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PHTY3250 > L10 Pre & Post Surgical PT > Flashcards

L10 Pre & Post Surgical PT Flashcards

1
Q

What are 4 reasons to care about surgery?

A
  1. Surgery –> adverse effects
    • PPCs (Post-operative Pulmonary Complications)
      • ↑ morbidity, mortality, length of stay (LOS) (Not ideal for patient or hospital)
  2. PT plays a crucial role in preventing & managing PPCs and other post-surgical problems
  3. Aim = Identify problems / risk factors for problems → select and implement most appropriate techniques for individual
  4. Ax outcome and modify Rx as needed
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2
Q

What are 6 differences in patients who have surgery?

A
  1. Incision
  2. Pain
  3. Anaesthetic
  4. Medications ; side-effects
  5. Immobility
  6. Possible complications
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3
Q

What are the 3 effects on respiratory function of surgery?

A

Due to incision to abdomen or thorax

  1. ↓ Lung volumes (restrictive effect), may persist for 5-10 days post-op:
    1. ↓ VC to 40% of pre-op levels
    2. ↓ FRC to 70% of pre-op levels (lowest day 1-2 post-op)
    3. May be combined with ↑ CC (age, smoking Hx, chronic lung disease…)
    4. ↓ breathing (hypoventilation)
    • Atelectasis
    • V/Q mismatch
    • Hypoxaemia (most severe day 1-2 post-op)
      • Supplemental O2 routinely given post-op (Reverse or prevent effects)
  2. ↓ Mucociliary function
  3. ↓ Diaphragm excursion
    • ↓ VC
    • Hypoxaemia
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4
Q

What does PPCs stand for?

A

Post-Operative Pulmonary Complications

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5
Q

What are 2 causes of PPCs?

A
  1. Atelectasis
  2. Pneumonia
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6
Q

What are 7 signs and symptoms (usually 4+ of the following) for PPCs?

A
  1. CXR evidence of atelectasis/consolidation
  2. Temp >38°after Day 1
  3. Raised WCC or Prescription of ABs specific for lung infection
  4. SpO2 <90% ORA
  5. New production of yellow / green sputum
  6. Dx of pneumonia/chest infection by Dr
  7. Readmission to or prolonged stay in (>36h) ICU/HDU with resp problems; New auscultation signs (abnormal BS)
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7
Q

What are the 5 impact on ventilation levels of abdominal surgery?

A
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8
Q

What are the 4 types of atelectasis?

A
  1. Microatelectasis
    • Patchy areas of atelectasis not resulting in shift of structures
    • If not adequately treated may became major atelectasis
    • All post-surgical patients will have microatelectasis
  2. Plate Atelectasis
    • Small areas of collapse
    • Thin white lines on CXR
    • Pulmonary oedema, pneumonia
  3. Absorption Atelectasis
    • If bronchus or bronchiole is blocked
      • Gas in unit distal to obstruction is trapped
      • Gas uptake by blood continues – gas pocket collapses
    • Or, if high FiO2 (oxygen therapy)
      • ↓ Nitrogen (Nitrogen is a structural unit)
      • V/Q mismatch
      • Airways become unstable –> ↑risk of collapse
  4. Surfactant Impairment
    1. Surfactant covers large alveolar surface
      1. Reduces alveolar surface tension
      2. –Stabilizes alveoli
      3. Prevents collapse
      4. Surfactant affected by:
        1. Anaesthesia
        2. Supplemental O2 (dry)
        3. Mechanical ventilation
        4. Infection
        5. Pre-term neonate
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9
Q

What are 3 characteristics of microatelectasis?

A
  1. Patchy areas of atelectasis not resulting in shift of structures
  2. If not adequately treated may became major atelectasis
  3. All post-surgical patients will have microatelectasis
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10
Q

What are 3 characteristics of plate atelectasis?

A
  1. Small areas of collapse
  2. Thin white lines on CXR
  3. Pulmonary oedema, pneumonia
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11
Q

What are 2 characteristics of absorption atelectasis?

A
  1. If bronchus or bronchiole is blocked
    1. Gas in unit distal to obstruction is trapped
    2. Gas uptake by blood continues – gas pocket collapses
  2. Or, if high FiO2 (oxygen therapy)
    1. ↓ Nitrogen (Nitrogen is a structural unit)
    2. V/Q mismatch
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12
Q

What are 2 characteristics of surfactant impairment atelectasis?

