CARDIAC TRANSPLANT PATIENT HANDBOOK

Kaiser Permanente Transplant Service

Santa Teresa Community Hospital

WHY DO YOU NEED A TRANSPLANT? Reasons for Heart Transplantation: End-stage heart disease with a prognosis of less than one year survival. Cardiomyopathy: a condition that results in a severely weakened heart muscle. Coronary artery disease: also known as ischemic cardiomyopathy. Congenital heart disease. Patients are considered for transplantation when the function of the heart cannot be significantly improved by either medical therapy or other types of surgeries. The cardiac failure results in severe limitations in activity and limited life expectancy. YOUR HEART - HOW DOES IT WORK? The function of the heart is to pump blood for circulation throughout the body. The blood provides the oxygen and nutrients the body needs to work and removes the waste products generated by the body’s cells. The heart has two atria (the top chambers) and two ventricles (bottom chambers). As shown in the diagram, blood is pumped through the right side of the heart into the lungs (where it picks up oxygen), to the left side of the heart and out the aorta for circulation throughout the body.

See Pages 37 through 40

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STATISTICS

Stanford University Medical Center Transplant Survival Statistics

as of 2001

1 year survival 3 year survival 5 year survival

82% 73% 65%

WAITING TIMES

Because of the critical shortage of donor organs, patients must wait to receive their life-saving transplants. Sadly, one person dies every four hours because not enough families say “yes” to donation.

For 803 patients at Stanford University Medical Center, the average waiting time was 119 days and the median waiting time was 45 days. The average waiting period for a heart transplant is 6-12 months. Many patients receive their transplants within days, sometime within hours, of their names appearing on the national waiting list. The United Network for Organ Sharing allocates organs according to medical matching and medical urgency, not according to social, economic, political or celebrity status. Patients waiting for a heart transplant are either: Status 1a: in the intensive care unit on life support medication or mechanical heart

support device (VAD). Status 1b: in the hospital (but not the ICU) on life support medication or at home

with a mechanical heart support device (VAD). Status 2: all other patients in the hospital or at home. Status 1 patients have a higher priority and go to the top of the list to receive a new heart.

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CONTINUOUS ORGAN FUNCTION

A recipient can live a long and productive life after receiving an organ transplant. The longest surviving recipient with continuous organ function is reported to be:

Kidney 32 years Kidney/Pancreas 14 years Pancreas/Liver 16 years Liver 25 years Heart 21 years Heart/Lung 12 years Lung (double) 10 years Lung (single) 8 years Bone Marrow 21 years

WHERE DO WE GET THE DONATED ORGANS FROM? UNOS: United Network for Organ Sharing. UNOS operates the Transplantation Network and keeps a list of all patients waiting for a transplant in the United States. UNOS is a neutral party which was established to provide fair distribution of organs to programs throughout the U.S. It is regulated by the federal government and must follow strict rules.

CTDN: California Transplant donor Network is a member of UNOS and serves more than 40 counties in Northern California and Nevada.

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WHAT INFORMATION CAN I KNOW ABOUT THE DONOR?

Curiosity about the donor is natural. Some people may think or dream about their donor, and this is normal. Some recipients worry that they may take on the emotional, psychological, or physical characteristics of their donor, but this will not happen. Some patients and family wish to know who their donor is, and some do not. It is natural to feel grateful tot he donor and the donor family. However, because of confidentiality we cannot provide information on the identity of the donor. If you wish, you can write an anonymous letter to the donor family and give it to the transplant social worker to pass on to the donor family. Donor families are appreciative of letters coming from individuals who have received the organs, as it helps them to know something positive has come from their tragedy.

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WHAT IS INVOLVED IN THE WORK-UP PRIOR TO A TRANSPLANT?

• History and Physical Examination

• Blood Work l- A number of blood samples are taken to evaluate your liver,

kidneys, blood counts, and prior exposure to certain viruses (such as chicken pox, hepatitis, etc.) and blood and tissue typing. You will also be tested for HIV.

• Electrocardiogram (EKG) - This test records your heart rhythm. Twelve small

pads or cups are placed on your chest, arms, and legs. These are connected to wires from a machine that records how fast your heart is beating as well as any abnormal beats. It can also show if there are any signs of an old heart attack. The test takes about 5-10 minutes.

• Heart Echocardiogram - The echo uses sound waves to look at your heart’s size

and how the chambers and valves are working. As you lie on a table, a technician moves the hand-held device (transducer) over your chest and takes pictures to record the functions of your heart.

• Right heart catheterization measures specific pressures in the lungs and in the

right side of the heart. • Left heart catheterization to check for coronary artery disease and the function of

the left side of the heart. Whether this is needed is decided on an individual basis. The catheterization involves putting a catheter (tube) into the large vein in either the upper leg or neck and moving it into the heart. Dye is then injected through this catheter and pictures of the heart are taken. Pressures in the chambers of the heart are recorded. If the pressures are very high, intravenous medication may be given to see if the pressures can be lowered. The test takes about 1-2 hours. You will need to lie almost flat for at least 6 hours afterwards to prevent bleeding at the area where the catheter was inserted.

• Chest x-ray.

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• Pulmonary Function Tests - are used to check the health (or disease) of your

lungs and airways. A number of specific tests will be done for a complete evaluation. These include different breathing tests such as breathing deeply and rapidly, breathing out rapidly and completely after taking a deep breath in, and other breathing exercises. This procedure takes about 15 minutes.

• Exercise Testing - is also done to assess your lung function when you are active.

You will be asked to walk on a treadmill while your heart and lung function is being monitored. Blood gas samples (to check oxygen and carbon dioxide levels) will be taken from a small catheter (tube) in your wrist artery. This procedure3 takes about 2 hours.

• Social Worker Evaluation - You will meet with our transplant social worker to

review you issues and concerns, discuss the emotional issues related to transplant, and answer any additional questions.

• Dietary Consult and Explanation - This is especially important for patients whose

weight is much greater than or less than ideal body weight. Your nutrition is extremely important in keeping you healthy during the waiting period, lowering the risk of the surgery and speeding your recovery.

• Individuals may require other tests as part of the evaluation for heart

transplantation. • Patient Contract - The patient contract is helpful for you, your family, and the

transplant team. It is a written document that explains the commitment we require from you and the transplant team’s involvement in your health and medical care. A copy of the patient contract is included at the end of this booklet, and will be signed by you at the time you are placed on the waiting list.

∗ Additional studies may be required on an individual basis.

