Elsie - lective laparotomy secondary to bowel cancer, resulting in a right hemi-colectomy and colostomy formation Flashcards
How old is Elsie
80
What’s her past medical history?
-Under weight
-Previous hysterectomy 30 years ago (removal of womb)
-Hypertensive (high blood pressure)
What’s Elsie’s drug history?
-Anxiolytics (manage anxiety)
-doxazosin for HT (manage high blood pressure)
What are the precautions & contraindications of Elsie’s medication?
-Anxiolytics: anxiety can cause low blood oxygen (hypoxemia) which can cause SOB and dizziness. This could worsen symptoms of atalectasis.
-Doxazosin for HT: Can cause drowziness & cough.
What’s Elsie’s HPC (History of Present Condition)?
-She presented to her GP c/o tiredness, abdominal pain and passing blood PR
-Localised colorectal (bowel) cancer diagnosed following colonoscopy; pt. aware of diagnosis
On an Enhanced Recovery After Surgery (ERAS) programme
What’s Elsie’s social history?
-Lives with her husband in a semi-detached house with stairs.
-Retired shop assistant, until 5 months ago.
-Involved in the care of teenage grandchildren post school, as her daughter is a working single mum.
Independent in all ADL prior to surgery, walks with a stick.
What was seen on examination?
-She was admitted to HDU post-surgery yesterday. Long (6 hours) surgery complicated by bowel adhesions (irregular bands of scar tissue that form between two structures that are normally not bound together).
-She is lying slumped in bed c/o pain. She has been prescribed regular oral analgesia.
-Obs: pyrexial (fever) (T 38.2) and tachycardic (HR 95) (fast HR) with a stable BP (130/90). SpO2 is 92% on FiO2 = 0.24 (approx.) 2L O2 via nasal cannula
-Her CXR shows Bibasilar atelectasis (partial lung collapse).
What Multi Disciplinary Members would be involved in Elsie’s care?
-Nurses: Oral analgesia administration; may be beneficial to conduct breathing exercises shortly after medication administration to minimise pain perception (also be mindful that patient may experience drowsiness due to medication)
Radiologist / doctor: Discuss CXR findings
-Nurse / OT: Involvement of a stoma care nurse & OT may be beneficial in the adaptation of ADL in relation to living with a colostomy post-surgery
-Oncologist / Gastroenterologist: advising on treatment plan post-surgery
-Dietician: advising on dietary changes post-surgery (colostomy) / prescription of Fresubin or similar to return to a healthy weight
-Outpatient Physio: Exercise therapy for tiredness to increase Elsie’s energy levels as well as Elsie benefiting from the physiological changes of exercise (Wender et al., 2022)
What would be included in Elsie’s subjective assessment?
-Check levels of coherency, understanding & pain
-Build relationship / trust, gain consent
-General understanding of her current presentation
-Ask how she is feeling - dizzy, SOB? Able to move?
What would be included in Elsie’s objective assessment?
-Auscultation & palpation of ribs: note any added / absent sounds, note temperature
-Neuro-integrity test before mobilising her
-Percussion notes; to assess chest resonance; identify areas of excess sputum / blockages (identify ‘dull’ sounds)
-Chest X-ray analysis; Bibasilar atelectasis
-BP / SpO2 / RR monitoring
-Weight-bearing status
-Motion sensitivity test: assess how stable she is when moving her arms / body in bed & make sure she is able to do tasks
What treatment would you use to manage Elsie’s Bibasal atelectasis and why?
TEE: BC / TEE x 3 / BC / TEE x 3 / BC; x (hourly; at least 3 – 4 cycles per day). With added sniff and hold as Elsie has bibasilar atelectasis.
Patient inclined to slump in bed due to wound orientation; upright posture should be maintained when completing breathing techniques.
Why: There are no secretions, however, she has atelectasis therefore we would want to focus on thoracic expansion with a sniff and a hold as this opens the airways by:
Alveolar interdependence: by increasing the air in the lungs the alveoli expand, when the air is exhaled the narrowing of the surrounding alveoli cause the collapsed airways to open.
Collateral airways: during the hold the air has time to move through the collateral airways, this means that it can get behind the closed airways opening them during exhalation.
Support during thoracic expansion exercises = optimising lung volume expansion
What evidence is there to support thoracic expansion exercises in Elsie’s case?
??
What else would support Elsie with her bibasal atalectasis and why?
Supported upright sitting in a chair; offer cushion for support when coughing– extra support for abdomen
Why: Supported sitting may be more comfortable for the patient due to surgery incision site location, as long sitting /supine may pull incision site more than upright positioning
Upright sitting allows access to the basal section of lower lobes; beneficial for percussion techniques / palpation / auscultation
What evidence is there for supported sitting?
?????
How would you support Elsie with her Mobilisation following surgery (first postoperative day +) and why?
Encourage the patient to perform a short walk around the bed with an accompanying PT
Measure temperature, respiratory rate, pulse, blood pressure before, during and after.
Why: Mobilisation shortly after surgery will encourage optimum lung expansion; reduce atelectasis / prevent muscle atrophy / optimise wound healing / facilitate optimum recovery and return home following surgery
Part of Elsies ERAS program focuses on early mobilisation post-surgery.
