ILP Acute 2007

ACUTE STREAM

Independent Learning Package

© Division of Physiotherapy The University of Queensland

2007

This manual has been compiled by Dr Angela Chang and Dr Jenny Paratz

Modified by Dr Angela Chang in 2007

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2007 2

TABLE OF CONTENTS

1. Acute Stream Program .............................................................................................................3 1.1. Welcome to the Acute Stream Clinical Unit....................................................................3 1.2. The Independent Learning Package, Computer Assisted Learning (CAL) packages and Recommended Text .....................................................................................................................3 1.3. Expectations upon commencing the unit .........................................................................3 1.4. Acute unit assessment ......................................................................................................4 1.5. Acknowledgements..........................................................................................................4

2. Check list for Further Preparation Required by Facilities for Day 1 .......................................5 3. Common Medications Guide ...................................................................................................7 4. Start Up Test ..........................................................................................................................10 5. Week 1 Activities: Surgical management ..............................................................................12

5.1. Interpretation of a medical chart ....................................................................................12 5.2. Patient attachments and their physiotherapy implications .............................................12 5.3. Surgical case study.........................................................................................................13 5.4. Reflective activities........................................................................................................14

6. Week 2 Activities: Medical management ..............................................................................15

6.1. Treatment progression....................................................................................................15 6.2. Discharge planning.........................................................................................................18 6.3. Medical cases - problem solving...................................................................................18 6.4. Reflective activities........................................................................................................20

7. Week 3 Activities: Specialised Surgical management...........................................................21

7.1. Case 1: Vascular surgery................................................................................................21 7.2. Case 2: CABG................................................................................................................22 7.3. Reflective activities........................................................................................................24

8. Week 4 Activities: Specialised cases .....................................................................................25

8.1. Case 1: Chest Trauma ....................................................................................................25 8.2. Case 2: Post ICU............................................................................................................26 8.3. Managing a Ward and Prioritizing patients ...................................................................26 8.4. Reflection activity: Professional issues..........................................................................29

9. Outline of Answers to Start Up Exam ...................................................................................30 10. Outline of Answers to Self-Directed Learning Activities..................................................32 Cardiothoracic Clinical Reasoning Sheet.......................................................................................51


1. ACUTE STREAM PROGRAM 1.1. Welcome to the Acute Stream Clinical Unit The aim of this acute unit is to assist you making the transition from an undergraduate student to a graduate physiotherapist, providing experience and an opportunity to develop and refine skills in the core areas of cardiothoracic physiotherapy. The development of your knowledge and skills base during this placement will enable you to take responsibility for the physiotherapy management of acute medical and surgical patients. Although there will be some variety in the acute clinical experiences you may have, our aim is to assist and encourage you to take responsibility for your own learning and development as a clinician, to facilitate your continued professional development. 1.2. The Independent Learning Package, Computer Assisted Learning (CAL) packages and

Recommended Text The Independent Learning Package (ILP) aims to complement and extend your acute clinical experience. It is to help you integrate your knowledge of medical and surgical conditions, develop skills in assessment, clinical decision-making and treatment planning. You should remember that the answers in the ILP are guidelines only, and differences may exist between institutions. It is therefore important to understand the rationale for the guidelines and to appreciate the reasons for any differences should they occur. The ILP is divided into activities to be completed each week of the four (4) week placement. However, this is a guide only and you may elect to complete components of the ILP, as they are appropriate. Not all the answers to every clinical question will be found within the ILP pages, as it has been designed to help you develop a clinical reasoning framework that you can apply to different settings and presentations. It is your responsibility as an active, adult learner to take initiative and seek the answers to any questions you may have, and optimise the opportunities to develop your knowledge and skills base during your Acute Unit. The following web-based computer assisted learning (CAL) packages are available as resources to be used in preparation for and during your Acute Unit. They are located in the Acute Clinical Unit CAL resources folder in the Blackboard site for PHTY4100 and PHTY7882. The following CAL packages are available: CAL 1: Arterial blood gas analysis CAL 2: Chest X Ray analysis CAL 3: Electrocardiogram analysis The recommended textbook is “Physiotherapy for respiratory and cardiac problems” by Pryor and Prasad, which is referenced in the preclinical cardiothoracic curriculum. In addition, revising your notes from PHTY3250-7825 last year will also help you to complete the weekly activities. 1.3. Expectations upon commencing the unit Upon entering the Acute Clinical Unit, it is anticipated that you will have the knowledge and skills needed to complete and full clinical assessment of a medical and surgical patient. A detailed list of the expected skills and knowledge in cardiothoracic physiotherapy is listed on page 5. This is a list created in conjunction with input from the clinical educators, and therefore