These work-up tests are done to:

1. Rule out individuals who

a. would not benefit from transplantation.

b. pose too great a risk for transplantation

2. Establish a baseline for individuals who will undergo transplantation.

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PHASES OF TRANSPLANTATION

After the evaluation takes place, a recommendation is made by the Kaiser Permanente Transplant Service medical director, the thoracic surgeons at Stanford University Medical Center and a board of Kaiser Physicians to determine if the individual is a candidate and should be listed for transplantation. Waiting for Transplantation Once an individual is accepted to a transplant waiting list, a pager is issued. This pager is used by SUMC to contact the individual when a heart becomes available for transplantation. The length of wait for a transplant can vary widely from a few weeks to two years or more. The availability of donor organs largely decides the length of wait before transplantation. Most candidates find awaiting surgery a stressful time. The longer the wait, the greater the stress. While on the waiting list, the individual needs to remain within two hours travel time (air or auto) from Stanford University Medical Center. Transplantation When a heart becomes available, the transplant usually takes place at Stanford University Medical Center. What is the Operating Time for a Heart Transplant? 3-4 hours; add 1-2 hours if you have had prior heart surgery. How is the Surgery Done? An incision is made down the middle of your chest. The surgeons remove your old heart leaving a small “cuff” behind. This is what they sew your new heart onto. In addition, they need to sew the main blood vessels to the lungs (pulmonary artery) and body (aorta) together. What About Blood Transfusions? It is quite common to receive blood in the operating room or in the immediate post-operative period after heart transplantation. It is impossible to donate blood for this because we never know when the transplant is going to take place. Therefore, the donor specific blood would not be fresh. If you should need blood after the immediate post-operative period, there may be time for you to have designated donors (i.e. family members). 8

What Should I Expect After Surgery in the Intensive Care Unit? Most patients will wake up 2-10 hours after surgery. You will have: 1. A breathing tube through your mouth or nose into the trachea (main air pipe).

You CANNOT talk or eat with this tube in place; the nurses are very good at communicating with you by asking yes and no questions to which you can nod your head. They will also give you paper and a pencil to write with. It is difficult to clear phlegm on your own with the tube in place so the nurse will insert a smaller tube (catheter) every 2-4 hours to suction out any phlegm. After the breathing tube is removed, it is very important to cough and breathe deeply. All patients will be on oxygen temporarily by mask or nasal prongs. Once the breathing tube is removed (usually 24-48 hours after surgery) your nurse will give you ice chips to suck and advance your diet to clear liquids. Then soft food, etc.

2. Wrist restraints: Your wrists will be gently tied down as a precaution so you do

not accidentally pull out your breathing tube as you are waking up. 3. Chest tubes: (drainage tubes coming out of your chest) drain the blood and

fluids from surgery in the chest. In most cases, they are removed after a few days.

4. Foley catheter in your bladder - we need to keep track of how much urine comes

out each hour. This is removed in 2-4 days. 5. Large intravenous (IV) catheters in your neck and your arm. We can draw most

of the blood that we will need from these IV’s so that you will not need to be continually poked for blood draws.

6. Because recovery in the ICU is busy and tiring to the patient, we request that

visitors be limited to the most immediate family only. A schedule of the visiting hours is posted outside the ICU at SUMC.

How Will I Feel After Surgery? After surgery, it is common to feel any or all of the following: 1. Lack of sleep:

Because you are being constantly monitored, lack of good sleep is very common in the intensive care unit (ICU). Often, your days and nights get confused here. The nurses will try to schedule naps to make up for your lack of sleep.

2. Strange dreams/nightmares/hallucinations:

Anesthesia, medications, lack of sleep, and other reasons often cause patients to have strange dreams, nightmares, or hallucinations. Please let us know if this is a problem for you.

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3. Pain/discomfort: For the first 24 hours, pain is not usually a problem because the anesthesia works

as pain medication. After 24 hours, when you begin to move and sit in a chair, you will feel incisional pain. There is pain medication ordered which is helpful to your recovery. It allows you to cough, deep breathe, sit up, walk and sleep comfortably all which speed you to good health. Please ask for this. We want no heroes.

4. Nausea, loss of appetite: Medications, anesthesia, and surgery often make you feel nauseated. There is medication ordered which may be helpful. Please ask for this. 5. Difficulty concentrating: This is temporary and will improve with time. Medication, anesthesia, lack of

sleep also contribute to this. 6. Weak of dizzy: The first few times out of bed (the nurses will always assist you until you are

stronger and comfortable enough to walk on your own). 7. Difficulty with coughing: This is due to pain and muscle weakness. We will try to give you adequate pain

medication, because coughing and deep breathing is extremely important. Doing this routinely helps to prevent infection.

∗ These are not meant to scare you. They are to let you know what is normal after

surgery so you are prepared for what you might experience. The more educated you are the less stressful the whole experience may seem.

WHAT HAPPENS WHEN I TRANSFER TO THE FLOOR?

1. There is an adjustment period going from the ICU, where your nurse is always in

your room, to the floor, where your nurse has 3-4 other patients to care for as well as you. You will become more independent but will still be closely monitored. This is a stepping stone to going home.

2. Visitors are required to wash their hands before entering your room. You will

need to put on a mask when you leave your room to protect yourself from infection. You will still tire easily, so we request that visitors and phone calls be limited.

3. A self-medication program will be started your second day on the floor. Initially,

the staff will set up your medications with you. However, you will progress to being in charge of your own medication schedule, understanding what the medications are for and taking the correct dosage. This seems difficult at first, but becomes second nature with time and is some of the most important material we will teach you.

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4. You will begin to record your daily weight, blood pressure, pulse, and temperature

in your home journal. There are also three laboratory values to keep track of which we will inform you of daily (White Blood Cell count, Gengraf/CSA level, and Creatinine).

5. Walking is a must, although it may be tiring for you. This will increase circulation,

decrease fluid retention, help healing, help keep your lungs clear, increase leg strength, and make you feel better!

6. Blood will be drawn daily, and you will have an electrocardiogram (EKG) every

few days.

DISCHARGE AFTER TRANSPLANTATION Patients are discharged from SUMC approximately 7-10 days after cardiac transplantation. After discharge, the post-transplant patient and a caregiver need to remain within twenty-thirty minutes from Santa Teresa Community Hospital for a period of time to be determined by the transplant doctor. Housing costs are not a covered benefit under the Kaiser plan. The transplant social worker will assist you with your relocation housing arrangements. There is an adjustment period in going from the hospital to home. While most people look forward to leaving the hospital, the actual discharge may be met with mixed emotions. You may feel overwhelmed by the medication schedules, blood pressure monitoring, etc. However, remember you will be in close contact with the transplant team. Clinic is twice a week. We will do a “head to toe” check, ask how you are feeling and go over your medications and any side effects you may be experiencing. You can bring any questions to the transplant team at this visit. We will take as much time as you need. Everyone recovers from surgery at a different pace. It is normal to have good days, as well as some not so good days, as you recover. Your body is going through many changes as you recover from surgery, get used to the new medications, and get back to activities. It is possible that the recipient may have forgotten how to be healthy, and re-adjustment may be difficult. WHAT ABOUT MY FAMILY? It is common for family members to feel very tired by the time of discharge. It is important to make sure that family members take care of themselves, get plenty of sleep, and eat a healthy diet. Family members may feel some anxiety about their loved one leaving the hospital. It can be overwhelming to learn all the new medications. etc. Please know that this is normal, and the transplant team is available for your concerns. At this time, you will all be redefining what life is like after a transplant. This is a time of change and adjustment which may take several months or longer. You may be experiencing a shifting of roles within your family. 11

The recipient may now be well enough to do tasks he or she may have been too sick to do before the transplant. It is possible that the recipient may have “forgotten” how to be healthy, and readjustment may be difficult. It is very important that you talk with each other about your feelings and perceptions. Talking about these issues with the transplant social worker and in support group meetings is also helpful. ADVANCE DIRECTIVE AND DURABLE POWER OF ATTORNEY - WHAT IS THIS? An advance directive is a written document in which you state what medical care you would want in the future (based on your values and what is important to you). Durable power of attorney for health care refers to a person (a relative or friend) you pick to make medical decisions for you if you cannot make them yourself. This person will follow the guidelines that you have given. More information is available on this – please ask. We highly recommend that you discuss both an advanced directive and durable power of attorney with your family - it is easier to talk about these things before a crisis situation occurs.