A
  1. Surfactant covers large alveolar surface
  2. Reduces alveolar surface tension
    1. Stabilizes alveoli
    2. Prevents collapse
    3. Surfactant affected by:
      1. Anaesthesia
      2. Supplemental O2 (dry)
      3. Mechanical ventilation
      4. Infection
      5. Pre-term neonate
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13
Q

What are 9 risk factors for atelectasis?

A
  1. Surgical Incision (abdo / thoracic / cardiac)
  2. Previous respiratory condition
  3. Smoking history
  4. Obesity
  5. Age
  6. Impaired cognitive function
  7. Monotonus pattern of mechanical ventilation
  8. Body position (supine, slouched)
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14
Q

What are 10 S’s that ↑ risk of atelectasis post surgery?

EXAM QUESTION

A
  1. Surgery
  2. Shallow breathing
  3. Splinting / Sore
  4. ↑ Secretions
  5. ↓ Surfactant
  6. Supine / Slumped
  7. Supplemental oxygen
  8. Synthetic (mechanical) ventilation
    • °Sighs
    • Smoking history
  10. Size (obesity)
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15
Q

What are 2 factors reducing mucociliary clearance?

A
  1. ↓ Cilial beating
    1. Temporary: Medications (eg, GA, narcotics) (Patient who have had surgery)
      1. Drying of mucosa, dehydration (mucous = 95% H2O)
      2. High inspired O2 concentration (FiO2)
      3. Positive Pressure Ventilation
      4. Endotracheal intubation
      5. Atelectasis, ↓ lung volumes
      6. ↓ Cough effectiveness
      7. Lack of sleep
      8. Pollutants
    2. Permanent: Smoking
      1. Disease states (eg. CF, bronchiectasis)
  2. ↑ Secretion volume / thickness (eg: CF, bronchiectasis, infection, dehydration)
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16
Q

What are the 2 main risk factors for PPCs?

A
  1. Patient-related
  2. Procedure-related
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17
Q

What are 7 patient-related risk factors of PPCs?

A
  1. Age >60y
  2. Respiratory & cardiac disease (eg COPD)
  3. Smoking history (esp. within last 8 weeks)
  4. Impaired functional status
  5. ASA Comorbity Score, class 3-5
  6. Serum albumin <3 g/dL
  7. Sleep apnoea
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18
Q

What are 2 procedure-related risk factors of PPCs?

A
  1. Anaesthesia
  2. Surgery
    1. Type (abdominal (esp. upper abdominal), thoracic, neuro, head and neck, vascular, aortic aneurysm repair)
    2. Duration >3 hours
    3. Emergency vs elective
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19
Q

What are 3 reasons why “age >60 years” is patient-related risks of PPCs?

A
  1. ↑ CC ↓FCR
  2. ↓ Elastic recoil of lungs
  3. Weaker respiratory muscles
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20
Q

What are 3 reasons why “respiratory disease” is patient-related risks of PPCs?

A
  1. Restrictive conditions eg pulmonary fibrosis, pulmonary oedema
    • Why? = Further ↓ TV and FRC with surgery
  2. Obstructive conditions eg COPD
    • Why? = ↓ Reserves
  3. Recent infection
    • Why? = ↑ Secretions, ↓ mucocillary clearance

↓ Ability for lungs to recovery post surgery

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21
Q

What are 2 reasons why “smoking history” is patient-related risks of PPCs?

A
  1. Narrowing of small airways
  2. ↑ mucus, ↓ mucocillary clearance
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22
Q

What are 2 reasons why “functional status” are patient-related risks of PPCs?

A
  1. ↓ Mobility / activity levels pre-operatively
  2. Deconditioned; Weaker and reduced endurance
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23
Q

What are 1 reasons why “BMI ≥ 27” are patient-related risks of PPCs?

A

BMI > 25 = overweight ; BMI > 30 = obese

  1. ↓ FRC; ↓ lung compliance
    • Less room to move (squashing lung)
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24
Q

What are 4 other patient-related risks for PPCs?

A
  1. Impaired nutritional status (Malnutrition)
    • May alter wound healing, antibody production
  2. Cancer
    • May alter wound healing, may impair nutrition
  3. Immunocompromised
    • May alter wound healing, risk of secondary infections
  4. Impaired cognitive function
    • May not be able to follow post-op procedures
    • Unable to do treatment appropriately
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25
Q

What are 2 procedure-related risks of PPCs?

A
  1. General Anaesthesia (GA)
  2. Adverse effects (Impaired airway clearance and ventilation)
    1. Drying of cilia → ↓mucociliary function
    2. Secretion retention
    3. Loss of cough reflex
    4. ↓FRC
    5. Respiratory inhibition
    6. Atelectasis
    7. ↓ Alveolar ventilation

“ Induction of anaesthesia causes unavoidable changes in lung mechanics, lung defences and gas exchange. The most profound effect on the lung of a GA is the reduction in lung volumes, particularly FRC.”