is expected that you have revised the appropriate pre-clinical lectures and practicals to be able to complete this checklist before day 1. In addition to the checklist, it is also anticipated that you will have already completed the “Start up test” on page 7 prior to commencement of the unit. It is strongly advised that you attempt this activity within the suggested time frame before referring to the answers. This test has been designed to reflect a reasonable level of preparedness prior to commencing the Acute Unit. If you are unable to answer the questions in the appropriate detail, you will need to revise your pre-clinical lectures and attempt the question again. Please note this test is in addition to the on-line start up exam that must be completed prior to the start of your acute placement. 1.4. Acute unit assessment A Cardiothoracic Clinical Reasoning Sheet has been provided in Appendix 1 (page 48) of this ILP. It is advised that you use this planning sheeting during the first 2 weeks of your unit to assist giving your clinical educator a summary of your treatment plans for new patients. It is also designed to help you integrate assessment findings and develop clinical reasoning and decision-making skills. Please discuss this with your clinical educator at the start of your placement. 1.5. Acknowledgements This Independent Learning Package is the result of the teaching and experience of a number of past and present cardiothoracic physiotherapy staff, including contributions by Ms Ruth Dunwoodie, Ms Marie Steer, Mrs Bernadette Pozzi, Ms Julie Adsett and Mrs Robyn Cupit.


2. CHECK LIST FOR FURTHER PREPARATION REQUIRED BY FACILITIES FOR DAY 1

The following are a list of skills and knowledge that students are expected to complete prior to commencing their Acute Unit developed with contribution from the clinical educators. This information has been covered in your pre-clinical cardiothoracic curriculum and you should use this checklist to monitor your level of understanding of each component. Please revise any areas in which you are not prepared in prior to your first day.

(Please tick to indicate the areas that you have read and understood)

Background Theory and Interpretation The student should know; � Spirometry - Definitions of FEV1 , FVC, FEV1 /FVC and interpretation of Volume –Time

curves and Flow-volume loops � Normal values Hb, WBC, Platelets, T, BP, HR, RR, oxygen saturations and BSL’s � Interpretation of arterial blood gases � Names of major abdominal surgeries and respective incision lines � Gravity Assisted Drainage Positions (PD) � Signs symptoms of cardiac disease (including (R) and (L) cardiac failure, IHD, acute coronary

syndromes, ECG recognition and implications) � Contraindications for all techniques eg. especially for osteoporosis � Oxygen therapy – principles, flow rates, effect on hypoxic drive, effect on pulmonary

hypertension � Basic groups of medications including

� Beta 2 agonists � Steroids- inhaled, oral, IV � Analgesics � Diuretics � Antibiotics � Anti hypertensives � Cardiac drugs, glycosides, anti-arrhythmics � Appreciate effects of steroid medications – short term and long term

Assessment The student should be able to: � List respiratory symptoms e.g. SOB, wheeze, pain, cough, sputum and haemoptysis � List accessory muscles of ventilation � Describe and recognise different ventilatory patterns � Know the questions to ask about a patient’s home situation and relevance to situation � Understand the effects of body position on assessment findings � Observe an ICC for swinging, bubbling, draining, understand implications, appreciate correct

handling � Auscultate using surface anatomy landmarks � Describe pre mobilisation checks, including a calf check and the signs of a DVT and checks

when an epidural is in situ � Conduct a 6 minute walk test (6MWT)


Treatment Planning Students are expected to know the theoretical background and indications for all treatment techniques covered in the PHTY7825 and PHTY3250 program. The clinical educators have highlighted that the student should know and be able to discuss indications for: � Methods of increasing ventilation: including deep breathing exercises, incentive spirometry,

especially for a range of patients including post op with atelectasis � ACBT � Circulatory exercises


3. COMMON MEDICATIONS GUIDE Please note this table is a summary of a few commonly used medications. For further information regarding respiratory or cardiac medications, please refer to your lecture notes or consult the MIMS.