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POST TRANSPLANT INSTRUCTIONS

You will be given a log to help you keep track of your medications and vitals. Bring this log with you to every clinic appointment. All medications should be listed by name, dosage and the number of times daily you take the medication. DO NOT change your medications or take any over-the-counter medications without first checking with the doctor or transplant coordinator. If any medication changes are made, you should always take the Gengraf/Prograf and Imuran/Cellcept/Rapamune. These medications are your anti-rejection medicines. Continue to monitor your weight and BP. In addition, you must monitor your temperature twice (2) a day. Record these in the log and bring it to your doctor visits. Call for any of the following conditions: • BP >180/110 • systolic BP >100 • Temperature >100°F • Shortness of breath • Increased peripheral edema (ankle swelling) • Lack of appetite/nausea/vomiting • Feeling “dried out” or significantly increased thirst • Increased urination • Any signs or symptoms of infection • sore throat, fever, chills, “cold” • New or increased cough • Headaches and severe tremors You may find it useful to have a cane or other assistance available during your first few months after transplant. During the first months, numerous biopsies, echocardiograms, and lab work will be performed. In addition, during the first few weeks IV medications will continue to be administered. Biopsies are performed in the Angiosuite or in the Cardiac Catheterization lab and are generally done beginning at 7:00 AM on Tuesday mornings. An echocardiogram will be done on the same day, as well as a chest x-ray. A doctor visit in the Transplant Clinic will be scheduled after the biopsy on Tuesday mornings.

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Registration for your biopsy is done in the Radiology Department on the first (1st) floor of the hospital. If enough time is available prior to your biopsy, the chest x-ray may be done before the biopsy; otherwise, it may be done at any time prior to coming to clinic. The Angiosuite is located on the first (1st) floor as is the Radiology Department. Echos are done on the 2nd floor of the 2-North building in the cardiology department. During the first few weeks, IV medications will continue to be administered at the Outpatient Infusion Clinic located on the 1st floor of 2 North. A schedule will be obtained for you by the Coordinator. Please adhere to this schedule as the Infusion Clinic is extremely busy, and your times are arranged to give you the maximum benefit from the medications. Sometime during the first 6 weeks a Left and a Right heart catheterization will be done along with your biopsy. This is done to establish a “baseline” for your new heart. These studies will be repeated yearly to monitor the functioning of your new heart. These procedures are done in the Cardiac Catheterization Lab on Wednesdays. As you progress your biopsies, labwork, echo’s, and clinic visits will become less frequent. If at any point a rejection occurs your required visits will increase, along with biopsies, echoes and labwork. A visit to the infusion clinic may also be required for IV medications to limit the rejection. Your schedule for the first year will approximate: 1st month biopsy every week clinic 1-2 times a week

labwork 1-2 times a week (Do not take Gengraf/Prograf prior to having labwork done)

infusion clinic 1 - 2 times a day for 4-6 weeks. 2nd month Biopsy every other week left and right heart cath with biopsy (annual) clinic every other week labs once a week 3rd month biopsy every other week clinic every other week labs every other week 4 - 6 months biopsy every month (patient dependent) clinic every month lab work every month

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6 - 12 months biopsy every 1 ½ - 3 months (patient dependent) clinic every month labs every month For six weeks after surgery: 1. Do not lift greater than 10 pounds for 6 weeks after surgery. Do not perform

strenuous activity for 6 weeks. 2. Do not drive for 4 weeks after surgery. 3. Check incision daily. If you have any unusual redness, welling, pus, or pain,

contact the transplant nurses. Clean your incision by showering with warm water and soap daily.

4. Keeping your journal and updated medication list is very important! Please always bring this to your clinic appointments.

WHAT ABOUT SEXUAL ACTIVITY AFTER TRANSPLANTATION? Sexual activity may be resumed after going home, however, be careful to avoid strain across your incision for 4-6 weeks after surgery. Some couples feel that they need to protect the newly transplanted organ and are fearful that sexual activity will be too stressful. This is not so. Kissing, intimacy, and sexual activity are safe. During the early months, your sexual interest and functioning may not be consistent. If you have concerns about either resuming sex or about your sexual functioning, discuss this with a transplant team member. FEMALE PATIENTS: We strongly advise against getting pregnant because of the unknown and potentially harmful effects the medications may have on the fetus. In addition, pregnancy places a great demand on your body, and we are unsure how this may affect your transplant. WHAT IS REJECTION? Rejection is the body’s normal reaction of trying to rid itself of a foreign heart. Everyone should expect to have at least one rejection episode (even though you’re following all instructions). For heart patients, acute rejection usually occurs within the first three months. Rejection is graded from mild to moderate to severe. Rejection is most often detected at the mild stage. Remember, rejection is treatable. Your new heart will continue to work well even if it has had episodes of rejection. Heart rejection is detected with the heart biopsy. A heart biopsy consists of inserting a 15

catheter (small, thin tube like an IV) into your neck that reaches the entrance of the heart. A bioptome, which is a special instrument to get the biopsies, is passed through the catheter into the heart. Several small pieces of heart tissue are taken. These are examined under a microscope to detect rejection. Complications are RARE with a heart biopsy. However, you should be aware of them. 1. Bleeding at the entrance site of the catheter. You will need to keep the bandage

on your neck until the following morning. Please check it for bleeding. 2. Pneumothorax, which is collapsing of the lung (from the catheter nicking the lung).

You will feel chest pain and shortness of breath if this happens. We always check a chest x-ray and listen to your lungs after your biopsy to make sure this has not happened.

Symptoms of heart rejection that you may feel: 1. Fever. 2. Palpitations, irregular heart beats or sudden increase in heart rate, (around 30

beats faster ) 3. Unexplained tiredness or lack of energy. 4. Similar symptoms to that of an infection or flu. Treatment depends on the extent of rejection (mild-moderate-severe): Mild rejection: no treatment, observe for any changes in condition; may perform the next scheduled biopsy earlier. Moderate rejection: increase oral prednisone dose, IV steroid (prednisone) dose, or leave medications the same and perform the next biopsy earlier. Severe rejection: Treat with IV steroids for three days. If you are experiencing rejection, you may require more frequent biopsies. WHAT IS CHRONIC REJECTION? Chronic rejection is not related to acute rejection in any way. It may occur as early as six months after transplant or many years late. In heart transplants, chronic rejection is termed accelerated coronary artery disease, that is, narrowing of the arteries which supply blood, oxygen, and nutrients to the heart. Eventually, chronic rejection causes failure of the transplanted heart. Chronic rejection can be detected in the hearts by cardiac catheterization (shooting dye into the coronary arteries). At this time, chronic rejection is poorly understood. However, researchers continue to learn more about it. The only form of treatment for chronic rejection is re-transplantation. Re-transplantation is not as successful as the first transplant. Survival rate is about 50% at one year.

