Week 8 (parts 1, 2 and 3)

Question 1

part 1

Answer 1

physiotherapy for surgical patients

Question 2

what abdominal regions do you need to know

Answer 2

liver
appendix
stomach
spleen
pancreas
small intestine
large intestine
ureter
kidneys
bladder
gall bladder

Question 3

which thoracic organs/ structures do you need to know

Answer 3

ribs
trachea
pericardium
base of heart
right lung
left lung
diaphragm
apex of heart

Question 4

what is a sternotomy

Answer 4

Incision made along the midline of the thorax through the sternum
Allows access to the heart and lungs
Used for cardiac procedures and some lung surgery
Often quite painful for the patient

Question 5

what are the precautions associated with a sternotomy

Answer 5

Precautions will vary surgeon to surgeon – no consensus

Generally,….
For 4-12 weeks post-op:
No pushing through arms (including sit -> stand)
No pulling (including banister upstairs, dog on lead)
No lifting heavy weights (e.g. nothing heavier than a kettle)
Some may restrict arm movements (e.g. overhead, behind back, unilateral movements vs bilateral movements)

Question 6

what is Functional residual Capacity

Answer 6

Functional residual capacity (FRC) is the volume remaining in the lungs after normal passive expiration (FRC= ERV + RV)
General anaesthesia decreases FRC (positional and diaphragm/intercostal relaxation)
Alteration in FRC can result in small airway closure and V/Q mismatch, and lead to ongoing post op respiratory complications

The volume of gas in the lungs at the end of normal expiration is the functional residual capacity (FRC), approximately 3000ml in a 70kg man.
ERV = Expiratory Reserve Volume, the volume that can be forcibly expired at the end of normal expirationRV = Residual Volume, the volume left in the lungs at the end of maximal expiration

Question 7

what is Atelectasis

Answer 7

Atelectasis,the collapse of part or all of a lung, is caused by a blockage of the air passages (bronchus orbronchioles) or by pressure on the lung. Risk factors for atelectasis include anaesthesia, prolonged bed rest with few changes in position, shallow breathing and underlying lung disease

Question 8

what are some respiratory complications post surgery

Answer 8

Patients with Post-op Pulmonary Complications (PPCs):
1 in 5 die within 30 days of major surgery (0.2-3% without)
Mortality rate at 1 year 45.9% (8.7% without)
Mortality rate at 5 years 71.4% (41.1% without)
Length of hospital stay (LOS) has been shown to be prolonged by 13–17 days

Question 9

what are the risk factors of pre-op

Answer 9

age, lung disease, heart failure, neurological disorder, functional status, obesity, smoking

Question 10

what are the peri-op risk factors

Answer 10

mechanical ventilation, anaesthesia, opioids, emergency surgery, length of surgery, lung deflation, surgical site

Question 11

what are the post-op risk factors

Answer 11

pain, reduced mobility, dehydration, altered mental state, recumbancy

Question 12

What problems may post op patients have that we can address?

Answer 12

Atelectasis
Sputum retention
Decreased mobility

Question 13

what are some key respiratory physiotherapy problems

Answer 13

Dyspnoea (breathlessness)
Secretion retention
Loss of lung volume
Respiratory Failure

Question 14

what are the aims of post-op physiotherapy management

Answer 14

Improve V/Q matching
Restore FRC
Maintain sputum clearance
Restore Mobility

Question 15

what are some considerations for post op Ax

Answer 15

Consider morphine, impact of this on resp drive
Prioritize
Seek wider sources of information
Closed questions/prioritized information gathering
Hand placement/positioning
Consent

Question 16

what are some respiratory physio options

Answer 16

Positioning
Mobilise
ACBT (splinted cough)
Humidification
Incentive spirometry
Intermittent Positive Pressure Breathing (IPPB)
CPAP
Suctioning

Question 17

what are some positioning tips

Answer 17

Avoid slumping, encourage high sitting
Patients are encouraged to sit out of bed as soon as possible
Positioning can re-expand atelectatic lung, but regular position change is needed to prevent atelectasis reappearing in dependent zones
Clinical assessment and chest X-ray will assist in decision about positioning

(should be turning someone every 2 hours while in intensive care)

Question 19

how does moving from supine to upright affect the body

Answer 19

Increase:
Tidal volume
Total lung capacity
Vital capacity
FRC
Residual volume
AP diameter of chest
Diaphragmatic excursion
Mobilisation of secretions

Question 20

what should you consider when mobilising post op patients

Answer 20

Early post op mobilisation combines the advantages of an upright posture with a natural increase in tidal volume
↑ FRC
All post-op patients should be sat out of bed first day, if medically stable, and mobilised as soon as possible

These patients may have lots of attachments
You may need x2 x3 physios/assistants to help!!
Ensure pain is controlled (take pain killers,
Ensure the patient is cardiovascularly stable