Groups Product Name Generic Name Narcotics

Pethidine Fentanyl Morphine Omnopon Physeptone Endone MS Contin

Methodone Oxycodone Morphine

Simple Analgesics Panadol Solprin

Paracetamol Asprin A

nal

ges

ics

Local Analgesics Marcain Lignocaine Xylocaine

Bupivacaine Lignocaine

Non Steroidal Anti- Inflammatories

Naprosyn Feldene Brufen Voltaren

Naproxen Piroxicam Ibuprofen Diclofenac

An

tiin

flam

mat

ory

Steroids Hydrocortisone Dexmethsone Depo-medrol Prednisone / Prednisolone

Hydrocortisone Dexamethasone Methylprednisolone

H2 Receptor Antagonist

Tagamet Zantac Pepcidine / Pepcid

Cimetidine Ranitidine Famotidine

Anti-emetics Maxalon Stemetil Zofran

Metoclopramide Prochlorperazine Ondansetron

GIT

Proton pump inhibitors, Losec Zoton

Omeprazole Iansoprazole

ββββ2 Agonists-Short-acting Long acting

Ventolin Bricanyl Serevent Oxis, Foradile

Salbutamol Terbutaline Salmeterol Eformoterol

Inhaled Corticosteroids

Qvar Pulmicort Flixotide

Beclomethasone Budesonide Fluticasone

Anticholinergic

Atrovent Spiriva

Ipratropium Bromide Tiatropium

Combination Medications

Combivent Seretide

Atrovent + salbutamol Flixotide + serevent

Res

pir

ato

ry

Mycolytics Mucomyst Pulmozyme

Dornase alpha


Groups Product Name Generic Name IDDM

Actrapid Monotard Mixtard

D

iabe

tes

Oral Hypoglycaemics NIDDM

Diabenese Diabex Diaformin

Chloropropamide Metformin

Diuretics Lasix Demadex

frusemide Torsemide

Nitrates

anginine Transiderm isordil

isosorbide dinitrate

Calcium Channel Blockers

isopten (arrhythmia) cardizem adalet

verapamil diltiazem nifedipine

ACE Inhibitors

capoten renitec

captopril enalapril

ββββ Blockers

inderal betaloc / lopressor tenormin

propranolol metoprolol atenolol

Car

diov

ascu

lar

AngiotensinII Receptor antagonist

avapro irbesarten

Penicillins

Amoxycilline Flucloxicillin

Amoxil, Moxacin

Cephalosporins

Keflex Rocephin

Cephalexin Ceftriaxone

Tetracyclines Vibramycin Doxycycline Aminoglycosides

Gentamicin Tobramycin A

ntib

iotic

s

Anti fungal Flagyl Metronidazole

Sed

ativ

es

normison rohypnol mogadon diazepam Valium

temazepam flunitrazepam nitrazepam

Anti-coagulant heparin warfarin clexane

streptokinase

Hypercholestraemia zocor / lipex vastin / lescol pravachol

simvastatin fluvastatin sodium pravastatin

Oth

er

Potassium Chloride

span K, slow K chlorvescent


4. NORMAL VALUES Blood Gases Pa O2 85 - 100 mm Hg (11-13 kpa) Pa CO2 35 - 45 mm Hg (4.5 - 6.0 Kpa) pH 7.35 - 7.45 HCO3

- 22 - 28 meq/l Serum Electrolytes Na+ 140 - 145 mlq/l K+ 4.0 - 4.5 mlq/l Cl- 105 meq/l Urea 20 - 40 mgm % (3.0-7.5) Creatinine .06 - 0.12 HC03

- 24 - 27 mlq/l Blood Values Male Female Hb 14 - 16 gm / 100 ml 12 - 15 gm / l00 ml PCV 40 - 54 % 36 - 47 % RBC 5 - 6 mill / c. mm. 4.5 - 5.5 mill / c. mm. WBC 4000 - l0000 / c.mm. ( 4 - 10 ) Platelets 150,000 - 400,000 / c.mm ( 150 - 400 ) Bleeding Time 2 - 5 mins. Whole blood clotting time 4 - 10 mins ESR 15 min in 1 hour. INR 2.0 - 3.0 for treatment of DVT APTT 22 - 38 secs 60 - 100 secs if heparinized