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WHY AM I PRONE TO INFECTIONS? The anti-rejection medications you take to prevent your new heart from being rejected work on the body’s immune system. The immune system has a two-fold purpose: 1. Prevent infection. 2. Reject anything foreign in the body (i.e., a new heart. The anti-rejection or immunosuppressive medications suppress or lower the body’s immune system. Therefore, while the anti-rejection medications do a good job of decreasing the body’s ability to reject the new heart, it makes the body more susceptible to infections. Infections can be caused by bacteria, viruses, or fungi. We have medication to treat almost all of the infections. This may be caused by bacteria, viruses, or fungi. We have medication to treat almost all of the infections. This may mean taking pills or IV medications for one week to several months. A long-term IV may be placed if long term antibiotics are necessary. While you may begin treatment in the hospital, we often teach patients to do IV’s at home for long-term needs. This allows you to keep a fairly normal routine/lifestyle. You will take some anti-infection medications every day after the transplant to prevent infection. The following instructions will help you to avoid infections: 1. Good hand washing - to avoid infections. 2. Check surgical incision daily until well healed. 3. Avoid persons with infections (i.e., colds, flu). 4. Clean and dress cuts or scrapes immediately. 5. Notify the transplant nurse, or doctor, if you have any signs or symptoms of an

infection/cold(i.e., cough, vomiting, fever, diarrhea, a cut with redness). 6. Wash raw fruit and vegetables well (to avoid viral and fungal infections). 7. Wear leather gloves when gardening or working with dirt, and clean hands and

nails afterwards to avoid fungal infections. 8. Avoid buildings under construction (such areas may carry fungal infections). 9. Avoid sharing drinking glasses/utensils during meals. 10. Wear a mask if you return to the hospital; otherwise, you do not need to wear a mask. WHAT ARE LONG-TERM COMPLICATIONS? 1. Chronic rejection (reviewed on page 16). 2. Lymphoproliferative disease (cancer): Approximately 3% of individuals who receive transplant develop

lymphoproliferative disease, that is cancer involving the lymph nodes. This may

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or may not be related to a viral infection called Epstein-barr virus. It may be responsive to decreased immunosuppressive medications, acyclovir, or chemotherapy. Patients may die from this.

3. Diabetes or high blood sugar counts: These may occur when taking prednisone. We check your blood sugar with each

blood draw. Symptoms of high blood sugars may include feeling extremely thirsty, weak, dizzy, having blurry vision, and urinating large amounts. These symptoms may also occur with other problems or medications you are taking, but it is important to tell us if you are experiencing them. If diabetes occurs, a patient may be required to be on a diabetic diet, take a pill, or take insulin shots to regulate his/her blood sugar. We work closely with the diabetic center to best manage your blood sugar should this become a problem.

4. High blood pressure (hypertension): Most transplant recipients will get high blood pressure from being on Gengraf. A

combination of weight control, regular walking or other exercise, and medication will keep your blood pressure in an acceptable range. Generally speaking, we like to see the systolic (or top number) less than 140 and the diastolic (or bottom number) less than 90.

5. Kidney failure: Taking immunosuppressant medications, particularly Gengraf can sometimes

cause kidney damage. This is why we monitor your Creatinine (Cr) level every time that you come into clinic. You may not feel differently even when your kidneys are not functioning normally. However, you may have increased swelling in your ankles, feet or hands.

Drink plenty of water or fluid every day to keep your kidneys working well (8

glasses or more). Remember, several of the medications you take are a bit nasty to the kidneys, and this is made worse if you do not drink enough (drinking helps “flush” the kidneys). In addition, if you become sick with vomiting, diarrhea, or flu you may be losing extra fluids. You need to be very aware of replacing your fluids by drinking plenty of water (water is always the best choice over soda, tea, etc.).

CONSTIPATION: Constipation can be a problem after surgery or after you return home. If you are

uncomfortable in the hospital, let the transplant team know so they can order medication or suppositories for you.

When you return home, the following will help to keep your bowels regular:

1. Walk and be as active as possible.

2. Eat fresh fruits and vegetables.

3. Drink plenty of water.

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4. Colace, which is prescribed when you leave the hospital. Take this 1-2 times daily as needed. Milk of Magnesia is also a good choice. Two tablespoons at bedtime may help if you are feeling constipated. Check with the transplant team to see if this is okay to take.

VOMITING: The general rule of thumb is to repeat your medicines if you vomit within an hour of taking them. If you are unsure, call the transplant nurse. You need to make sure you are replacing the fluids lost by vomiting. If vomiting persists, you need to call the transplant nurse. EXERCISE: Daily exercise is strongly recommended. You may participate in any form of non-contact sport or activity. We recommend walking as an excellent form of exercise. Recent studies suggest that a leisurely walk once a day may offer health benefits comparable to those derived from more intense exercise. Walking or other exercise helps to maintain weight, reduce loss of calcium from the bones, and work you heart and lungs. In addition, walking may lower blood pressure and help reduce stress. **See Exercise Appendix. SKIN CARE: You will not need any special skin care unless you have problems with acne or dry skin. You may use any soap. Oily Skin or Acne You may have acne on your face, chest, shoulders, or back caused by prednisone. The primary measures used to control this acne are aimed at removing the excess oil and preventing formation of whiteheads and blackheads. Wash the area of acne thoroughly three times a day, scrubbing gently with a soapy washcloth to remove the oils, dead skin, and bacteria. Neutrogena soap has worked well, but any drying soap is fine. Rinse soap off of your skin completely to leave your pores open and clean. Use a clean washcloth each time. Shampoo your hair and scalp frequently and keep your hair away from areas of acne. Benzoyl peroxide 5-10% cream or lotion, which can be purchased over the counter, is helpful in drying acne. To improve acne, it is best not to use cosmetics, but if you must, use them sparingly. It is extremely important to keep your hands away from your face (don’t pick or touch areas of acne).

