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Management of complex patients > Week 7 > Flashcards

Week 7 Flashcards

1
Q

What are the mechanical causes of bowel obstruction?

A
  • Adhesions
  • Hernias
  • Tumors
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2
Q

What are the other causes of bowel obstruction?

A
  • Diverticulitis
  • Foreign bodies
  • Intussusception
  • Fecal impaction
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3
Q

What is a post-op ileus, which may also result in bowel obstruction?

A

A paralytic ileus, that is marked by dissociation of bowel motility. This commonly follows a spinal surgery, traumatic injury, or some LE joint reconstruction, but can also occur following minor orthopedic procedures

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4
Q

What may cause a post-op ileus that may result in bowel obstruction?

A
  • Use of opioid medications which slows bowel motility

* Inactivity after a surgery or recovery from anesthesia

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5
Q

What are the consequences of a post op ileus?

A
  • Abdominal pain
  • Malnutrition
  • More prolonged hospital stay
  • Readmission to the hospital after being released
  • Bowel perforation
  • Death
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6
Q

What are the symptoms of a post op ileus?

A 
Abdominal distention and discomfort
Bloating, belching
Nausea
Constipation
Emacis
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7
Q

What is the ogilvie syndrome?

A

A syndrome that occurs after orthopedic structures, that tends to affect specific population such as an elderly nursing home resident that has been admitted for a hip fx. Their medication is the usual cause

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8
Q

Ogilvie syndrome is a functional bowel obstruction and it consist of massive dilation of…?

A

Massive dilation of the cecum and the ascending colon

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9
Q

What is an ogilvie syndrome as a result of?

A

An autonomic dysfunction and the inhibition of the parasympathetic activity on the colonic motor function, and if left untreated, can result in toxic megacolon, which can lead to ischemia and bowel wall thinning, colonic perforation, intra-abdominal sepsis and death

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10
Q

True or False

Bowel obstruction can be partial or complete

A

True, Bowel obstruction can be partial or complete

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11
Q

True or False

Suspicion of bowel obstruction requires hospitalization

A

True, Suspicion of bowel obstruction requires hospitalization

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12
Q

What are the interventions for a bowel obstruction?

A
  • Nasogastric (NG) suction
  • IV Fluids (inc. TPN, electrolyte replacement)
  • NPO
  • Antibiotics if bowel ischemia suspected, before any surgery
  • Surgery if needed, which includes a resection or possible colostomy
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13
Q

What should guide the use of electrolyte replacement as an intervention for bowel obstruction?

A

The test results, but if the pt is repeatedly vomiting, they are going to be low on serum sodium and potassium

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14
Q

What should be done if a pt’s exam/CT scan suggests a strangulation of the bowel, what should be done?

A

An operative intervention

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15
Q

What should be done if a pt’s exam/CT scan suggests no strangulation of the bowel, what should be done?

A

The non-operative interventions may be used

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16
Q

What does the type of bowel resection/partial colectomy performed on a pt with a bowel obstruction depend on?

A

The condition, location, a size of the diseased/damaged valve.

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17
Q

Why would a surgeon chose to perform a colectomy for a patient with bowel obstruction?

A

If the bowel needs to have rest for healing or if they can not determine a functioning bowel exit. This may be (temporary or permanent)

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18
Q

An open right hemicolectomy is another way to treat a bowel obstruction. What does this procedure involve?

A

It involves removing the cecum, the ascending colon, the hepatic flexure where the ascending colon joins the transverse colon

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19
Q

___ is the standard treatment for any malignant neoplasm of the R colon

A

Open right hemicolectomy is the standard treatment for any malignant neoplasm of the R colon

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20
Q

When is a pt at risk for a bowel obstruction?

A
  • S/p abdominal surgeries
  • S/p most any surgery where mobility is decreased
  • Patients on opioid pain meds
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21
Q

At what point does a PT come in contact with a pt with a bowel obstruction?

A

At any point in their continuum of care or in any setting

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22
Q

Why would a pt with a bowel obstruction be treated in a post-acute facility/setting?

A
  • Delayed mobility recovery s/p surgery

* Impaired functional status from illness, nutritional deficiencies, deconditioning

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23
Q

What are the PT Interventions for at risk individuals and those
admitted w/bowel obstruction signs and symptoms?

