Pre & Post-op Physiotherapy Flashcards
What is the perioperative period?
The time surrounding a surgery.
What are the three phases of the perioperative period?
Preoperative, intraoperative, postoperative.
What is the goal of Enhanced Recovery After Surgery (ERAS)?
To optimize patient outcomes using a multi-disciplinary approach.
When can preoperative physiotherapy start?
Before hospital admission (prehabilitation) or during admission.
What is the main role of a physiotherapist in the perioperative period (aims)?
- To improve pts ability to cope with stressors
- Improve post-op outcomes
- Minimise post-op risks/complications
Name two ways prehabilitation improves post-op outcomes.
Strength training and aerobic exercises.
What is the main aim of pre-operative physiotherapy?
- To minimize adverse physiological changes from surgery
- Teach pt about role of physio & post-op recovery
What is the indication for pre-op physio?
For any pts that have an increased risk of developing postoperative pulmonary complications (PPCs).
How long should a prehabilitation program last?
2-4 weeks before elective surgery, 3-7 days/week
What is an ideal exercise intensity for prehabilitation?
40-70% of maximum heart rate (HRmax).
What does the pre-op exercise programme consist of?
- Strength training
- Strengthening respiratory muscles
- Deep breathing exercises & inspiratory muscle training
- Aerobic exercises (imporve exercise tolerance)
What circulatory exercise is taught preoperatively to prevent DVT?
Ankle pumps, isometric calf & quad holds, knee extentions, seated marches.
What should be taught for post-op pulmonary function?
- Supported coughing (if appropriate for surgical incision)
- Deep breathing exercises & inspiratory muscle training
- Circulatory exercises to prevent DVTs
What should be assessed before surgery?
Functional status, muscle strength, and exercise tolerance.
Why should a patient be educated about post-op positioning?
To optimize lung function and prevent complications.
What are PPCs?
Respiratory complications after surgery/anaethesia
Name examples of PPCs.
Atelectasis, pneumonia, infecions, poor cough effort, DVTs - PE
What are the implications of PPCs
Increased mortality rate, LOS at hospital & hospital costs
Name the patient-related risk factors for PPCs.
- Age > 60 years
- Frailty (decreased fx)
- Smoking hx
- Acute infection within the last month
- Comorbidities (obesity, diabetes, HPT, COPD & astma, cong. HF & angina)
How does smoking affect PPC risk?
It increases the likelihood of respiratory complications.
How does obesity contribute to PPCs?
It impairs lung function and mobility.
What type of surgery has a higher PPC risk?
- Upper abdominal > lower abdominal surgery
- Open lapartomoy > laparoscopic
- Thoracotomy, neck/neuro/major vascular surgery
- Emergency > elective
- Re-operations
What are the “other” risk factors for developing PPCs?
Duration of surgery/anaesthesia & type of surgery
How does surgery duration affect PPC risk?
Surgeries lasting >2 hours increase the risk.
What would you asses for in the pre-operative period?
Pts risk for developing PPCS, functional levels, muscle strength& exercise teolerance
What would you educate the pt on during the per-operative period?
Educate pt on:
- Surgery – site of incision & implications
- Effects of anaesthesia
- Medical equipment/devices (eg: IV lines, catheters, etc.)
- Role of physio in their recovery
- Benefits of early mobilisations & optimal positioning
What is a thoracotomy?
Surgical incision to chest wall to gain access to thoracic cavity
What are the three types of thoracotomy approaches?
Posterolateral, muscle-sparing, anterior-lateral.
Describe a posterolateral thoracotomy.
Incision through the latissimus dorsi, serratus anterior, rhomboids & trapezius.
Describe muscle sparring thoracotomy
Incision is made but latissimus dorsi & serratus anterior are spared.
Describe an anterolateral thoracotomy
Small incision is made on the anterior chest wall. Pec major & minor are dissected.
What are the implications for the posterolateral thoracotomy?
Lots of pain & shoulder dysfunction
What are the implications for the muscle sparring thoracotomy?
Decreased pain & shoulder dysfunctin compared to Posterolateral thoracotomy
What is a lobectomy?
Surgical removal of one or two lung lobes.
What is a pneumonectomy?
Surgical removal of an entire lung.
What is a laparotomy?
An incision in the abdominal wall.
What is a sleeve resection?
Resection of upper lobe & sleeve of main bronchus to preserve the lung tissue
What is a resection?
Surgery to remove tissue or part/all of an organ
What is a pleurectomy?
Partial stripping of the parietal pleura
What is decortication?
The removal of thickened pleura/drainiage of pus
What is an oesophagogastrectomy?
Removal of the lower portion of the oesophagus & stomach
What is a sternotomy?
A midline incision through the sternum.
What is pleurodesis?
A procedure using an irritant to fuse the pleura (basically adheres lung to chest wall to decrease pleural space if enlarged)
What is an oesophagectomy?