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You may want to stop treatment when your skin appears dry. But drying your skin is the objective of the treatment. If your skin becomes excessively dry, stop washing the area temporarily to allow the skin to recover natural moisture. Do not apply skin lotions to treat dry skin. If acne persists, you may need a dermatology referral. Check with the transplant nurse or doctor. Dry Skin Use a mild soap (Dove) for bathing and apply body lotion after bathing if you have problems with dry skin. Keri lotion or Moisturel are good over-the-counter lotions. Lac-Hydrin (which requires a prescription) can be ordered if severe dry skin persists. SUN EXPOSURE: Prednisone and Septra will make your skin more sensitive to the sun. You will probably burn and tan easier, faster, and to a greater degree than you did before your transplant. Transplant patients have an increased chance of developing skin and lip cancers. These cancers are TEN TIMES MORE COMMON IN TRANSPLANT PATIENTS than in the general population. It is the ultraviolet rays from the sun that can cause skin cancers. Ultraviolet rays are present even on cloudy days. We advise you to always protect your skin by using sunscreen with an SPF of 15 or greater on any exposed skin and to avoid midday sun (since ultraviolet rays are stronger then). Skin lesions Warts may be more problematic after your transplant but can be burned or frozen off. Moles that are changing, raised skin lesions, or sores that do not heal should be pointed out to the transplant nurse or doctor. You should never try to cut, pick or remove these by yourself. They require professional attention. We will refer you to a dermatologist if necessary. CUTS AND SCRATCHES: Prednisone can cause your skin to become thin, making it tear, scratch, and bruise easily. Keep your skin clean so such areas do not become infected. Keep minor cuts and scratches clean and dry by washing with soap and water. You may cleanse with hydrogen peroxide as well. For large cuts, dog bites, or cuts/skin tears that appear infected (redness, swelling, pus, increased tenderness), contact the transplant nurse.

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HAIR CARE: Prednisone will probably affect the condition of your hair. Tints, dyes, bleaches, and permanent wave solutions may cause your hair to break. We recommend that you wait until your prednisone dose is less than 20 mg/day before you have a permanent or color your hair. Tell your beautician that you are on prednisone and to use a good conditioner on your hair. INCREASED HAIR GROWTH: This problem affects both men and women and may be rather annoying or distressing. Hair growth increases on both the face and body. You may remove hair with a hair remover cream, or depilatory (surgicream has worked well for facial hair or hair on outer ears - for men too!) Be sure to test a skin area according to the directions on the bottle. This cream causes severe irritation to the eyes and mucous membranes (even to your lips), so apply it carefully. You may use a 50% peroxide solution to bleach excess hair growth. After your prednisone dose is less than 20 mg/day, you may use electrolysis for permanent hair removal. SMOKING: You must not smoke. Smoking causes damage to your lungs, making it easier for you to develop a lung infection. You should stay away from smoke filled areas as much as possible. If family members smoke, they should smoke outside of your home. However, should you start smoking, please let a transplant team member know so that we can assist you in quitting. We are here to help you keep healthy! PETS: We advise against getting new pets. If you do have pets, please discuss this with the transplant team. You should not change kitty litter because of the potential infection toxoplasmosis. You should not have birds as they also transmit various infections. COLDS: At some point, you will probably get a “cold”. Colds are caused by viruses and are spread most often by contaminated hands (i.e., by wiping your nose and not hand washing). Because a cold is caused by a virus, it cannot be cured by antibiotics. However, sometimes a bacterial infection will occur as a complication of a cold which will be treated with antibiotics. Hints to help prevent a cold include: • Eat and sleep properly and get plenty of exercise to keep your resistance up. • Wash your hands frequently, particularly when you are around people with colds. • Keep your hands away from your nose, eyes, and mouth.

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• Use disposable tissues, not handkerchiefs, to reduce the spread of viruses to

others. If you do get a cold, the following home treatment will help: • Get extra rest. • Drink plenty of fluids, particularly warm fluids, which will help reduce congestion. • Humidify your bedroom. • Decongestants may help (check with the transplant nurse before taking these). Colds usually last 1 to 2 weeks. If you have the following signs, you should call the transplant nurse: Fever cough with colored sputum or persistent cough colored nasal drainage sinus pressure, sinus headaches sore throat swollen glands trouble breathing diarrhea or vomiting anything else that seems abnormal **If you have any questions or are just not sure about your symptoms, please call. It’s always better to double check with us. COLD SORES (HERPES SIMPLEX) These sores look like tiny water blisters on the lip or face. You can use Blistex or similar products on these. If they are persistent, you may need Acyclovir; let the transplant nurse or doctor know. SHINGLES (VARICELLA ZOSTER) Shingles appear as a rash or small water blisters, usually on the chest, back or hips, but they may occur on other areas. The rash may or may not be painful. You will need treatment with Acyclovir (pills) so please contact the transplant nurse. You may also use any topical treatment or pain medication that gives you relief. VACCINATIONS: We recommend annual flu (influenza) shots for patients. You should also have received a pneumovax shot (once in a lifetime) and a tetanus shot every ten years. DENTAL: Dental visits are necessary every six months. Wait until six months after your transplant to schedule the first visit. You will require prophylactic antibiotic therapy before any dental cleaning or work. This is because your mouth is a warm, moist 22

area where bacteria can grow fast. Please inform your dentist that you will require antibiotics according to the American Heart Association “Standard Regimen in Patient’s at Risk” (Amoxicillin or Erythromycin). Please call us if there is a question. Good mouth care, including brushing teeth, tongue, palate (to help avoid yeast infections), and flossing (to prevent tender, swollen gums) should be done regularly. Remember, even if you wear dentures, you must still have your gums checked! A mixture of hydrogen peroxide and tap water (do not swallow this!) or Liquadent mouthwash works well to clean the tongue and palate (sometimes the yeast or coating on the tongue is tough to get rid of). Rinsing and/or brushing with these helps. EYES: It is common to have focusing problems in the first few months. Check with the transplant nurse or doctor first if you feel you should see an eye doctor. We do recommend yearly eye examinations because over time the medications can affect your eyes. OTHER: Women should continue to have a yearly pap smear and mammogram. Yearly stool cards - to check for hidden blood in your stool. MEDIC-ALERT JEWELRY - DO I NEED IT? We advise all transplant recipients to wear a medical identification bracelet or necklace. Information about medic-alert jewelry can be obtained by calling 1-800-ID-ALERT or picking up a brochure in the Transplant Service Office. You may also want to include medication, allergies, etc. Check with the transplant nurse or physician if you have questions.

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MEDICATIONS IMMUNOSUPPRESSIVE AGENTS These agents help prevent your immune system from rejecting your transplanted heart. Remember that you will be more susceptible to infection. You should notify your doctor or dentist that you are a transplant patient and that you are taking immunosuppressive agents. These medications must be taken on the schedule you were given. Your blood levels, white blood cell counts, and other laboratory tests must be monitored to check your response to the medications. Gengraf (cyclosporine) Gengraf helps prevent rejection of your new heart by suppressing or lowering the immune system’s response to the new heart. How to take Gengraf: Gengraf is available in capsule or liquid form. In liquid form, it may be mixed in a glass with milk, chocolate milk, or orange juice. You must use a glass container. Gengraf may be stored in a kitchen cabinet. We will measure your blood level of Neoral each time you have labs drawn. At first, we would like this level to be 400-600. We will adjust your medication as needed according to blood levels. Initially, Gengraf levels may vary often as your body adjusts to this medicine. Don’t worry, it will eventually level out. Possible side effects: Decreased function of the kidney or liver High blood pressure Trembling or shaking of hands Increased body hair. Headache

Swollen gums or increased growth of gum tissue Oily skin Clear runny nose (especially when eating!) Tingling in hands and feet *Neoral pills are sensitive to extreme heat and may be altered by it. Check that your pills have not lost their shape or pliability before taking them. Prograf (tacrolimus, FK 506) Similar to and used in place of Gengraf at the discretion of your transplant doctor. Prevents rejection by suppressing the immune system’s response to your new heart. Prograf comes in 5 mg (red) and 1 mg (white) capsules. It should be taken every 12 hours on an empty stomach (1 hour before or 2 hours after meals). We will be

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measuring your blood level each time you have your lab work drawn. This will be a trough level (lowest) and should ideally be 12 hours after your last dose. Blood levels for Prograf are usually 5-20. We will adjust your dose of medication as needed according to this level. Side effects• Decreased kidney function • Increased blood sugar. Some people may require the use of insulin. • Tremors, headaches, numbness & tingling of hands and feet. • Nausea/vomiting, diarrhea.