A
  • Techniques for abdominal protection( mobility techniques like log rolling or wear an abdominal binder)
  • Core abdominal strengthening
  • Deep breathing techniques, cough instruction , and postural education
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24
Q

What are one of the big risk as a result of an abdominal surgery?

A

↑ risk of adhesion formation

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25
Q

What is the PT intervention for a pt with a stomach adhesion s/p an abdominal surgery?

A

Manual therapy, used for the prevention/treatment of a stomach adhesion. Called the clear passage approach.

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26
Q

What are the PT interventions that we use with pts s/p any surgery or illness causing immobility or use of medications that slow intestinal motility; those dx with bowel obstruction (non-surgical)?

A
  • EARLY mobility protocols s/p surgery

* General effects of exercise and ambulation on intestinal motility and constipation

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27
Q

What are the PT Interventions for a pt s/p bowel resection

surgery?

A

Enhanced Recovery After Surgery (ERAS) protocol which includes:
• Pre-operative optimization & screening(not usually done by the PT)
• Early mobilization for post-op, no specifics on type of exercise, just MOVE!

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28
Q

What are the complications of prolonged bedrest post surgery?

A
  • Skeletal muscle atrophy and weakness
  • Bone loss
  • Decreased insulin sensitivity(can be detected after 3 days of bedrest)
  • Thromboembolytic disease
  • Macrovascular dysfunction
  • Atelectasis
  • Pressure ulcers
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29
Q

What are the symptoms post-op fatigue?

A
  • Tiredness
  • Lack of concentration
  • Increased exercise induced HR
  • Elevated production of proinflammatory cytokines
  • Decrease in cardiorespiratory effort
  • Weight loss
  • Muscle weakness
  • Anorexia
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30
Q

What is a colostomy?

A

Surgical procedure bringing a
portion of the large intestine through the abdominal wall to allow passage of bowel
material out of the body as an alternate method than through the anus

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31
Q

What are the reasons to perform a colostomy?

A
  • Treat various large intestine disorders (cancer, obstruction, IBS, ruptured diverticulum, ischemia)
  • Can be temporary to divert stool from injured or diseased section of large intestine
  • Can be permanent when distal bowel removed or blocked or inoperable (i.e., colorectal CA)
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32
Q

What happens in an end colostomy?

A

The functioning end of the intestine(the section of the bowel attached to the upper GI tract), is brought out to the surface of the abdomen and forms the stoma, by cuffing the intestine back on itself and suturing the end of the skin. This is usually permanent, resulting from trauma, cancer, or other pathological conditions

33
Q

What happens in a double barrel colostomy?

A

It involves the creation of two separate stomas, in the abdominal wall. The proximal/nearest stoma is the functional end that is connected to the upper GI tract, and will drain stool. The distal stoma is connected to the rectum, and is also called the mucous fistula and it drains small amounts of the mucus material. This is more than often a temporary colostomy, performed to rest an area of the bowel and later be closed

34
Q

What happens in a loop colostomy?

A

A loop of bowel is brought through an incision in the abdominal wall. The loop is held in place outside the abdomen by a plastic rod, slipped beneath it. This is often performed for the creation of a temporary stoma to avert stool away from an area of the intestine that has been blocked or ruptured

35
Q

For pts that undergo a double barrel or loop colostomy, what usually happens after?

A

They come back for a colostomy takedown, at which the ends are put back together

36
Q

Some colostomies are categorized by the region that they are in. What are they?

A
  • Ascending colostomy
  • Transverse colostomy
  • Descending colostomy
  • Sigmoid colostomy
37
Q

____ is the most distinctive feature of a colostomy

A

A stoma is the most distinctive feature of a colostomy

38
Q

What is a stoma?

A

External opening of the

colostomy made by bringing the end of the intestine through an opening in the abdomen & attaching it to the skin

39
Q

What is the purpose of a stoma?

A

Serves as connection for the

removable external collection pouch called the ostomy appliance

40
Q

What are the typical post op care after getting a stoma?