5. START UP TEST You should attempt to complete this test after revising the notes on the following topics: • Respiratory Assessment and Assessment of the Surgical Patient • Chest Xray • Auscultation • Interpretation of Blood Gases The suggested time frame is 45 minutes. Question 1 You are reviewing the chart of a bronchiectatic patient who has been referred to physiotherapy for treatment of her chest infection. a. In a table format, discuss the key points or information you would look to obtain from the

patient’s medical chart and indicate why this information is important Question 2 Your COPD patient is admitted with ↑↑ SOB and an inability to cope at home alone. His ABG’s are as outlined:

FiO2 - 0.30 via a multi-vent mask pH - 7.31 pCO2 - 59 mmHg HCO3 - 30 pO2 - 60 mmHg

a. Interpret the ABG’s b. Discuss the breathing pattern that your patient may be demonstrating c. Outline the signs and symptoms of Type I and Type II respiratory failure Question 3 Mrs Brown is a 76 year old COPD patient admitted with a ( R ) ML bronchopneumonia. As part of your assessment you are reviewing her chest X Ray. a. Outline using headings the steps you would take in this review. b. What classical sign would demonstrate the involvement of the ( R ) ML? Question 4 Mr Jones has returned to the Ward from the High Dependency Unit (HDU) Day 1 post elective AAA Repair. He received initial post op physiotherapy in the Unit. He had poor pain control with pain at rest 6/10 and with movement 8/10. His BP had been in the range 140 – 175/ 75 – 90 mmHg. The APS (Acute Pain Service) reviewed his pain relief and increased the range he was


able to receive via the epidural. He had an episode of chest pain this am and an ECG and serial cardiac enzymes were ordered a. Discuss any results or information you would wish to know prior to treating this patient and

the reasons this information is needed b. Provide the range of normal values for these results c. Explain the precautions you would take prior to mobilisation of this patient d. Explain the precautions you would take during mobilisation of this patient e. Outline the signs that you would monitor that may indicate the patient was having difficulty

during the walk

Once you have completed the test, compare your responses to the answers on page 27.


6. WEEK 1 ACTIVITIES: SURGICAL MANAGEMENT 6.1. Interpretation of a medical chart When assessing a patient for the first time, it is important to gain the critical information from the patient’s medical and bed charts, as this will impact your subjective and objective assessment as well as your treatment plan. Over the next 4 weeks, you will develop and refine your skills in navigating through and interpreting a variety of medical charts, to identify key findings and their physiotherapy implications, such as safety issues. For this activity, select one medical chart for a surgical patient you have seen this week. If you have not had the opportunity to see a surgical patient, ask your clinical educator if you can view the chart of a surgical patient for this activity. After reading the patient’s medical chart, answer the following questions:

A. What is the patient’s main reason for admission? B. What is the patient’s relevant past history?

i. What are the physiotherapy implications of these conditions? ii. Are there any safety issues you need to consider for this patient?

C. Do you think this patient was at high risk of post operative complications? i. Why or why not? ii. Outline the risk factors for post operative complications. iii. How would you manage a patient who you thought was “high risk”?

D. Summarise the patient’s operation notes. i. What are some intra-operative events that can occur? What are their

implications for physiotherapy treatment? ii. What post operative pain relief was the patient prescribed? What are the

implications for physiotherapy treatment? iii. What are the other common methods of analgesia delivery? What are the

implications for physiotherapy treatment? E. What other sections of the medical chart should you review prior to seeing this patient?

i. Why are they important? ii. How might your management of this patient change?

6.2. Patient attachments and their physiotherapy implications Patients may have a variety of different attachments during their admission. It is important that you know the function of each of the following items as well as their implications for your physiotherapy management.

A. Oxygen mask B. Wound drain C. Nasogastric tube D. Urinary catheter E. IV drip F. Intercostal catheter G. Epidural

For each of the above item: i) what is its function? ii) What are the implications for physiotherapy management? And iii) How would you know the device was working properly?