Imuran (Azathioprine) Imuran is an anti-rejection or immunosuppression drug which also suppresses or lowers the immune system’s response to the new heart. Specifically, it decreases the number of WBC (white blood cells). How to take Imuran: Imuran is available as a tablet that is usually well tolerated if taken with food or a glass of milk. We will monitor your white blood count and adjust your medication as needed. Possible side effects: Nausea/vomiting Upset stomach Unusual bleeding or bruising WBC too low Cellcept ( mycophenolate mofetil (MMF) Used in place of Imuran at the discretion of your transplant doctor. It is used in conjunction with Neoral or Prograf to suppress your immune system to prevent rejection of your new heart. Cellcept comes 250 mg (blue/brown) capsules. Usual is 100 mg twice a day, 12 hrs apart. This may be adjusted by your transplant doctor according to your labwork. Cellcept should be taken on an empty stomach (1 hour before or 2 hours after meals). Do not crush or open capsules. Wash thoroughly with soap and water if you come into contact with powder. If contact with eyes, rinse with plain water. Side effects:• Nausea/vomiting diarrhea • anemia

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PrednisonePrednisone is a member of the family of medications called steroids. This medication is used to prevent your body from rejecting the transplanted heart. How to take prednisone: Prednisone is available in varying strengths and forms. You will take this medication with food and an antacid to help prevent an upset stomach. If stomach upset, burning, or pain continues, check with your transplant nurse or doctor. Possible side effects: Stomach upset Increased appetite and, therefore, weight gain Increased hair growth Bruise easily Difficulty sleeping Mood changes Restlessness Oily skin or acne Cataracts Muscle weakness Weakening of the bone (osteoporosis) High blood sugars (diabetes) BLOOD PRESSURE LOWERING (Antihypertensive medications) (diltiazem, lisinopril) These medications lower blood pressure and are often used in combination with other drugs. Remember, high blood pressure is very common when taking Neoral. Medications can lower blood pressure in many ways. Some dilate (open wider) the blood vessels. Others change the kidney’s effect to control blood pressure. Still others block part of the nervous system that increases blood pressure. Rather than include information on all of these medications here, your nurse, physician, or pharmacist will give you information on your specific medication when it is prescribed for you. It is important that you check your blood pressure daily, and that you take any antihypertensive medication exactly as you are instructed. We will take your blood pressure at each clinic visit.

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*Hypotension (low blood pressure), feeling lightheaded or dizzy, cold or clammy, weak or tired: Check your blood pressure should these symptoms occur. DIURETICS OR WATER PILLS (lasix, bumex) A diuretic pill is a medication that helps your body get rid of excess fluid by making more urine. This causes patients to urinate more often during the night. This, in turn decreases the amount of fluid (blood) your heart needs to pump. You may have been taking one of these medications before your transplant. After your transplant, you may continue to take a diuretic. The diuretic may help control blood pressure or may offset the action of some medications, such as prednisone, that may cause you to retain excess fluid. It is important to have your blood pressure and blood electrolyte levels checked frequently when you are taking diuretics (we will do this with each clinic visit). Electrolytes are necessary for the body to work properly. Symptoms such as muscle aches, nausea, headache, and fatigue may indicate that electrolyte levels are abnormal. You should report any of these symptoms to the transplant nurses or doctor. • Most often, after your transplant, you will NOT NEED TO TAKE ANY

POTASSIUM SUPPLEMENTS with the diuretic (even though you may have needed them before).

PROPHYLACTIC MEDICATIONS These are medications that you will take to prevent infections or other complications. Nystatin (Mycostatin, Mycelex troche or lozenge) Nystatin is an antifungal medication used to prevent or treat fungal infections such as thrush in the mouth or vaginal yeast infections. How to take nystatin: Nystatin can be taken as a liquid or a lozenge. This liquid should be swished around the entire mouth and then swallowed. The lozenge is held in the mouth and allowed to dissolve slowly and completely. It may take thirty minutes to completely dissolve. Do not chew or swallow a lozenge whole. Take your Nystatin last (after your other pills) and do not eat or drink anything for 15 to 30 minutes after taking it; otherwise, you will wash away its effect. Nystatin vaginal cream or tablets are used if a female patient gets a vaginal yeast infection. Possible side effects (rare): Stomach cramping or diarrhea 27

Cytovene (DHPG. Gancyclovir) Used to prevent and treat cytomegalovirus (CMV) infection. You will receive IV cytovene for the first month after your transplant. If you have had prior exposure to CMV (determined by lab tests) your course of treatment will be finished. If you have not had prior exposure to CMV (determined by lab tests) you will receive cytovene in capsule form for approximately 6 months after your transplant. Both IV & oral cytovene are used for the treatment of active CMV infection without transplant. Oral cytovene comes in 250 mg (opaque, green, hard) capsules and is taken twice a day. Take with food to maximize absorption. Side effects: • nausea/vomit8ing/diarrhea • decreased kidney function • decreased wbc • fever, chills Acyclovir (Zovirax) Acyclovir is an antiviral drug (pill) that is often used after transplantation to prevent CMV (cytomegalovirus) or treat a herpes infection (cold sores or genital herpes), varicella zoster (shingles), and Epstein-Barr (mononucleosis). You will be on acyclovir for at least two months after surgery. How to take acyclovir: It may be helpful to take acyclovir with meals to reduce stomach upset. Possible side effects: Skin rash Tenderness, swelling or bleeding of the gums Dizziness Diarrhea Headache Joint pain Nausea or vomiting Decreased appetite Septra (Bactrim, Co-Trimethoprim, or Sulfamethoxazole) This is an antibacterial medication (pill). You will be taking this medication to prevent infection. Specifically, it prevents a pneumonia called pneumonocystis carini pneumonia which you are susceptible to because of your lowered immune system. 28