A

• NG tube in place w/low to intermittent suction until bowel
activity returns
• IV fluids
• Diet advanced as stoma becomes active, but eventually w/regular diet
• Colostomy education & dietary consult
• Psychological counseling
• ERAS
• D/c home w/in 2-4 days depending on pain control & GI activity
• Possible return in 3-6 months for a colostomy “take down”

41
Q

How is stoma activity monitored?

A
  • Within 72 hours, passage of gas & stool through stoma begins
  • Initially stool is liquid and thickens as solid food added
42
Q

What are the dietary guidelines a pt should go comply to after a stoma/colostomy?

A
  • Avoid large amounts of liquids with meals
  • Drink plenty of liquids, between meals
  • Eat regularly
  • Avoid eating high fiber foods on an empty stomach
  • Introduce new foods gradually
43
Q

What are the activity restrictions post colostomy?

A

• No driving, heavy lifting x
2-3 wks post-op
• Avoid extreme physical
exercise and sports activities for first 3 months post-op
• Eventually, no activity restrictions, except maybe contact sports
• Swimming is fine and encouraged

44
Q

What are the components of living with a colostomy?

A

• Regular exercise regimens are highly encouraged focusing on endurance, strength, balance, and flexibility
• May need to target core and pelvic floor exercises, esp post-op
• Pouching systems should be emptied prior to sessions, “picture-framed” w/waterproof
tape, or modified to accommodate the activity
• Keep in mind other co-morbidities, as these are highly possible if a patient has had a
colostomy, such as arthritis or spondylitis

45
Q

What is the goal of PT for a pt with spondylitis as a result of IBS?

A

Ensure maximum functional ROM to the spine, by using postural and stretching exercises, in conjunction with the use of moist heat and NSAIDs

46
Q

What is the BMI that is considered to be underweight?

A

Below 18.5

47
Q

How is obesity defined in the literature?

A
  • Via BMI: weight (kg) / height (m)2

- Via measurement of waist circumference(better way)

48
Q

What is the BMI that is considered to be normal weight?

A

18.5-24.9

49
Q

What is the BMI that is considered to be overweight?

A

25-29.9

50
Q

What is the BMI that is considered to be obese class 1?

A

30.0-34.9

51
Q

What is the BMI that is considered to be obese class 2?

A

35-39.9

52
Q

What is the BMI that is considered to be morbidly obese?

A

40 and above

53
Q

What is the waist circumference that is considered obese for men?

A

Men > 40 inches

54
Q

What is the waist circumference that is considered obese for women?

A

Women > 35 inches

55
Q

What is increased waist circumference correlated with

A

Increased risk of heart disease and type II diabetes

56
Q

What is bariatric medicine?

A

Branch of medicine that deals with the causes, prevention, and treatment of obesity

57
Q

Obesity in associated with an increased risk of…?

A
  • Cardiovascular disease
  • Diabetes
  • Stoke
  • Arthritis
  • Gall bladder disease
  • Respiratory conditions
  • Cancers
58
Q

What is a metabolic syndrome?

A

Group of conditions that lead to the development of cardiovascular disease and type II diabetes

59
Q

What are the primary risk factors of metabolic syndrome?

A
  • Abdominal adipose (central obesity)

* Insulin resistance

60
Q

A metabolic syndrome is diagnosed after 3/5 conditions are met. What are the conditions that must met?

A
  • Waist circumference: Men >40in, women >35in
  • Fasting glucose of 100mg/dL or use of meds of hyperglycemia
  • Triglycerides greater than or equal to 150 mg/dL
  • BP greater than or equal to 130/85 mmHg or use of meds for HTN
  • HDL for men < 40mg/dL and for women < 50 mg/dL
61
Q

A person carries their weight 2 different ways. The apple or the pear weight distribution. What are the types of apple distribution?

A
  • Apple Pannus: there is an inferior abdominal drift of the adipose tissue to the lower abdomen
  • Apple Ascites: very large abdomen that reduces their ability to lie flat well

Can be seen in males and females

62
Q

A person carries their weight 2 different ways. The apple or the pear weight distribution. What are the types of pear distribution?