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26
Q

List 3 patient-related risk factors associated with increased risk of PPCs.

EXAM QUESTION

A
  1. Age >60y
  2. Respiratory & cardiac disease (eg COPD)
  3. Smoking history (esp. within last 8 weeks)
  4. Impaired functional status
  5. ASA Comorbity Score, class 3-5
  6. Serum albumin <3 g/dL
  7. Sleep apnoea
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27
Q

What are the procedure-related risks in PPCs?

A
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28
Q

What are the risk factors of respiratory failure?

A
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29
Q

What are the 3 factors responsible for pain (post-operatively)?

A
  1. Poor cough → impaired airway clearance
  2. Impaired ability to breathe deeply and sigh →
    1. Impaired ventilation
    2. Atelectasis
    3. Hypoxaemia
  3. Respiratory distress

Thus, critical to optimise pain management

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30
Q

What are 2 types of pain management post-op?

A
  1. Narcotics
    1. Morphine, Pethidine, Fentanyl
  2. Epidural
    1. Local anaesthetic + opiods
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31
Q

What are the 7 complications of narcotic analgesia post-op?

EXAM QUESTION

  • If a patient is on narcotics analgesia , what are the signs in presentation?
  • OR
  • These … are the signs, what could that be due to?
A
  1. Respiratory depression
  2. Postural hypotension, syncope
  3. Nausea, vomiting
  4. Drowsiness
  5. Paralytic ileus
  6. Pruritis / itchiness
  7. Urinary retention
32
Q

What are 2 characteristics of multimodal administration of post-op pain management?

A
  1. Smaller doses
  2. Less side effects
33
Q

What are 3 side effects of local anaesthetics as post op pain management?

A
34
Q

What are 5 effects of post-op immobility?

A
  1. ↓ Lung volumes (esp. FRC), Hypoxaemia
  2. ↓ VO2max ; deconditioning
  3. ↓ CO, ↓ SV , ↑ HR
  4. Orthostatic intolerance
  5. Pressure areas ; MS changes
35
Q

What are 4 goals of post-op mobilisation?

A
  1. Prevent above effects
  2. ↑ Minute ventilation
  3. ↑ CO
  4. BUT, within SAFE physiological limits
36
Q

What are 6 risk factors of DVT?

A
  1. DVT Hx
  2. Smoking Hx
  3. Immobility
  4. Malignancy
  5. Oral contraceptive pill
  6. Previous pelvic or LL surgery
37
Q

List 2 risk factors for DVT.

EXAM QUESTION

A
  1. DVT Hx
  2. Smoking Hx
  3. Immobility
  4. Malignancy
  5. Oral contraceptive pill
  6. Previous pelvic or LL surgery
38
Q

When will you see the surgical patient (3)?

A
  1. ± PREAC (Pre-Admission Clinic)
  2. ± Pre-operatively (On the day before or on the day before surgery)
    1. Access is dependent on admission, procedure and patient status
    2. Varies from several days → hours → minutes
  3. ± Post-operatively
39
Q

Which surgical patient/s will you see (2)?

A
  1. Prioritise patients who are at high risk
    1. Patient-related risks
    2. Procedure-related risks
  2. ‘Prediction models’ of PPCs
40
Q

What are 4 assessments pre-op?

A
  1. Medical chart
  2. Bed chart
  3. Patient interview
  4. Physical examination

= Identify the patient’s main problems & risk factors and determine goals of physiotherapy management

Not drowsy or in pain

41
Q

What are 9 features of the medical chart pre-op?

A
  1. Ensure you have the correct patient’s chart
  2. Presenting condition
  3. Past medical history, & Management
  4. Social history
  5. Functional history
  6. Investigations
  7. Medical management
  8. Operation plans
  9. Special orders

This information will guide assessment and treatment

42
Q

What are 6 features of the bed chart pre-op?

A
  1. Vital signs
  2. Pain
  3. Medications
  4. Fluid balance
  5. Blood glucose
  6. Neurological status(eg. GCS)

This information will guide assessment and treatment

43
Q

What are the 5 normal vital signs in the bed chart?

A
  1. Blood pressure (normal ~120/80)
    1. Hypotension (90/60)
    2. Hypertension (140/90)
  2. Heart rate (normal ~60-100)
    1. Bradycardia <60 beats/min
    2. Tachycardia >100 beats/min
  3. Temperature (normal ~37 degrees)
  4. Respiratory rate (normal ~12-16)
    1. Bradypnoea <10 breaths/min
    2. Tachypnoea >20 breaths/min
  5. Oxygen saturation (SpO2), Fractional concentration (FiO2)
44
Q

What are 6 features of the patient interview pre-op?