6.3. Surgical case study Answer the following questions regarding Mr C, a 58 year old man is admitted to a Colorectal ward prior to surgery. Routine Admission for a ( R ) Hemicolectomy HPC : 10 kg weight loss over last 4 / 12 PR bleeding / melena Lethargy Abdominal pain → “cramping“ sensation, worse at night, worsening over last 1/12 PMHx : Smoker 20 / day for last 40 years COPD - RFT’s FEV1 / FVC = 1.6 / 2.9 Hypertension OT : ( R ) Hemicolectomy Post op orders : NBM IV fluids Analgesia via epidural Hourly UO measures Routine post op observations

A. What would you include in your pre-operative assessment of this patient? B. Mr C asks you to explain what a (R) hemicolectomy is. How would you explain it to

him? He now presents Day 1 post op : C/O : Inadequate analgesia pain 7/10 at rest Itchy Nausea and vomiting O/E : Distressed RR - 30/min Accessory muscle use +++ ↓↓ lateral costal expansion BS - absent in the bases with no added sounds Weak ineffective cough Calf check √√ Wound - nil ooze

C. Complete the clinical reasoning sheet (see Appendix 1) for your management of this patient on Day 1.

It is now Day 3 post op and Mr C presents with the following: Abdominal distension ++ ↑ temperature 39 0C ↑↑ WCC - 20 Abdominal pain ++ - 9/10 at rest

D. What do you think is happening? What condition is this? E. How would you modify your management of Mr C?


6.4. Reflective activities These activities are designed to help you take an active role in your clinical experience and to identify strategies to optimise your learning by reflecting on your performance over the past week. By identifying your strengths and areas of improvement, you can develop strategies to improve your performance during the placement and help you identify areas to discuss with your supervisor. Consider your performance over the past week and answer the following questions. A. On a scale from 0 to 10, what score would you give yourself on your performance this past

week? Why did you select the above score? B. Consider the feedback your supervisor has given you this past week. List 5 occasions of

feedback (either positive or negative) that your supervisor has provided this week. C. Are they mainly positive or negative? D. For the positive feedback, outline how you will develop these skills/attributes further during

your placement. E. For the negative feedback, outline what you are doing to address this issue. What strategies

will you implement next week to overcome this?


7. WEEK 2 ACTIVITIES: MEDICAL MANAGEMENT 7.1. Treatment progression As the patient’s condition progresses, you must also modify your assessment and management of your patient. During your remaining 3 weeks in the acute unit, you will be asked to consider how to progress your management of patients, and also consider discharge planning (this will be addressed in the next section). As part of your continuing assessment of the patient, including their medical and bed chart, you will notice certain signs and symptoms that demonstrate an improvement or deterioration of the patient’s condition and need to modify your treatment accordingly. For the following cases, consider what signs and symptoms would indicate an improvement or deterioration in the patient’s condition and how this might impact on your management of the patient. Case 1: Mr L, a 64 year old man admitted with acute exacerbation of his COPD PHx: Emphysema/Asthma

Hiatus Hernia Medications: Prednisolone 15 mg/day – long standing dose Serevent bd Ventolin and Atrovent via nebuliser Current History: Thin man

Increased SOB over 1/52 Increased cough and slight increase in yellowish sputum, haemoptysis Decreased exercise tolerance, able to walk 15m with 1 person assist (previously independent, no SOB on flat)

Investigations: CXR Small area patchy consolidation at lung bases Hyperinflated lung fields, elongated mediastinum ABG’s on 2 L/min : pH 7.35, pCO2 45, pO 2 67, HCO3 27 Temp 375 Pulse 90 Resp: marked increase RR – 30 Ausn scattered exp wheeze, fine basal crackles, soft breath sounds Dx Acute exacerbation of chronic lung disease Rx Oral antibiotics, nebulised Ventolin/Atrovent 2/24, IV hydrocortisone, O2 2 L/min

intranasal, AFB x 3, Cytology x 3, M&C x 1


For Mr L, consider the signs and symptoms that would suggest to you an improvement in his current condition. How could this improvement influence your treatment? With these improvements in Mr L’s condition, how could you progress his Rx?

Sign/Symptom Improvement Impact on Rx/ Progression Sputum

Cough

Breathlessness

Exercise tolerance

Mobility

Auscultation

ABGs

CXR

Vital signs

Now, consider what would indicate deterioration in Mr L’s condition and how this might impact on your management of the patient. How could this deterioration influence your treatment?

