B3 L33: Introduction to Orthopaedic Inpatients Flashcards
What is orthopaedic physiotherapy?
Orthopaedic Physiotherapy is that branch of physiotherapy related to the preparation for, or rehabilitation from orthopaedic surgery or related to an orthopaedic hospital admission.
What are 8 reasons why people have orthopaedic surgery?
- Degenerative disease (OA)
- Trauma (fractures, dislocations)
- Pain
- Reconstruction (knee, shoulder- eg. varus or valgus deformity)
- Pathological processes (Ca, RA)
- Prophylaxis/Function (spinal scoliosis)
- Arthroplasty (replacement of joint- eg. hip, knee, shoulders)
- Internal fixation (not conservative- look at bony healing)
When should surgery be considered and when should it not?
How debilitating is the pain VS functional problem
What are the 7 components of the orthopaedic team?
- Patient, family and carers
- Doctors (Consultant (orthopaedic surgeon), Registrar, Resident)
- Pain team (Anaesthetist) (operatively and post-op acute management)
- Nursing (Pre-admission, Theatre, Ward)
- Support staff (Ward receptionist, transport, food services, cleaners)
- Community liaison (CHIP nurse)
- Allied Health (post-surgical management)
- Physiotherapist, assistants and students
- Occupational therapist
- Social worker
- Pharmacist
- Community referral organisations (Mobile rehab, DART, Blue Care etc)
What are the 6 steps in the assessment of an orthopaedic inpatient?
- Preparation
- Interpretation and planning (medical chart)
- Subjective Examination (inteview- talk to the patient, carer, family to get a good overview)
- Assessment, interpretation and planning
- Objective Examination
- (Goal: identify implications which help to guide treatment)
- Assessment, interpretation and planning
- Treatment
- Re-assessment (to see if intervention is effective)
- Assessment, interpretation and planning
- Documentation
How is preparation a step for an orthopaedic inpatient?
Medical chart / Clinical pathway
- Obtaining RELEVANT information
- HPC
- Operation report, post op orders, protocols
- Demographic info
- Investigations − Hb, imaging, blood tests etc
- PMHx
- Respiratory Hx, Cardiac Hx, Osteoporosis etc
- PSHx
- Previous orthopaedic surgery, other major surgery
- Social Hx
- Home support, home access
- Functional Hx
- Previous level of function (aids, distance, assistance required)
Bed chart
- Medications (what, when, route), observations (HR, BP, Temp, RR, SaO2).
How is subjective examination a step for an orthopaedic inpatient?
- Confirm what you know from the chart and attempt to fill the gaps
- Maintain rapport but keep control of the situation
- open v closed questions
- paraphrasing
- Elements of subjective examination
- HPC
- PMHx
- PSHx
- Social Hx
- Functional Hx
- Current Condition
- Pain (where, x /10 at rest, with movement, taking pain relief)
- Dizziness, nausea, drowsiness
- Respiratorystatus (Cough, SOB, Smoker) and
- Neurological status P&N or N – esp if epidural or nerve block
How is objective examination a step for an orthopaedic inpatient?
General observation • Environment • Systems assessment • Respiratory • Circulatory • Neurological • Musculoskeletal • Examination of the specific body region • Functional assessment General observation • This begins as soon as you lay eyes on the patient • Posture/position….gait • Environment • Walking aids, chairs to sit out in…(planning) • Apparatus (IV poles, O2, drains, catheter, compression stockings, pumps, pillows, slings, splints)
What is required in an objective examination system Ax for respiratory assessment?
Respiratory assessment - screening
Cough – Effective? Productive? • Observe RR – Work of breathing • Normal bi-basal expansion • Auscultation - Normal breath sounds? • When necessary, a full respiratory assessment should be performed Selectively choose tests- If not = move on If yes = do more comprehensive test (check history)
What is required in an objective examination system Ax for circulatory assessment?
Circulatory assessment
- For patients at risk of deep vein thromboses
- Commonly seen in the calf and assessed by looking for:
- Swelling of the calf
- Redness of the calf
- Localised pain/tenderness
- Increased temperature on palpation
- Positive Homan’s sign (calf pain on passive ankle dorsiflexion)
What is required in an objective examination system Ax for neurological assessment?
