12.3 Vitals Monitoring and Cardiac Safety

Quick Answer: Build every high-risk cardiac session around HR, BP, SpO2, RPE + symptoms. Absolute stops (ACS, syncope, severe desaturation/distress, alarming arrhythmia, exertional hypotension with compromise) mean stop and escalate. Manage orthostasis with staged posture change. Treat PAD rest pain/tissue loss as urgent vascular care; use supervised walking for stable claudication. Mobilise with chest drains only with system-safe technique.

Safe cardiorespiratory physiotherapy is measurement plus judgment. The APC Written Assessment repeatedly tests whether you monitor the right signals, recognise stop criteria, manage orthostatic hypotension, distinguish claudication from limb-threatening ischaemia, and mobilise people with chest drains without causing harm. Fancy equipment is secondary to disciplined process across Australian wards, rehab gyms, private rooms, and home visits.

Core Monitoring Set: HR, BP, SpO2, RPE

Heart rate (HR)

Measure resting HR when relevant, then response to activity and recovery. Interpret in context of:

• Medications (beta-blockers, digoxin, calcium-channel blockers)
• Pacemaker/ICD presence (paced rhythms may look regular at a set rate)
• Fever, anaemia, pain, anxiety, dehydration (raise HR)
• Athletic conditioning or conduction disease (lower HR)

Concerning patterns: new irregularly irregular pulse with symptoms (possible AF), extreme tachycardia relative to low workload, symptomatic bradycardia, or failure to recover toward baseline after rest. Palpate rhythm quality, not only the number on a watch.

Blood pressure (BP)

Record posture (lying/sitting/standing) when orthostasis is possible. Normal exercise response is a rise in systolic BP with stable or slightly reduced diastolic in many aerobic tasks. Concerning patterns include:

• Exertional hypotension (systolic falling with increasing work) → stop and investigate/escalate
• Extreme hypertensive response with symptoms (severe headache, chest pain, visual change)
• Symptomatic low BP limiting safe upright work

Know the person’s medical targets after stroke, aortic surgery, or HF—generic “normal” is not always the unit goal.

Oxygen saturation (SpO2)

Use pulse oximetry with good signal quality (warm perfusion, still finger). Pair SpO2 with work of breathing, colour, and cognition. Targets are individual: many COPD patients have prescribed lower target ranges (e.g., 88–92% themes in oxygen guidelines—follow the prescription in front of you). Desaturation with disproportionate dyspnoea, cyanosis, or confusion is a stop/modify cue. Do not ignore SpO2 84% because the patient “wants to finish the corridor.”

Rating of perceived exertion (RPE)

RPE (Borg 6–20 or modified 0–10) captures integrated effort when HR is blunted or devices limit interpretation. Teach the scale; re-check understanding in older adults and people with cognitive impairment. For many clinical rehab sessions, moderate RPE bands are used unless a specific test protocol says otherwise. Rising RPE at the same external work can signal decompensation, anaemia, infection, or overreaching.

How to structure monitoring in a session

1. Baseline symptoms and vitals (as indicated by risk)
2. Start activity at planned low dose
3. Recheck symptoms ± vitals at steady state or peak of bout
4. Watch recovery for 3–5 minutes after stopping when risk is high
5. Document and adjust the plan

High-risk examples needing tighter monitoring: recent MI/ACS, decompensated or advanced HF, severe aortic stenosis themes in notes, pulmonary hypertension, fresh post-op cardiac/thoracic surgery, known malignant arrhythmias, and first upright session after prolonged bed rest.

Absolute vs Relative Stop Criteria (Concepts)

Exact institutional lists vary; learn the logic for MCQs.

Absolute-style stop / do-not-continue cues (escalate, do not negotiate “one more lap”):

• Suspected ACS (ischaemic chest pain pattern, equivalents with autonomic features)
• Syncope or near-syncope with ongoing instability
• Signs of acute heart failure decompensation with severe distress / possible pulmonary oedema
• Uncontrolled symptomatic arrhythmia, ICD shock with ongoing symptoms (follow local emergency process)
• Severe desaturation with respiratory distress outside safe recovery, or inability to speak due to breathlessness at low load
• Acute neurological event signs (stroke FAST features)
• Severe hypertensive emergency symptoms or exertional hypotension with compromise
• New severe musculoskeletal trauma or uncontrolled bleeding

Relative stop / modify cues (reduce intensity, shorten bout, change mode, increase rest, or stop if not improving):

• Excessive fatigue disproportionate to plan
• Mild dizziness that resolves quickly with posture correction (still investigate orthostasis)
• Claudication pain reaching prescribed stop level in PAD walking programs
• RPE higher than intended zone
• Moderate BP rise above preferred session limits without emergency features
• Oxygen need increasing to maintain target during activity (review with team)

Exam skill: choose the option that matches severity. Mild calf ache in known stable PAD ≠ crushing chest pain. Do not over-call every symptom as code blue, and do not under-call ACS.

