Week 2- Pre & Post Surgical Ax Flashcards
What are the 6 core cardiorespiratory problems?
- Respiratory Failure (Type 1 and Type 2 Respiratory Failure)
- Increased Work of Breathing/Breathlessness
- Sputum Retention
- Loss of Volume
- Pain
- Reduced Exercise Tolerance
What are the 5 additional concerns that may impact on treatment?
- Anxiety;
- Cognition;
- Functional and mobility limitations;
- Social problems;
- Consciousness i.e. ventilated and sedated in ITU.
What are clinic signs and symptoms in cardio respiratory?
- Cough
- Wheeze
- Tachycardia
- Bradycardia
- Cyanosis
- Oedema
- Increased respiratory rate
- Low SpO2
- Polycythemia
- Sputum colour
- Syncope
Before treating a patient what do you need to ask yourself?
- what problems does this patient have?
- can I treat these problems?
- is the patient likely to respond to Physiotherapy?
What is the definition of clinical reasoning?
A structured process, through interaction with the patient and others in the multidisciplinary team, the structures meaning, goals and health management strategies, that are based on clinical data, client/ patient choices and professional judgement and knowledge
What is the cycle of clinical reasoning process
Where to you gain information to identify the patients main problems and determine goals of Physiotherapy management?
- background information
- medical chart
- bed chart
- subjective assessment followed by an objective assessment
What is the flow of treating a patient
When does a physio see a surgical patient?
+/- pre admission clinic
+/- pre operatively
Post operatively
What surgical patients do physios see?
Prioritise patients who are at high risk
- patient related risks
- procedure related risks
What information in required in the pre operation assessment
- Presenting condition
- Past medical history
- Social history
- Functional history
- Investigations
- Medical management
- Planned Surgical Procedure
- Special Orders
- Patient’s normal respiratory – breathlessness, cough, sputum
- Pain
What needs to included in a pre operation physical assessment?
- observation
- palpation
- auscultation
- cough
- lower limbs
- special assessment
Remember to prioritise and modify depending on the patient’s presentation
What should you education the patient around in regards to pre op management?
- role of physio
- expected post op presentation
- effects of surgery
- early mobilisation
- pain relief importance
What is the aim of pre op management?
- gain patients confidence
- ax and prevent risks of developing post op complications
- respiratory
- immobility
- DVT’s
What are post op complications?
- changes to planned procedure
- large blood loss
- cardiac complications
- labile BP
- GA complications
- Aspiration
- ventitlation issues
- pain control issues
- investigations
What should be included in the post op patient interview
- pain: at rest, movement, effect of pain relief
- cough: productive, pain
- SOB: current vs normal
- confirm information gathered from medical chart: past medical history, smoking history, social history, functional history, current history
- special post surgical questions: N&V, dizziness, drowsy, pins and needles, numbness
What to include in the post op physical assessment
- observation: environment, patient
- palpation
- Auscultation
- Cough: justify timing
- Lower limbs: DVT, circulation
- special assessments: strength, numbness
What should you document in post op management
- distance mobilised
- assistance required
- tolerance
- effect: important to re-assess
- adverse events: dizziness, N&V
Why have orthopaedic surgery?
- degenerative disease (OA)
- trauma (fractures, dislocations)
- pain
- reconstruction (knee, shoulder)
- pathological process (Ca, RA)
- Prophylaxis/ Function (spinal scoliosis)
Why in the objective assessment is the environment important?
Safety concern: a clustered environment is unsafe to mobilise a patient
Look for:
- walking aids, chairs to sit out in.. PLAN
- apparatus (IV poles, O2, drains, catheter, compression stockings, pumps, pillows, slings, splints)
What attachments need to be considered?
-IV lines: where? _wound drains: where, what, on suction? -NGT- suction? -Colostomy/ ileostomy: check leakage, may need to be emptied prior to moving -Check length of tubing
What is included in the 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 the neurological assessment
• Modified neurological 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,anklestrength&sensation
• Full neurological assessment (reflexes, power, sensation) if
indicated by the subjective examination - especially in the presence of spinal injury
What is the musculoskeletal assessment
• Major joints in unaffected limbs as required
-normal range of motion, no tenderness or swelling
• Cardinal signs of Orthopaedic Musculoskeletal Assessment
- Mobility Level (Independence)
- Range of motion
- Muscle Strength
- Balance
What is included the examination of a specific body region post op?
- observation (swelling, wound ooze…)
- active movement (as indicated)
- passive movement (as Indicated)
- muscle strength (as indicated)
- sensation (checked in neurological)
What is included in the functional assessment post op?