Neurological Assessment
- Modified neurological (eg. pins and needles-if yes = do test, if not = move on) assessment is required in the presence of spinal or epidural anaesthetic. It will help assess patient’s ability to mobilise and should include:
- Hip, knee, ankle strength & sensation
- Full neurological assessment (reflexes, power, sensation) if indicated by the subjective examination - especially in the presence of spinal injury
What is required in an objective examination system Ax for musculosketal assessment?
Musculoskeletal Assessment
- Major joints in unaffected limbs as required
- normal ROM, no tenderness or swelling
What is required in an objective examination system Ax for specific body part assessment? List 5 things
- Observation (wound ooze- signs of infection (for early detection, infection can be catastrophic), swelling…)
- Active movement (as indicated)
- Passive movement (as indicated)
- Muscle strength (as indicated- functional)
- Sensation (Already checked in systems assessment - neurological)
What is required in an objective examination system Ax for functional assessment? List 4 things
- Bed mobility
- Transfers
- Supine ↔ sit
- Sit ↔ stand
- Mobility
- Stairs
In regards to mobility, what does need “assistance” mean?
- Therapist manual/hands on assistance
- 1 x assist, 2 x assist
In regards to mobility, what does need “supervision” mean?
Requires verbal cues, no manual/hands on assistance required
In regards to mobility, what does “independent” mean?
Patient can perform task without manual/hands on assistance or verbal cues
What does FWB stand for?
Full weight bearing
What does WBAT stand for?
Weight bearing is tolerated (might have pain or discomfort)
What does PWB stand for?
Partial weight bearing (eg. if need clarification- 25%-75% = 50%)
What does TWB stand for?
Touch weight bearing (eg. <25%= 10%)
What does HWB stand for?
Heel weight bearing (mid or forefoot injury/only heel on ground- heel raised )
What does NWB stand for?
Non-weight bearing (LL fracture -unstable)
What are 4 treatment principles?
- Use SMART principles
- Facilitate independence as early as possible
- Usually involves:
- postural advice and education
- exercises
- gait re-education with appropriate walking aid
- Requires the use of outcome measures to ensure efficacy
What are outcome measures? Why are they important? Give some examples.
- Used to measure effectiveness of treatment
- Goniometry assessment of RoM
- Mobility progression (aid, distance, stairs, level of assistance)
- TUG
Good ___management is vital to physiotherapy management
pain
What are the 5 types of routes for pain management?
- Slow acting
- Fast acting
- Continuous acting
- Patient controlled- intermittent
- Operative anaesthetic
What are slow acting pain management treatments?
- Oral (paracetamol, endone, targin, panadeine forte, tramadol)
- Subcutaneous narcotic (eg morphine)
- Intramuscular narcotic (eg morphine
What are fast acting pain management treatments?
Intravenous - (morphine, fentanyl)
What are continuous acting pain management treatments?
- Epidural (ropivocaine, fentanyl)
- Nerve Block - continuous infusion or local infiltration in theatre(sensory fibres on superficial surface/motor deep)
What are patient controlled (intermittent) pain management treatments?
Patient Controlled Analgesia - PCA
What are operative anaesthetic pain management treatments?
- Spinal (wears off 3-4 hours post surgery)
- General (associated with respiratory complications - atelectasis…)
What is important to do with given pain medication?
Time to action (5-30minutes) - plan your treatment times around this where possible
What are the the 2 side effects or narcotic analgesia?
- Drowsiness &reduced central respiratory drive therefore require supplementary O2 (2L/min via nasal prongs) at rest
- Nausea and vomiting
- Countered with antiemetics - maxalon, stemetil
Thus, as a summary, what are the 8 things to remember in assessment?
Systematic approach- logical, sequential way
- Read and interpret medical records and imaging
- HPC, PMHx, PSHx, FnlHx, SocHx
- Subjective assessment
- HPC, PMHx, PSHx, FnlHx, SocHx
- Objective assessment
- General observation
- Environment
- Systems assessment (resp, circ, neuro, MSk)
- Specific body region
- Functional assessment
- Rx Plan (plan and prepare environment- as soon as walk in- observe and interpret for treatment)
- Rx & Re-Ax using outcome measures
- Modify and progress
- Document
- Importance of pain Mx