A
  1. (Patient’s main problem)
  2. Breathlessness
  3. Cough, sputum, wheeze
  4. Pain
  5. Past medical history – Respiratory Hx; Risk factors
  6. Function, mobility
  7. Social history
  8. Home environment
  9. Special questions

Ideal to get info at this time, rather than Day 1 post-op.

***Prioritise and modify depending on patient’s presentation

45
Q

What are 7 features of the physical examination pre-op?

A

“TOP TO TOE” approach

  1. Observation
    1. Environment; Attachments
    2. Patient
  2. Palpation
  3. Auscultation
  4. Cough
  5. Lower limbs
  6. Bed mobility + function
  7. Special assessment
46
Q

What are the 8 patient-related risk factors of PPCs?

A
  1. Age >60y
  2. Respiratory & cardiac disease (eg COPD)
  3. Smoking history (esp. within last 8 weeks)
  4. Impaired functional status
  5. ASA Comorbity Score, class 3-5
  6. Serum albumin <3 g/dL
  7. Sleep apnoea
47
Q

What are the 2 procedure-related risk factors of PPCs?

A
  1. Anaesthesia
  2. Surgery
    1. Type (abdominal (esp. upper abdominal), thoracic, neuro, head and neck, vascular, aortic aneurysm repair)
    2. Duration >3 hours
    3. Emergency vs elective
48
Q

What are the 2 aims of pre-op management?

A
  1. Gain patient’s confidence
  2. Ax and prevent risks of developing PPCs
49
Q

What are the 5 education of pre-op management?

A
  1. Role of PT within team; re chest, circulation, ambulation, specific exercises (rationale)
    • Eg. ACBT, FET or supported, assisted cough
  2. Expected post-op presentation – incision, attachments
  3. Effects of surgery, GA, pain on CR system
  4. Early mobilisation program
  5. Importance of pain relief

May require measurement for TED stockings (Compression stockings)

50
Q

What are 5 demonstrations of pre-op management?

A
  1. Breathing exercises
  2. Supported cough or FET
  3. Circulation exercises
  4. Bed mobility and transfers
  5. Specific exercises for procedures (eg. UL & trunk for cardiothoracic surgery)

Prior to surgery (to avoid pain)

51
Q

What are treatments of pre-op management?

A

May require airway clearance – to optimise lung function prior to surgery

  • Right before surgery (is also possible)
52
Q

What is an operation?

A
53
Q

What are the 4 assessments post-op?

A
  1. Medical chart
  2. Bed chart
  3. Patient interview
  4. Physical examination

= Identify the patient’s main problems & risk factors and determine goals of physiotherapy management

54
Q

What are the 7 features of medical chart post-op?

A
  1. Presenting condition
  2. Past medical history
  3. Social history
  4. Functional history
  5. Investigations
  6. Medical management
  7. Operation notes
    1. Special orders
    2. Recovery notes

This information will guide assessment and treatment

55
Q

What are the 3 features of operation notes of medical chart post-op?

A

Can have implications for physio

  1. Procedure:
    1. Incision / structures cut
    2. Wound closure / drains
  2. Anaesthesia:
    1. Anaesthesia time
    2. Surgical time
    3. Recovery – any events
  3. Management:
    1. Return to ward
    2. Pain relief
    3. Initial post-op course
56
Q

What are the 5 features of special orders of medical chart post-op?

A
  1. Physiotherapy
  2. Oxygen therapy (device, flow rate)
  3. Fluid orders (clear, free, thickened, soft, full)
  4. Pain relief (Oral; Epidural; IV; PCA, PCEA; IM)
  5. Other specific orders (eg, WB status; ROM allowance)
57
Q

What are the 8 features of peri-/post-op complications of medical chart post-op?

A
  1. Changes to planned procedure
    1. Eg. laproscopic procedure becomes open (Eg. longer surgery and anaesthesia time)
  2. Large blood loss → low Hb post-op
  3. Cardiac complications
    1. ECG changes intra-op, MI
  4. Labile BP, intra-operative CVA
  5. Contamination of the field
  6. Other tissue damage
  7. GA complications
  8. Aspiration
58
Q

What are the 6 features of reovery notes of medical chart post-op?