- bed mobility
- transfers
- mobility
- stairs
What is the difference between assistance/ supervision/ independent ?
Assistance
- therapist manual hand on assistance
- 1x assist, 2x assist
Supervision
-requires verbal cues, no manual hands on assistance required
Independent
-patient can perform task without manual hands on assistance or verbal cues
Outcome measures
-used to measure effectiveness of treatment
examples:
- Goniometry assessment of ROM
- Mobility progression (aid, distance, stairs, level of assistance)
- timed up and go (TUG)
Who is at risk with surgery?
- smoking history
- location of surgery: upper abdomen or thorax
- prolonged anaesthesia > 180mins
- elective vs emergency surgery
- comorbidities
- obesity: BMI > 27
- Age > 60 years
- Pain
- medications
- immobility: pre and post op
What are the surgery effects on respiratory function?
Leads to sputum retention and loss of volume
Abdominal surgery impacts on ventilation
What are common respiratory complications?
- loss of volume: Atelectasis
- chest infection
- hypoxaemia
- other complications
What are common complications
- fatigue
- depression
- fluid imbalance
- urine retention, constipation
- would infection or dehiscence
- hypothermia
- BP disturbances
- neurological problems
- DVT
- post op bleeding
What are signs and symptoms that their is a post surgical chest infection
- SpO2 <90% on 2 consecutive days
- chest x-ray findings
- temp .38 degrees after dat 1 post op
- sputum productive
- abnormal lung auscultation
- raised WCC
What are the two types of Atelectasis?
Obstructive
-bronchial obstruction occurs and there is progressive collapse of the airways distal to the obstruction
Non-obstructive
- compressive (surgery; tumour; pneumothorax; haemothorax; abdominal content weight; pleural effusion)
- passive (loss of negative pressure in pleural space)
- adhesive loss of pulmonary surfactant)
- Cicatrizing (wound that leads to scarring)
What are clinical signs of Atelectasis
- reduced PaO2
- reduced lung compliance
- reduced FRC
- non-productive cough, tachycardia, tachypnoea, wheeze, chest pain
- changes on chest x-ray and auscultation and percussion note
What are Atelectasis risk factors?
-surgical incision
-previous respiratory condition
Smoking history
-obesity
-age
-impaired cognitive function
-mechanical ventilation
-body position
What is surfactant impairment
- surfactant covers alveolar surface
- reduces the surface tension
- stabilises the alveoli
- prevents collapse
What are risk factors of surfactant impairment?
- GA
- Supplemental oxygen
- mechanical ventilation
- Infection
What reduces mucociliary clearance?
Decreased cilial beating
- temporary eg decreased ventilation, lack of sleep, decreased cough effectiveness, dehydrated, pollutants
- permanent eg smoking, disease state
Increased sputum volume/ thickness
- disease state
- dehydration
- infection
What re risk factors of a DVT
- DVT history
- smoking
- immobility
- oral contraceptive
- obesity
- LL surgery
What are post op problems
- pain
- may be the most important factor which causes: loss of volume and an ineffective cough
- immobilty, which can cause
- loss of volume
- hypoxeamia
- decreased CO, SV
- increase hR
- orthostatic intolerance
Slow acting pain management routes
- oral (paracetamol, endone, targin, panadeine forte, tramadol)
- subcutaneous narcotic (eg morphine)
- Intramusclar narcotic (eg morphine)
What needs to be considered in pain management
- timing, frequency and does (medications)
- routes eg oral, subcutaneous narcotic, intramuscular narcotic, intravenous, epidural, nerve block, PCA
- operative anaesthetic (spinal wears off 3-4hrs vs general likely to have respiratory complications)
Note plan your treatment around these pain managements where possible
What are common pain managements
-NSAIDs
-Prescribed pain medication
_Patient controlled analgesia
_intercostal blocks
-Spinal blocks
-epidurals
-antiemetics
-ITU
-neuromuscular blocking agent
What are side effects of narcotic analgesia
- drowsiness and reduced central respiratory drive therefore require supplementary o2 at rest
- nausea and vomiting
What are things to consider when mobilising post op
- incision location
- level of pain
- presence of adverse effects
- presence of attachments
- level of assistances that requires and available
- equipment available
- pre-existing conditions
- premorbid mobility level
What rehabilitation targets decreased exercise tolerance?
- pulmonary rehabilitation
- cardiac rehabilitation
- neurological rehabilitation
