over toes" sit-to-stand without arm pushing from the bed rail.
Document the cueing level and the distance; the goal is functional transfer of training, not laps.