How to take Septra: You will take the Bactrim or Septra as “DS” which is “double strength” or “SS” which is “single strength,” three times per week (Monday, Wednesday, and Friday). You should take it with a full glass of water. This medication works best when there is a constant amount in the blood. To help keep this amount constant, do not miss any doses. You should stay out of direct or use sunblock/sunscreen with an SPF of 15 or greater when taking this medication. Exposure to sunlight without sunscreen, even for brief periods of time, may cause sunburn. Pentamidine: If you are or become intolerant to Bactrim, you will be placed on Pentamidine to prevent pneumocystis carinii. Given by inhalation in the respiratory therapy department once a month. This usually take 30-45 minutes. Breathe in and out through your mouth. The therapist may give a bronchodilator if needed. Side effects: • Wheezing • Shortness of breath • coughing Aspirin Aspirin is often prescribed to decrease the risk of coronary artery disease in the transplanted heart. How to take aspirin: You should take one baby aspirin per day. If aspirin tends to upset your stomach, take it with food or a snack. Possible side effects: Nausea, vomiting, stomach pain Skin rash Unusual bleeding or bruising Colace (Docusate sodium) Colace is a stool softener which is sometimes needed after surgery. Constipation can occur after surgery because you are less active, not eating a regular diet, and are taking pain medications. How to take Colace: This medication can usually be discontinued after you are back to having regular bowel movements. How to take Colace: This medication can usually be discontinued after you are back to having regular bowel movements. Possible side effects: Diarrhea Zantac (Ranitidine)

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Zantac is a stronger acid blocker medication for the stomach which you may be required to take. This will be determined on an individual basis. How to take Zantac: You will take this once or twice daily depending on your symptoms. Possible side effects: Constipation Diarrhea Nausea/vomiting Decreased blood counts Ketoconazole (Nizoral) Ketoconazole is an antifungal medication which is used to prevent fungal infections. It also has the added benefit of increasing Neoral blood levels (so you have to take less Neoral pills to get the same Neoral blood level). How to take Ketoconazole: You should take one Ketoconazole tablet daily at about the same time each day. This should be taken with food to avoid stomach pains or cramping. You should not take your Ketoconazole with either an antacid or zantac since this lowers the effect of the medication. Because it increases the cyclosporine levels, it is as important as taking your Neoral pills. Possible side effects: Nausea/vomiting Stomach pain Diarrhea Decreased function of the liver Dizziness Headache Sensitivity to sunlight MVI (Multivitamin) A multivitamin is given to make sure you get all the proper nutrients to assist healing after surgery. Any type of multivitamin is fine. REMEMBER to take all of your medications as prescribed. Please ask the transplant coordinators or doctors if you have questions about your medications. Remember, your medication schedule is specific for your body’s needs, and no two transplant patients are alike. Because your medications may interact with other drugs, check with the transplant team before taking any over-the-counter medications. In addition, be sure to tell your dentist or any other health-care professional who treats you about the medications you are taking. Even when you feel okay, you must still take your medications. They will be necessary for the rest of your life.

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ALWAYS REMEMBER: Transplant is not a “cure”, it is a change in lifestyle. Transplant may take a lot of work and not always be easy, but it can greatly improve the quality of your life, and we’re here to help you in any way we can. Thank you for choosing our program; we look forward to a long and happy relationship with you.

MEDICATIONS

GOALS 1. CSA level of 400-600 will adjust CSA dose accordingly 2. WBC > 4.0 - will adjust imuran dose accordingly 3. Creatinine level (Cr) of 1.0 - 2.0 (kidney function) 4. Diastolic BP (lower number) < 90 5. Acyclovir for 2 months

ANTI-REJECTION

ANTI-INFECTION HEART

CSA (Cyclosporine) Septra/Co-Trimaxazole (antibacterial)

Aspirin (for coronary arteries)

Imuran (Azathioprine) Nystatin (antifungal) Diltiazem (for blood pressure)

Prednisone Acyclovir (antiviral) Lasix or Bumex (diuretic

Ketoconazole (antifungal, also increases CSA levels)

OTHER Vitamin (MVI) Colace (stool softener) Maalox or Alternagel

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(antacid) Hydrocodone/Vicodin (pain) Zantac (acid blocker)

EXERCISES

Getting Started

∗ Active Warm-up: Examples include walking, marching, dancing. ∗ Stretching: Static - Do NOT bounce. (**) The exercises in this manual noted with a double asterisk (**) can be used for both warm-up and cooldown exercises.

Spinal Flexion

∗ Spinal Flexion - Forward: Stand with feet shoulder width apart. Bend forward from the hips, placing hands on upper thigh. Keep neck in alignment with the spine. Hold. Release Repeat.

Standing Leg Work Abductor/Adductor/Hamstrings/Gluteals

∗ Modified Squats: Feet apart width apart, abdominals pulled in, chest lifted,

shoulders back, head in neutral position. Bend your knees and squat keeping knee lined up with big toe. Pretend you are about to sit down. Sit out your buttocks and thigh muscles as you return to starting position. Do NOT drop below knee level. 8-10 repetitions.

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∗ Wide Stance Squats: Hands on hips, feet wider than shoulders. Knees are bent,

abdominals pulled tight, chest pulled up, shoulders back, head in neutral position. Squat slowly squeezing buttocks and thigh muscles as you return to starting position. Do NOT drop below knee level. 8-10 repetitions.

Seated Upper-body Strengthening

Key Points to Remember for These Exercises: Sit Tall, Spine Straight Abdominals Contracted Shoulders Back and Relaxed ∗ Point and Flex: Extend leg, lifting ankle 2-3 inches off of floor. Point and flex 8-10

repetitions. ∗ Ankle Rotations: Extend leg, heel lifted 2-3 inches off of floor. Rotate left then

right. ∗ Calf Raises: Feet are hip distance apart. Lift ankles as you roll onto ball of foot

(spreading toes out evenly) contracting calf muscles. ∗ Leg Lifts Seated: Extend one leg straight out, flex foot. Stationary leg is at a right

angle (90 degrees). Lift extended leg to the height of the opposite knee. Sit straight up. Use thigh muscle to lift leg – DO NOT use upper body to lift leg.

∗ Abductor (inner thigh): Cross hands at wrist, placing palms on inside of knees.

Press out with your hands and in with your knees - Resist. ∗ Abductor (outer thigh): Place palms on the outside of your knees - Resist. Press

“out” with knees and “in” with hands. ∗ Abdominals: Place hands gently behind head or across chest. Bend forward

from the hips without rounding your back, keeping neck in alignment with spine. Bring chest to thigh, thigh to chest.

∗ Obliques: Bend to the left to first point of tension. Return to center. Repeat on

opposite side. ∗ Lower Back: Place hands behind head. Bend forward from the hips. Do NOT roll

upper back. Return to starting position.

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∗ Torso Turn: Cross arms in front of chest “Indian style.” Turn left (head stays in

alignment and follows) to first position of tension. Return to center. Repeat on other side.