Orthostatic Hypotension

Orthostatic (postural) hypotension is a sustained drop in BP on sitting or standing (classic teaching thresholds involve ≥20 mmHg systolic or ≥10 mmHg diastolic drops—use local definitions) with or without symptoms: dizziness, vision greying, nausea, syncope risk. Common in:

• Prolonged bed rest and deconditioning
• Antihypertensives, diuretics, vasodilators
• Autonomic dysfunction (diabetes, Parkinson’s, some neuropathies)
• Hypovolaemia, sepsis recovery, adrenal issues
• Post-prandial states in frail older adults

Physiotherapy management:

• Rise in stages: lie → sit → stand; pause and reassess symptoms/vitals
• Ankle pumps and leg muscle activation before standing when appropriate
• Adequate hydration within medical fluid limits; timing sessions away from peak diuretic effect when possible
• Compression garments only if prescribed/appropriate
• Guard against falls; use gait belt/assistance as needed
• Do not force corridor walking through symptomatic orthostasis “for numbers”
• Escalate recurrent syncope, injury, or BP outside medical parameters

Document lying and standing measurements when orthostasis is the clinical question. After HF diuresis or first mobilisation post-MI, orthostasis is an expected exam theme—link cardiac safety to fall prevention and gerontology reasoning without abandoning the cardiac diagnosis.

Peripheral Arterial Disease: Claudication vs Rest Pain

Peripheral arterial disease (PAD) from atherosclerosis limits limb blood flow.

Intermittent claudication

• Reproducible aching/cramping in calves (or thighs/buttocks) with walking
• Relieved by standing rest within minutes (not needing to sit necessarily)
• Stable claudication is a classic indication for supervised exercise therapy (walk to near-maximal claudication pain as prescribed in programs, rest, repeat)—improves distance over time
• Still screen for cardiac disease: PAD is a coronary risk marker; stop if cardiac red flags appear

Rest pain and critical limb ischaemia themes

• Ischaemic pain at rest, often nocturnal, hanging the foot out of bed for relief
• Non-healing wounds, gangrene, severe colour/temperature change, absent pulses with threatened tissue
• These are urgent vascular review problems—not “walk through the pain harder” physiotherapy alone

Exam contrast: stable claudication → structured walking program + risk-factor support + medical vascular care as indicated. Rest pain/tissue loss → urgent escalation, protect limb, do not run a claudication treadmill protocol as the primary response.

Also differentiate neurogenic claudication (spinal stenosis: often improves with flexion, may need sitting) from vascular claudication using history; if uncertain and red flags exist, assess both systems and escalate appropriately.

Chest Drains and Mobilisation Awareness

Patients after thoracic surgery, pneumothorax, pleural effusion, or empyema may have intercostal catheters / chest drains. Physiotherapy often mobilises these patients early, but with system awareness:

• Confirm medical clearance parameters and whether suction is required or can be disconnected per protocol for walking
• Keep tubing free of kinks; maintain the drainage bottle upright and below chest level—never raise the bottle above the insertion site in a way that risks fluid backflow
• Secure the tubing; prevent accidental pull-out during transfers—coordinate two-person assistance if needed
• Monitor pain, SpO2, subcutaneous emphysema concerns reported by team, bubbling patterns as documented by nursing, and wound site
• Encourage shoulder range and deep breathing as allowed to prevent stiffness and atelectasis, while respecting pain and surgical limits
• If the drain dislodges or the system cracks open: emergency medical/nursing response immediately—do not improvise complex reinsertions outside protocol and training

Exam traps: swinging a drain bottle above the chest during a transfer; ignoring sudden dyspnoea after drain issues; or refusing all mobility forever solely because a drain is present when the team expects assisted mobilisation with a portable system.

Putting It Together: A Safety Algorithm

1. Screen for red flags (ACS, acute HF, critical limb, drain emergency, stroke)
2. Set monitoring plan matched to risk
3. Dose activity with clear intensity anchors (RPE, distance, time)
4. Respond to absolute stops with escalation; relative stops with modification
5. Document vitals, symptoms, assistance, and plan changes
6. Communicate with the multidisciplinary team

This algorithm applies in ICU step-down, surgical wards, cardiac rehab gyms, and home visits—only the escalation pathway phone number changes. When multiple problems coexist (post-MI + orthostasis + PAD), prioritise life-threatening cardiac/respiratory instability first, then falls, then graded function.

Competency and Professional Practice Links

Monitoring and stop criteria are risk-management and scope competencies in action. Knowing when not to treat is as important as exercise prescription skill. Cultural safety and communication still apply: explain why you are stopping a session in plain language; shared decision-making does not mean agreeing to unsafe requests. Document baseline and response vitals, assistance level, and the clinical reason for stopping—good notes protect patients and support team decision-making in Australian health services.

Closing Exam Anchor

Measure HR, BP, SpO2, and RPE; honour absolute stops; respect orthostasis; treat rest pain as vascular urgency; mobilise with drains only with system-safe technique.