MUST KNOW FOR OSPE

If patient can mobilise – must mobilise in OSPE, improves circulation, removes secretions, increase tidal volume (improve/increase independence), increase FRC, aid digestion

DON’T MOBILISE IF
HR above 100bpm
If they have atrial fibrilation

Question 21

what is active cycle of breathing technique (ACBT)

Answer 21

The active cycle of breathing techniques (ACBT) is used to mobilise and clear excess secretions
The ACBT is very useful as it can be adapted to a wide variety of patient presentations
The technique comprises a cycle of:
Breathing control (as before)
Thoracic expansion exercises (TEEs) (deep breathing)
Forced expiration technique (FET) (huff)

Question 22

what are some post op respiratory techniques

Answer 22

For the post-operative patient, the following manoeuvres may be added to the TEEs:

Inspiration is active and may be combined with a 3-second hold before the passive relaxed expiration
An additional increase in lung volume can be achieved by using a ‘sniff’ manoeuvre at the end of a deep inspiration
This aims to decrease atelectasis and restore lung volume

Once a patient has brought their secretions to the central airways, patients can either huff or cough with or without support
Patients can be taught to use a pillow or a towel to support their wound as many surgical patients are reluctant to cough due to pain or a fear that their stitches will burst
Can also use splinting for huffing

Question 23

what is an incentive spirometer

Answer 23

An Incentive Spirometer is a device which provides visual feedback on inspiratory effort and volume The patient should take a slow deep breath in watching the indicator and aiming to achieve a set target Diaphragmatic excursion must be encouraged while using the incentive spirometer

Question 24

what are some indications for IPPB

Answer 24

Increased work of breathing Atelectasis Low tidal volumes Sputum retention Not resolving with other techniques

Question 25

what is Mechanical insufflation/ exsufflation (MI-E)

Answer 25

MI-E, commonly known as the ‘cough assist’, is a device that simulates a normal cough to aid secretion clearance by delivering positive pressure, with a rapid change to negative pressure. Can also be used in the same way as IPPB to deliver insufflation only. Can be used with a facemask, mouthpiece, tracheostomy attachment or entrained in a ventilator circuit.

Question 26

what is continuous Positive Airway Pressure CPAP

Answer 26

Continuous positive airway pressure Constant flow of gas throughout inspiration and expiration Splinting open the airways CPAP increases FRC – by increasing the surface area of the alveoli ​ This increase in alveoli surface area improves and allows for greater gas exchange (oxygenation & ventilation)​ This improves SpO2/SaO2​ Will improve oxygen levels but wont change carbon dioxide levels Doesn’t increase tv so not good for type 2 RF as CO2 isn’t flushed out

Question 27

what does CPAP do to the body

Answer 27

Increases pressure within the airway and holds open collapsed alveoli, pushing more oxygen across the alveolar membrane , forcing interstitial fluid back into the pulmonary vasculature​ Airways at risk from excess fluid are stented open​ It increases intrathoracic pressure which decreases venous return to the heart and reduces the preload (pressure in the ventricles at the end of diastole)​ This lowers the pressure that the heart must pump against (afterload), both of which improve left ventricular function​ Gas exchange is therefore maintained or improved ​ Reduces increased work of breathing  

Question 28

what are the contraindications and precautions for IPPB, CPAP, MI-E

Answer 28

Vomiting Facial trauma / surgery Raised intracranial pressure Recent upper GI surgery – D/W consultant Recent thoracic surgery – D/W consultant Low GCS/impaired consciousness Undrained pneumothorax Large emphysematous bullae Open bronchopleural fistula Lung abscess Severe haemoptysis Ca Bronchus Active pulmonary tuberculosis Frank haemoptysis Positive pressure increased risk of raising ICP GI surgery risk of rupturing sutures if air goes down into stomach Increase pneumothorax or cause one Pushing air through fistula With tumour possibility of air trapping in partially occluded airway

Question 29

what is suctioning

Answer 29

Suction is occasionally required in the non-intubated patient who has retained secretions and where previous treatments have failed The indication for airway suction is an inability to cough effectively and expectorate when airway secretions are retained Airway suction can be carried out in 3 main ways on the non-intubated patient: Nasopharyngeal (NP) Oropharyngeal Mini-tracheostomy

Question 30

what is nasopharyngeal suction

Answer 30

Via an NP (nasopharangeal) airway Helps guide suction catheter into trachea (rather than oesophagus) if patient sticks tongue out Often stimulates a cough Oxygen should be available throughout procedure

Question 31

what is Oropharangeal suction

Answer 31

Via oral airway AKA Guedel Not easy!

