Week 5 Flashcards
Things to consider about surgery
post op pulmonary complications
-leading cause of morbidity and mortality
-increase length of stay
Risk factors
smoking history location of surgery - upper abdomen or thorax prolonged anaestheasia - >180 mins effective vs emergency surgery somorbidities Obesity - BMI > 27 Age >60 Pain Meds Immobility - pre and post op
Review locations of incisions
P.g. 5
Signs and symptoms
SpO2 38 after 1 day post op
sputum productive
abnormal lung auscultation
Raised WCC
Common complications
Respiratory complications – Decreased Ventilation – atelectasis – Chest infections – Hypoxaemia • Other complications – Fatigue – Depression – Fluid imbalances – Urine retention, constipation – Wound infection or dehiscence – Hypothermia – BP disturbances – Neurological problems – DVT – Post-‐op bleeding
What is atelectasis
aveoli collapse
Types of atelectasis
micro
- patchy areas of atelectasis
- can progress to major
- most post ops have
Plate
- small areas of collapse
- thin white lines on xray
Reabsorption /absorption
- bronchus or bronchiole is blocked (sputum)
- High FiO2 - decrease nitrogen
Risk factors for atelectasis
surgical incision previous respiratory condition smoking history obesity age impaired cognitive function mechanical ventilation body position
What is surfactant impairment
surfactant impairment -surfactant covers alveolar surface reduces the surface tension stabilises the alveoli prevents collapse
Risk factors for surfactant impairement
GA
supplement oxygen
mechanical ventilation
infection
Risk factors for DVT’s
DVT history smoking history immobility oral contraceptive obesity LL surgery
Post op problems
pain
-may be the most important factor that causes ineffective ventilation and ineffective cough
Immobility -causes: decreased lung volumes hypoxaemia decreased CO, SV Increased HR Orthostatic intolerance
Pain management
critical to optimize types - narcotics - morphine 0 pethidine - fentanyl - complications -respiratory depression - postural hypotension -N&V Drowsiness itch syncope
Epidural - nerve blocks - localised anaesthetics + opioids
- complications
- hypotension, urinary retention, motor block
Post op mobilisation aims
prevent immobilisation effects
increase minute ventilation
increases CO
Maintain strength
thing to consider regarding post op mobilisation
incision location level of pain presence of adverse effects presence of attachments level of assistance available vs required equipment available pre-existing conditions premorbid mobility level
Pre op assessment required information
presenting condition past medical history social history functional history investigations medical management planned surgical procedure special orders Pt's normal respiratory - breathlessness, cough, sputum Pain
Pre op physical assessment
observation palpation auscultation cough lower ribs special assessment
Pre op management aims and education
aim - gain patients confidence AX and prevent risks of developing post op complication -respiratory -immobility -DVT's
Education -role of physio -expected post op presentation effects of surgery early mobilisation pain relief importance
Pre-op management
demonstrate
- breathing exercises
- circulation exercises
- supported cough
- bed mobility and transfers
- post op exercises
+/- treatment
- may require airway clearance
Post op assessment
required information
- presenting condition
- past medical history
- functional ability
- investigations
- Medical management
- Surgical procedure - found in operation note
- post op orders
- recovery notes
Post op assessment operation note and post op orders
-procedure : incision, structures cut, wound closure, drains
-Anaethetic time and surgery time, recovery events
-management : return to ward , pain relief , initial post op course
-
Post op orders
- physio orders - WB status, ROM
- oxygen therapy
- fluid orders
- pain relief
- suture , stable or dressing removal
Peri or post op complications
changes to planned procedure large blood loss cardiac complications labile BP GA complications aspiration ventilation issues pain control issues investigations
What are the differences between adult and children patients
understanding behaviour long term emotional disturbance own belongings involvement of family age appropriate language **Listen to the child**
Rib cage and chest shape for children
Rib cage and chest shape
infants - cylindrical, soft and horizontal ribs (no bucket handle movement) poor intercostal development
-Age 3 yrs - adult chest wall shape achieved
Diaphragm
-infants - horizontal insertion - mechanical disadvantage, main muscle of inspiration
Preferential nasal breathing
- infants - shape and orientation of head and neck
Further anatomical differences
alveoli -
- at birth - 150 million alveoli
- 3-4 years - 300-400 million alveoli (adult number)
- alveolar growth continues until 7 years
Collateral ventilation
- starts to develop at 1-2 years and continue to develop until 6 years
Internal organs and lymphatic tissue
- tonsils and adenoids - upper airway obstruction
- heart and liver - less lung expansion
-Height and exposure to air pollution
Physiological differences
respiratory compliance
-cartilaginous
Closing capacity (CC)
-CC> FRC in infants - closure can occur before the end of expiration
Ventilation and perfusion
-ventilation greater of upper most lung
- perfusion remains best in the dependant regions
Further physiological differences
oxygen consumption, CO and response to hypoxia
- sympathetic nervous system not developed in infants
- infants response to hypoxia = bradycardia , decreased CO and pulmonary vasoconstriction - further causing hypoxia
What is a neonate
new born child
What to include in observation
vital signs - HR, RR, SaO2, Temp, ABG's Regularity and pattern of respiration - apnoeix spells Thoracic cage shape and movement Feeding and eating cyanosis attachements - 02
Respiratory distress characteristics
increased HR and RR recession nasal flaring grunting tracheal tug stridor neck extension head throbbing
Auscultation
unreliable
no signs on auscultation secondaty to laminar flow and static secretions
important to use with palpation and possibly huff / cough
Treatment
airway clearance exercise managing breathlessness posture MSK inhaled medication
Airway clearance
manual techniques - including suctioning ' ACBT Postural drainage FLutter PEP Autogenic drainage
Percussions and vibrations
short periords - 30sec /1min
not to vigorous
1 handed or fingers only usuallt
use easily with postural drainage
considerations
age of the infant/ child pre or co-existing conditions Aim of Rx Outcome measures acute vs long term
Exercise
use as an adjunct to formal airway clearance techniques
benefits well known
Make it fun
barriers to exercise
parental involvement age of the child - adolescents enjoyment and self esteem individualised programme health benefits and perceptions part of airway clearance