Partial/complete removal of the esophagus.
What is a laproscopic procedure
Minimally invasive abdominal surgery
What are the advantages of laparoscopic surgery?
Faster recovery time & lower PPC risk because it’s minilally invasive
What are the indications for a laparotomy?
- Elective surgery (eg: rectal resection if cancerous)
- Explorative surgery due to blunt/penetrating trauma
What is an open abdomen procedure?
A laparotomy left open with a vacuum dressing. A drain is inserted to suction out any excess fluids
What type of surgery is used for coronary artery bypass grafting (CABG)?
Median sternotomy.
What are the indications for a median sternotomy?
- CABG – coronary artery obstruction
- Thoracic trauma involving the mediastinum (eg: stab wound)
- Unstable fractured sternum
What are the effects of surgery on respiratory processes?
Effects are due to a combination of surgery, anaesthesia, pain & inactivity post-op. May persist up to 5-10 days post-op
- Decreased:
Lung volumes (VC, FRC)
Diaphragmatic excursion/movement (respiratory muscle dysfunction)
Musculociliary clearance
- Ineffective cough
- V/Q mismatch & hypoxaemia
- PPCs may develop
What are the effects of anaesthesia?
- Decreased muscociliary activity (paralyses cilia)
- If high flow O2 used – dehydration & sputum retention
- Basal actelectasis – due to intubation, position/use of paralytic agents during surgery
- Hypoxaemia
- Hypoxia (in severe cases)
Why is pain management important postoperatively?
- To ↓ physiological symptoms (eg: tachycardia/HPT)
- ↓ Secondary resp dysfunction by ↑ tidal volumes & effective coughing
- Allow pts to start with mobilisation
Name the common methods of pain relief.
- Intramuscular
- Intravenous
- Epidural (Catheter inserted into thoracic/lumbar epidural space)
- Peripheral blocks (eg: intercostal nerve block, intra-pleural analgesia)
- Pt controlled analgesia (PCA)
- Pt controlled epidural analgesia (PCEA)
What does PCA stand for?
Patient-Controlled Analgesia.
What is the purpose of an intercostal nerve block?
To relieve pain in thoracic surgery patients.
What is PCEA?
Patient-Controlled Epidural Analgesia.
How does pain affect respiration?
It reduces tidal volume and increases the risk of atelectasis.
What is the main goal of post-op physiotherapy?
To restore function and prevent complications.
Name two side effects of epidural anesthesia.
Hypotension and urinary retention.
What is a peripheral nerve block?
A targeted injection to block pain in a specific area.
Why is early mobility encouraged postoperatively?
It prevents DVT and respiratory issues.
What technique is used to improve lung function?
Deep breathing exercises.
What technique helps clear secretions?
Huffing and supported coughing.
What does a PEP device help with?
Sputum clearance.
Why should a pneumonectomy patient not lie on the non-operative side?
To prevent fluid from shifting to the remaining lung & damaging the structures of that lung.
What is atelectasis?
Partial or complete lung collapse due to alveolar deflation.
How does anesthesia contribute to atelectasis?
Reduces lung expansion and impairs mucociliary clearance.
What does OLDCART stand for in pain assessment?
Onset, Location, Duration, Comorbidities, Associated symptoms, Radiation, Treatment.
What is one reason to avoid excessive oxygen therapy post-op?
It can cause dehydration and sputum retention.
What is the primary risk of prolonged immobility post-op?
Deep vein thrombosis (DVT).
What technique should be avoided directly on a surgical incision?
Manual chest clearance techniques.
What are two vital signs that should be monitored before mobilizing a post-op patient?
Blood pressure and oxygen saturation.
Why should post-op patients be encouraged to sit up and move early?
To prevent pulmonary and circulatory complications.
What is one respiratory effect of high-flow oxygen therapy?
Drying of the airway mucosa, thus causing secretion retention
Why should a sternotomy patient avoid lifting heavy objects?
To prevent stress on the healing sternum.
What is one key indicator of post-op pneumonia?
Increased temperature (>38°C) with no other infection source.
What is the best position for a patient with respiratory distress post-op?
Semi-Fowler’s (30-45° upright).
What is a common complication of prolonged bed rest?
Muscle atrophy and weakness.
What does a nasogastric tube prevent post-op?
Aspiration and gastric distension.
Why should a laparotomy patient avoid prone positioning?
To prevent excessive strain on the abdominal wall - weight of structures above will press into incision
How can post-op physiotherapy help prevent ileus (aka constipation)?
Mobilization stimulates gut motility.
Why should patients be taught to use supported coughing after surgery?
To reduce pain and prevent incision stress.
What is one main reason post-op patients are at risk of lung infections?
Impaired cough and mucociliary clearance due to anaesthsia, pain, immobility/inactivity post-op
Why is deep breathing encouraged post-op?