Seated Upper-Body Strengthening

Key points to Remember for These Exercises: Proper Form is VERY Important Work Through Your Full Range of Motion

Do NOT Lock Joint - DO Keep a Slight Bend on the Elbow Keep Movements slow, Controlled, and Deliberate

Concentrate on the Muscle Being used Do NOT Squeeze the Weights - DO Squeeze the Muscle

Breathe Normally - Do NOT hold your breath Exhale on the Exertion (Hardest Part of the Move)

Do NOT “Break” (Bend) Your Wrists DO Keep wrist in Alignment with your Arm Concentrate on Proper Body Alignment Keep Shoulders Back and Relaxed ∗ Shoulder Presses: Palms face forward. Raise elbows to shoulder height. Raise

arms in an arch over head. Do NOT lock joints. Repeat. ∗ Frontal Raises: Palms rest on thighs. Raise arms out in front of you (one at a

time) no higher than shoulder level. Squeeze your muscle. Return to start position. Repeat.

∗ Lateral Raises: Palms face in by your thighs. Raise and squeeze your arms out to

the side no higher than shoulder level. Make sure palms face down. Do NOT swing arm. Keep a slight bend in the elbow. Repeat.

∗ Biceps: Palms face in towards your body. Elbow bent. Keep elbow tucked and

move through full range of motion. Bright weight to your shoulder. Squeeze the muscle to raise your arm.

∗ Triceps: Palms face in towards body. Elbow bent. Keep elbows in close to body.

Upper part of arm remains stationary as you press back (behind you). ∗ Chest Presses: Elbows raised to shoulder level (90 degree angle). Palms facing

out. Bring elbows in toward center of body (leading with your elbows - not your palms) while squeezing chest muscles.

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∗ Seated Back Rows: Sit on the edge of your chair. Bend forward from the hips.

Place weights behind ankles so that arms are fully extended. Pull up and back, squeezing shoulder blades together. After each pull,

∗ let arms come all of the way down so that you feel a slight stretch. Repeat.

Seated Stretches

Key Points to Remember for These Exercises: Keep Feet Flat on the Floor at a Right Angle (90 degrees) Sit Tall, Spine Straight Keep Abdominals Contracted Shoulders Should Be Back and Relaxed Head in Neutral Position Do NOT Bounce Sit on edge of chair (unless noted otherwise). ∗ (**) One-Leg Extension: Feet are flat, hip distance apart. Extend one leg forward,

flex the foot and lift the leg to height of opposite knee. Return to starting position. Use front thigh muscle (quadriceps) to lift leg. Do NOT round back while lifting leg. Repeat on opposite side.

∗ (**) Hip/Groin Stretch: While sitting on the edge of the chair, place on leg on floor,

knee bent at 90 degree angle. Lift opposite leg and place ankle across the knee. Gently press, causing resistance. Hold the resistance. Release. Repeat on opposite side.

∗ (**) Lower Back Stretch: Feet are flat, knees at right ankle, hip distance apart.

Place palms on thighs. Slowly bend from the waist forward bringing chest toward thighs.

∗ (**) Spinal Stretch: Feet are flat, knees at right angle, hip distance apart. Place

left hand on the outside of your knee. Press into the knee as you rotate your upper body to the right. Repeat on the opposite side.

∗ (**) Chest Stretch: Extend arms out from shoulders. Palms are facing out. Press

arms back squeezing shoulder blades. Repeat. ∗ (**) Upper Back Stretch: Feet are flat, knees at right angle, hip distance apart.

Bend forward. Grab your arms under your knees. Round the upper back opening up the shoulder blades. Hold for 10 seconds. Release. Repeat.

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∗ (**)Shoulders/Arm Stretch: Feet are flat, knees at right angle, hip distance apart.

Extend right arm gently across chest. Place left hand above elbow and exert gentle pressure “in” toward chest. Hold for 10 seconds. Release. Repeat.

∗ (**) Neck Stretch: Feet are flat, knees at right angle, hip distance apart. Slowly

rotate head left, then back to center, then back to the right, then back to center. Repeat. Gently drop your left ear to your left shoulder keeping shoulders back and relaxed. Elongate your right arm, pressing your palm to the floor. Gently reach up with your left hand, placing fingertips on your head and gently press ear towards left shoulder taking stretch deeper. Hold for 10 seconds. Release. Return to center position. Repeat on opposite. Side.

∗ (**) Biceps Stretch: Reach your left hand behind your right elbow, holding your

right arm straight. Stretch your back, causing resistance. Hold. Release. Repeat on opposite side.

∗ (**) Triceps Stretch: Reach your right arm up over your head. Grasp your right

hand with your left hand. Pull your right arm towards your left shoulder. Repeat on the opposite side.

lower Work/Stretches ∗ Back Extensions: Lying on your stomach, hips and toes pressed into the floor,

legs together. Place palms (faced down) under your chin so that elbows are extended to the side. Rest chin on palms. Tense your buttocks and pull in your abdominal muscles. Now lift your chest off of the floor by contracting the muscles in your lower back. Don’t worry about how high you raise yourself off of the floor - it is a small movement and a big squeeze. Pause at the top of the movement before releasing.

∗ Abdominal Crunches: Lying on your back, feet flat on floor, knees bent with legs

about shoulder-width apart. Make sure back is flush to the floor. Support your head lightly by placing your hands on your head just above your ears. Keep neck in alignment with your spin; pretend you have an orange between your chin and chest and lift head, neck and shoulders in one fluid motion. Squeeze your abdominal muscles as though you were aiming them towards your spine. Exhale as you come up. Inhale as you come down.

∗ (**) Low-Back/Hamstring Stretch:

Beginner: Lying on your back, bend your right leg then raise it. Place hands behind your knee, pull knee gently into your chest to first point of tension. Release. Repeat. Repeat on opposite side. Advanced: Fully extend right leg above you. Slide hands onto calf. Pull leg into chest. Repeat. Repeat on opposite side.

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The Circulatory System

The Heart’s Structure .

I. Size and Location

A. Located in the middle of the chest behind the breastbone, between the lungs, the heart rests in a moistened chamber called the pericardial cavity which is surrounded by the ribcage. The diaphragm, a tough layer of muscle, lies below.

B. Size of your fist, and weighs about 11 ounces II. Function

A. pumps 4300 gallons of blood a day B. The heart’s muscle, contracts and relaxes

about 70-80 times per minute C. delivers oxygen-rich blood to every cell in

the body. III. Transport system

A. Arteries are the passageways through which the blood is delivered. 1. Aorta is the largest artery, and branches off the heart and then divides into many smaller arteries.

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B. Veins carry deoxygenated blood back to the

lungs to pick up more oxygen.

III. The inside of the heart

A. 4 cavities (open spaces) 1. Atria (top 2 cavities) 2. Ventricles (bottom cavities.)

B. Septum- a wall between the left side of the heart and the right side. C. Valves- connects each atrium to the ventricle below it. 1.bicuspid valve- connects the left atrium with the left ventricle

2. tricuspid valve connects the right atrium with the right ventricle 38

D. 2 large veins bring deoxygenated blood to the right atrium. 1.superior vena cava- the large vein on the top (superior) end of the heart. 2. inferior vena cava- the large vein on the

bottom (inferior) end. 39

E. Pulmonary artery-

a large artery that sends deoxygenated blood from the right ventricle to the lungs. F. pulmonary veins- Two small veins bring oxygen-rich blood from the lungs to the left atrium.

Aorta- a large artery the oxygen-rich blood leaves the left ventricle through.

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