A
  1. Length of time in recovery
  2. Returned to ward, time since surgery
  3. Medical or surgical review required
  4. Any initial post-op complications
    1. Egs: poor pain control, SOB, low urine output (UO), fluid overload, wound ooze, bleeding, post-op pyrexia
  5. Investigations undertaken since surgery - eg. Hb
  6. Nursing notes
59
Q

What are the 8 features of bed chart post-op?

A
  1. Vital signs
  2. Pain
  3. Medications / narcotic infusion sheet
  4. Fluid balance
  5. Blood glucose
  6. Observations
    1. Circulation
    2. Neurological status(eg. GCS)

This information will guide assessment and treatment

60
Q

What are the 8 features of patient interview post-op?

A
  1. Special questions* (post-surgical)
  2. Pain*
  3. Cough*
  4. SOB*
  5. Past medical Hx
  6. Smoking history*
  7. Functional Hx
  8. Social Hx

*Prioritise interview for patient Day 1 post surgery (Need to know vs good to know)

Consider questioning approach. Gather information from chart.

61
Q

What are the 5 main features of special questions patient interview post-op?

A
  1. Post-operative
    1. Nausea
    2. Dizziness
    3. Drowsy
    4. Vomiting
  2. Pain
    1. rest ; movement (& cough)
    2. Relate to timing / nature of analgesia
    3. PCA - monitor dose / bolus
  3. +/- Epidural pain relief
    1. Pins and needles
    2. Numbness
    3. Weakness
    4. Heaviness
    5. Headache, back ache
  4. Cough
    1. Performed?
    2. ?Productive: sputum quality, quantity
  5. SOB
    1. Compare current to usual
62
Q

What are 6 features of physical examination post-op?

A
  1. Observation
    1. Environment; Attachments; Medications
      1. Patient; Incision
      2. Wound
        1. Location
        2. Dressing (clean & dry, vs ooze)
  2. Palpation
  3. Auscultation
  4. ± Cough (justify timing)
  5. Lower limbs
    1. DVT
    2. Circulation
  6. Special assessment
    1. Epidural (site; sensation; muscle strength)
    2. Readiness to mobilise
63
Q

What are 7 considerations of attachments post op?

A
  1. IV line - which arm?
  2. Wound drain - where, what, drainage, suction?
  3. NGT - suction?
  4. Colostomy / ileostomy – check leakages; may need to empty prior to mobilising / rolling pt
  5. Check length of tubing
  6. Don’t pull anything out!/Do not dislodge
  7. Check if line is:
    1. Attached to patient
    2. Attached to pillow / bed
    3. Looped under bed rail
64
Q

What are the 3 post-op management?

A
  1. Guided by assessment
  2. Remember techniques covered so far:
    1. Improve ventilation
    2. Airway clearance
  3. Mobilisation*

“Techniques to increase ventilation are recommended for individuals at high risk of developing PPCs”

65
Q

What are 9 physiotherapy techniques to improve ventilation?

A
  1. Pain relief
  2. Positioning
  3. Breathing exercises
  4. Demand ventilation / Mobilisation
  5. Facilitation techniques
  6. Incentive spirometry
  7. PEP devices
  8. Non-invasive ventilation
  9. Oxygen therapy
66
Q

What are 6 things that mobilisation limited by?

A
  1. Pain, incision
  2. Anxiety
  3. Drowsiness
  4. Medications
  5. Attachments
  6. Blood pressure, syncope
67
Q

What are 2 things that should be monitored during mobilisation?

A
  1. HR, RR, SpO2, Borg RPE / RPB
  2. Tolerance (N&V, pain)
68
Q

What are 4 documentations during mobilisation?

A
  1. Distance
  2. Assistance (aid, staff)
  3. Tolerance
  4. Effect (re-assess)
69
Q

What are 7 ACTs techniques?

A
  1. ACBT
  2. Cough [supported]
  3. PEP
  4. MPD
  5. P & V
  6. Inhalation therapy, Humidification
  7. Exercise therapy / Mobilisation
70
Q

______ surgery = “Evidence to support physiotherapy to reduce incidence of PPCs”

A

Upper abdominal

71
Q

_______ surgery = “Pre- and postsurgery physiotherapy should be provided”

A

Thoracic, oesophageal

72
Q

What is the selection of physio strategies?

A
73
Q

What are the ages and stages?

A
74
Q

What does the problem, evidence, likely pathophysiological cause, Management (+ brief rationale) and outcome measures for Mrs Dalton look like?

A
75
Q

What are the considerations and implications for physiotherapy for Mrs Dalton?

A
76
Q

What does the chart entry for Mrs Dalton look like?

A

PHTY3250 (20 decks)

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