Question 32

what do you need to consider about suctioning

Answer 32

Very unpleasant for the patient when alert Can cause trauma to the epithelium Catheter may not be inserted into the trachea Infection risk Desaturation during procedure

Question 33

what should you consider when mobilising a post-op patient

Answer 33

- Early post op mobilisation combines the advantages of an upright posture with a natural increase in tidal volume/deep breathing - All post-op patients should be sat out of bed first day and mobilised as soon as possible - Increases Tidal volume and mobilisation of secretions - These patients may have lots of attachments - You may need x2 x3 physios/assistants to help!! - Ensure pain is controlled - Ensure the patient is cardiovascularly stable - Mobilise patients within the bounds of their physiological limits

Question 40

part 2

Answer 40

SOAP notes

Question 40

what is the purpose of clinical notes

Answer 40

Clinical notes are a recording of our patient/client encounters: from assessment and treatment to clinical handover Is a NECESSITY/FUNDAMENTAL REQUIREMENT as per the HCPC and CSP Notes must record the interaction to address the ‘who’, ‘what’, ‘where’ and ‘when’ of the clinical encounter Also important from a quality assurance and quality control standpoint Clinical notes describe how we understand our patient: Act as a memory aid Reflect our communication and understanding of the patient, their condition, progression/regression Help with our clinical reasoning Clinical notes facilitate safe, high-quality care: Clearly shows what the physio/clinician has done in that session Valuable source of data for research, service improvement Clinical notes demonstrate our accountability for our practice: Allows for the support/feedback/critique of the MDT Allows for other members of the physiotherapy team to review session/therapy plan and continue it in the absence of the treating physiotherapist By documenting notes, it is a form of evidence for both good and adverse outcomes

Question 40

when do you write clinical notes

Answer 40

Ideally, at the same time/immediately after the clinical encounter or at least, when the encounter is fresh in our minds This is especially true of the ICU Record the date and time Why? We add to the notes/record a new set of notes when they add value If you do not write notes after every interaction, it is important to justify why In many in-patient centres or care homes, we write clinical notes only in the cases of “remarkable” interactions Notes should reflect three (potentially 4) clear clinical phases: Prehabilitation/Peri-operative (where appropriate) Initial assessment Progress Discharge

Question 40

what do we write in the clinical notes

Answer 40

Notes must reflect the narrative/story of the patient over time Must cover: Assessment and findings Any investigations: ABG, CxR, blood tests etc Physiotherapy specific assessment Goals Treatment/management plan Also includes other materials/information such as: Referrals Screening tools Questionnaires, outcome measures Lastly notes must consider the “4 audiences” for clinical notes Clinician writing the notes Patient MDT Third parties (Hospital manager, quality assurance auditors, researchers etc)

Question 40

what does the 's' in SOAP stand for

Answer 40

Subjective Ax Documentation under this heading comes from the “subjective” experiences, personal views or feelings of a patient or someone close to them. In the inpatient setting, interim information is included here. This section provides context for the Assessment and Plan. Comprised of: Chief complaint (CC) or presenting problem History of current condition/presenting illness (use acronym OLDCARTS) Onset, Location, Duration, Characterisation, Alleviating and Aggravating factors, Radiation, Time/Temporal patterns, Severity All the patients’ symptoms will be mentioned here Other components of subjective history Review of systems (ROS) General Gastrointestinal MSK Medication, allergies

Question 40

what does the 'o' in SOAP stand for

Answer 40

Objective Ax This section documents the objective data from the patient encounter. This includes: Vitals/obs Physical exam findings Laboratory data (blood tests, LFTs, PFTs etc) Imaging/radiographic investigations Other diagnostic data Recognition and review of documentation of the other clinicians A key finding to note is the difference between where to document something like stomach pain vs abdominal tenderness on palpation

Question 40

what does the 'a' in SOAP stand for

Answer 40

Assessment: This section documents the synthesis of “subjective” and “objective” evidence to arrive at a diagnosis. This is the assessment of the patient’s status through analysis of the problem, possible interaction of the problems, and changes in the status of the problems. The section includes the following: Differential diagnosis/hypotheses based on objective assessments (more seen in MSK) Problem list (must be prioritised) Any discussion around the patient, problem list, contraindications, precautions etc

Question 41

what does the 'p' in SOAP stand for

Answer 41

Plan (Physiotherapy/ management plan): Details the management plan for the patient, with emphasis on the current session. It is also good to include some information around the plan for future sessions (plan for progression) This section also details the need for additional testing and consultation with other clinicians to address the patient's illnesses The notes must clearly state: Treatment/technique details (including load, sets and reps) Specialist referrals or consults (eg: requesting clinician support to prescribe O2) Patient and carer education, counselling Any additional tests and why including next steps if positive or negative (eg: requesting CxR to see if pleural effusion resolved) Follow-up plan