To expand the lungs and prevent complications.
What is the goal of pulmonary physiotherapy after surgery?
To maintain airway clearance and lung function.
There are 10 aims of physio post-op. Name min 7
- Assess for signs of PPC
- Re-inflate collapsed lung
- Maintain adequate ventilation
- Remove excess secretions & improve pt’s cough effort
- Monitor humidification & O2 therapy
- Monitor analgesia
- Bed mobility (moving in bed, transfer comfortably from supine to sit)
- Early mobility out of bed
- Prevent joint stiffness
- Posture re-education
What is an incentive spirometer used for?
To encourage deep breathing and lung expansion.
Why should a thoracotomy patient avoid head-down positioning?
To prevent excessive fluid movement into the lungs.
What is the first step before mobilizing a patient post-op?
Assess vital signs and pain levels.
What is one precaution for mobilizing a patient with a chest tube?
Ensure the drainage system remains below chest level.
What is the primary focus of post-op rehabilitation?
Restoring mobility and preventing complications.
What is the impact of prolonged bed rest on muscle function?
Leads to muscle atrophy and weakness.
Why should post-op patients avoid holding their breath during movement?
It increases intra-abdominal and intrathoracic pressure, thus will put strain on incision site (risk of rupture)
What is one reason why post-op patients may have difficulty clearing secretions?
Pain inhibits effective coughing.
What is one function of a wound drain after surgery?
To remove excess fluid and reduce infection risk.
Why should a patient avoid excessive sedation post-op?
It increases the risk of respiratory depression.
Why should post-op patients be closely monitored for dehydration?
Dehydration thickens mucus and impairs clearance.
Why is humidified oxygen used postoperatively?
To maintain airway moisture and aid secretion clearance.
What is one factor that contributes to post-op pulmonary edema?
Fluid overload.
Why is hydration important for post-op pulmonary function?
Prevents thickening of mucus and improves secretion clearance.
What is a key precaution after a median sternotomy?
Support the sternum during functional activities.
What does early ambulation post-op help prevent?
Deep vein thrombosis (DVT) and pulmonary embolism.
What is the main reason for assessing oxygen saturation before mobilization?
To ensure the patient is oxygenating adequately.
Why should a patient be encouraged to take slow, deep breaths post-op?
To prevent lung collapse and improve ventilation.
What type of post-op pain relief involves a catheter in the epidural space?
Epidural analgesia.
What is a sign that a patient may need post-op respiratory support?
Low oxygen saturation and increased work of breathing.
Why is checking the positioning of IV lines important during mobilization?
To prevent dislodging or infiltration.
What is one respiratory effect of prolonged high-flow oxygen therapy?
Airway dryness and irritation.
Why should a patient use both arms together when lifting after a sternotomy?
To avoid excess strain on the healing sternum.
What is one reason why post-op patients should avoid lying flat for long periods?
It can impair lung expansion and secretion clearance.
What should always be done before assisting a post-op patient to stand?
Assess their strength, stability, and dizziness.
Why should post-op patients be taught ankle pumps and leg exercises?
To improve circulation and reduce DVT risk.
What is the best way to encourage post-op patients to stay active?
Educate them on the benefits of early mobilization.
What is one key factor in preventing post-op pneumonia?
Effective airway clearance through physiotherapy.
What should be done if a post-op patient has difficulty breathing?
Assess oxygen levels and assist with deep breathing.
Why is frequent patient repositioning important post-op?
To prevent pressure bed/pressure sores & improve circulation.
What are the precautions you must take when treating a pt with a thoracotomy?
- Supported huffing & coughing
- If a pneumonectomy was performed:
Pt MUST NOT lie on non-operated side. Operated side down ONLY!
↓ risk of fluid moving onto remaining lung & causing damage
Check with the surgeon regarding local protocol for positioning pt in side-lying - Transfer pt out of bed over NON-OPERATIVE SIDE
- NO manual chest clearance techniques directly on incision
- NO head down tilting with PD
What are the precautions you must take when treating a pt with a laparotomy?
- Supported huffing & coughing
- Liaise with medical team regarding mobilisation orders
- NO prone positioning
- NO aggressive MCT on anterior basal lung segment if pt has an ‘open abdomen’
- Teach transferring from supine over the side-lying position
What are the precuations you must take when treating a pt with a median sternotomy?
- Supported huffing and coughing
- When doing activities with UL:
>90 degrees = bilateral arm movements
<90 = unilateral movements - NO prone positioning
- Support sternum with fx activities (eg: rolling in bed, moving from side-lying to sitting on EOB)
- DON’T use shoulder girdle as lever when assisting pt - as bone formation is occurring at sternum. Support pt around thoracic cage instead
- Time for following sternotomy precautions will depend on pt (eg: risk factors for sternal instability, comorbidities, & recovery period - usually followed for 6 weeks)