Sign/Symptom Deterioration Impact on Rx/ Progression Sputum

Cough

Breathlessness

Exercise tolerance

Mobility

Auscultation

ABGs

CXR

Vital signs


Case 2: Mrs O, a 62 year old woman is admitted to a general surgery ward for ? Liver resection / Biliary Reconstruction for metastatic Ca PMHx: Transverse Colectomy 6/95 for Ca Ex-smoker - ceased 6/95 with a 40 pack year history COPD IHD Hypertension OT: Hemihepatectomy via bilateral subcostal incisions with xiphisternal extension Post op orders: ICU Day 1 post op: RTW in pm C/O: Adequate analgesia via PCA (morphine) Nil nausea Dizziness when transferred from bed to chair in ICU Nil SOB Productive s/a yellow sputum O/E: Non distressed, sitting in bed ↓ Lateral costal expansion (R) > (L) ↓ BS (R) base, nil added sounds Effective productive cough For Mrs O, consider the signs and symptoms that would suggest to you an improvement in her current condition. How could this improvement influence your treatment? With these improvements in Mrs O’s condition, how could you progress her Rx? A. In a table, outline the following i) Sign/Symptoms; ii) Improvement and iii) Impact on

your treatment and progression of Rx. On Day 3, Mrs O demonstrates the following signs/symptoms.

Abdominal distension ++ ↑↑ Abdominal pain → 6/10 at rest BS absent Nausea CXR: (R) pleural effusion Bilateral basal collapse B. What condition is this? What is the medical management? C. How will your physiotherapy management be modified?


7.2. Discharge planning It is important to consider when the patient will be ready to be discharged from your initial assessment, as it will influence your treatment progression.

A. What factors regarding the patient’s social history should you consider when planning for discharge?

B. What factors regarding the patient’s mobility should you consider when planning for discharge?

C. What members of the multidisciplinary team can be involved in the discharge planning of a patient? What are their roles?

D. When would you refer the patient to outpatient or on going physiotherapy management? How would you organise these services?

7.3. Medical cases - problem solving Case 1 Answer the following questions regarding Mrs K, a 50 year old female is admitted to a Medical Ward via Casualty PMHx : Asthma since 45 years old - 3 previous hospital admissions, never ventilated Non-smoker Nil other relevant O / E : Fatigued looking, agitated

SOBAR ++ - unable to speak in short sentences Laboured breathing Accessory muscle use ++ Not cyanosed

BP - 170 / 90 PR - 130 b / min RR - 32 b / min CXR : Hyperinflated, poor inspiratory effort

Clear lung fields Auscultation : Quiet chest

↓ BS throughout both lung fields No added sounds ABG’s : On R/A

pH - 7.47 PaCO2 - 28 PaO2 - 60 HCO3 - 24 A. Discuss the significance of Mrs K’s past medical history

B. What do the auscultation findings suggest?

C. Interpret the ABGs

D. Consider how your assessment of Mrs. K might be modified.


Three hours later in the Ward on 30% O2 ABG’s : pH - 7.33 PaCO2 - 58 PaO2 - 65 HCO3 - 24 E. Discuss the ABG’s that were taken three (3) hours later. F. What condition is now evident? G. Outline the aims of treatment and techniques that may be appropriate at this stage? Case 2 A 56 year old man is admitted to a Medical Ward via Casualty PMHx : Severe pneumonia in childhood ~ Bronchiectasis IHD Current Medications :

Ventolin qid Atrovent tds Pulmicort bd Amoxil Anginine prn

O / E : Barrel shaped chest Cyanosis Clubbing SOBOE Productive cough - ↑ production of mucopurulent, slightly

blood-stained secretions Auscultation : ↓ BS throughout both lung fields

Scattered crackles and wheezes throughout lung fields LL > UL CXR : No local lesions

Fibrosis and peribronchial thickening in the lower lobes ABG’s : On Room Air

pH - 7.41 PaCO2 - 37 PaO2 - 68 HCO3 - 25 A. Discuss the significance of this patient’s past medical history. Consider the medications. B. Complete the clinical reasoning sheet for this patient. (see Appendix 1) C. What are changes in the patient’s signs and symptoms would indicate an improvement

in his condition? D. How would you change your treatment plan (from question B) in response to these

improvements? E. What do you have to consider prior to discharge from hospital?