A
  • Pear Abduction: the larger portion of the weight is carried from the hips and LEs down, including the bottom. Presents with knee valgus
  • Pear Adduction: Presents with a knee varus
  • Gluteal Shelf: large gluteal mass

Mostly seen in women

63
Q

How do we create an environment of sensitivity when treating pts?

A
  1. Use empathetic language
  2. Don’t judge
  3. Have a plan
  4. Be patient
64
Q

What are some ways to make the mobilization of an obese pt easier?

A 
• Consider using:
  - Transfer sheets
  - Overhead grab bar or trapeze
  - Bariatric gait belts
  - Other bariatric equipment
• Spend more time planning than doing
• Include the patient in decision making
• Number of people needed (Consider 2-3 at most)
65
Q

What is the best way to move a pt with an apple ascites weight distribution while in bed?

A
  • Little tolerance for supine or prone positioning

* Supine to sit: flat spin with a sheet

66
Q

What is the best way to move a pt with an apple pannus weight distribution while in bed?

A

• Some variable supine tolerance
• Supine to sit: flat spine with sheet or prone flat spin with UE
push up to standing

67
Q

What is the best way to move a pt with a pear weight distribution while in bed?

A

Supine to sit: via long siting to raise head of bed and use of
sheet to assist to edge of bed

68
Q

How is the thumb gait belt grip, which is used with bariatric pts done?

A
  • Facing patient
  • Cross arms
  • Stick hand under belt from top, palm faces out
  • Bring first two fingers to thumb
  • Control slack with wrist flexion, radial deviation, elbow flexion
69
Q

How is the twist gait belt grip, which is used with bariatric pts done?

A
  • Stand at patient side
  • Place hand down into gait belt with palm to back
  • Twist toward thumb
  • Control slack with wrist flexion, radial deviation, elbow flexion
70
Q

What are some transfer options to use while mobilizing a bariatric pt?

A
  • Assisted Scoot with rolled sheet
  • One person belt and cross
  • Two person belt and hammock
  • Transition to a twist grip
71
Q

How is the assisted scoot with rolled sheet technique which is used to ease mobility with a bariatric pt done?

A
  • Prepare sheet ahead of time
  • Tuck into belt
  • Block knees
  • Gently pull hips forward while using sitting technique
72
Q

How is the one person belt and cross technique which is used to ease mobility with a bariatric pt done?

A 
• Thumb grip
• Cross hands
• Have patient grab your elbows and pinch your hand to
their side
• Block knees
• Communicate
• Test sit stand first
• Use sitting technique
73
Q

How is the two person belt and hammock technique, which is used to ease mobility with a bariatric pt done?

A 
• Position sheet and tuck into belt
• Thumb grip
• Have patient grab your elbow and pinch your hand to their
side
• Cross over free hand
• Block knee
• Communicate
• Test sit stand first
• Use sitting technique
74
Q

How is the transition to twist grip technique, which is used to ease mobility with a bariatric pt done?

A

• Be sure patient is stable
• Pivot to side
• Release cross grip and place hand under belt posterior
to patient in twist grip
• Release thumb grip and place patient’s hand on
walker
• Keep hips close to patient with wide base of support

75
Q

What is the egress test for?

A

It allows you to know whether it is safe to commence ambulation with a pt (can be done with any pt)

76
Q

What are the steps of the egress test?

A
  1. Ask patient to lift bottom off of surface as if going to stand (need clearance of 1-2 inches) then return to sitting
  2. Ask the patient to come all the way up to standing and
    bear weight on both lower extremities 2x
  3. Ask the patient to perform 3 repetitions of march in place
  4. Ask the patient to take one step forward and then return
    to start position. Do this bilaterally
77
Q

What are the exercise goals of a bariatric pt?

A

• Patient Centered- behavior modification (not always
weight related)
• Weight loss 10% at 1-2 pounds a week
• Increase physical activity to reduce risk of obesity related
disease – aim for up to 1 hour moderate intensity 5x/week(65-85% of target HR, 3-6 METs, 12-16 on the borg scale)

Consider using The Physical Activity Readiness
Questionnaire

78
Q

What is the information to acquire prior to an exercise prescription for a bariatric pt?

A
  • PLOF
  • Preferences
  • Impairments
  • Co-morbidities
  • Time constraints

Management of complex patients (7 decks)

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