7.4. Reflective activities Consider your performance over the past week and answer the following questions. A. On a scale from 0 to 10, what score would you give yourself on your performance this past

week? Why did you select the above score? B. Compare your performance this week to last week. Have you addressed the issues you

identified last week? Have the strategies been effective? C. Consider the feedback your supervisor has given you this past week. List 5 occasions of

feedback (either positive or negative) that your supervisor has provided this week. D. For the positive feedback, outline how you will develop these skills/attributes further during

your placement. E. For the negative feedback, outline what you are doing to address this issue. What strategies

will you implement next week to overcome this?


8. WEEK 3 ACTIVITIES: SPECIALISED SURGICAL MANAGEMENT In the past two weeks you have seen mainly basic surgical and medical cases. In these last two weeks you will be introduced to more specialized surgery and conditions, or patient who have combined problems. You will still need all your basic assessment and clinical reasoning skills but will need to have extra knowledge about the conditions. 8.1. Case 1: Vascular surgery A 55 year old lady is Day 1 post aorto-bifemoral bypass PMH x: • Severe PVD, Prior to her admission she had a walking distance of 40m on the flat • Ischaemic heart disease, • Has smoked 30 cigarettes a day for 38 years. Current Medications: Anginine prn, Simvastin (Zocor), Prandin; Pentoxifylline (Trental)

O/E: BMI 29, Supine lying, Pain 2/10 rest, 5/10 movement

Equipment: IV Drip – PCA Urinary catheter Auscultation: ↓ ↓ BS in both bases CXR: Bi-basal atelectasis ABG’s: On MVM FiO2 0.35

PH - 7.46 PaCO2 - 38 PaO2 - 67 HCO3 - 25

A. What are signs and symptoms of Peripheral Vascular Disease? B. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient

on Day 1. C. On Day 2 you approach the patient and she complains of severe pain in her right leg.

On examination it is pale and cold. What could this indicate? What would be your actions?

D. What are some precautions taken when treating patients post this particular surgery and

with PVD?


8.2. Case 2: CABG A 68-year-old male admitted to the Cardiac Surgery Ward for CABG tomorrow PMH x: HT - 30 years IHD - AMI 1990 with ongoing angina Ex-smoker ceased 2 years ago previously 20 per day for 35 years Investigations : Echocardiography LVEF - 40% Angiography LAD - 90% blocked RCA - 70% blocked Circumflex - 75% blocked OT Notes : Time in OR 1325 - 1550 hrs Time on bypass 60 minutes

CABG x 3 vessels IMAG for LAD and OM1 SVG for RCA and Circumflex Temp 32 0 C CPB - 56 minutes Pacing wires inserted 3 drains on low suction

Post op orders : Remain ventilated IV fluids as charted Morphine (PCA) Dopamine infusion at 5 mcg /kg/min Tridil infusion 1.5mcg/kg/min Keflex 3 doses Hourly UO measures → notify if > 30 mls per hour

Patient weaned and extubated at 0600hrs Registrar Review at 0800hrs

Patient drowsy but rousable FIO2 6 litres via mask SpO2 93% HR 70 b/min paced BP 100/55mmHg

Orders:

Leave paced Gradually wean tridil leave dopamine for present Remove one pericardial drain Continue IV fluids pain relief and medications as ordered

Your examination: C/O : Minimal pain 1/10 at rest and 4/10 with movement Pain in posterior mid thoracic spine O/E : Non distressed


O2 2 litres via nasal prongs, SpO2 95% Obs. ↓ Bibasal expansion Palp. ↓ Lateral costal expansion ↓ (L) > (R) base Ausc. ↓ BS (L)LL anterior, lateral and posterior basal segments A. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient

on Day 1. B. Discuss your pre-operative management of a patient undergoing cardiac surgery. What

information is it necessary to give? C. Outline the pathophysiological effects of the surgery on the respiratory system. D. What are the pulmonary complications that can occur after cardiac surgery? E. Describe the patient’s presentation when you see him post extubation. F. Discuss the medications that the patient is requiring post operatively. What effect will

this have on your management? G. What factors would you consider prior to mobilising this patient? H. Discuss progression of this patient and the discharge advice that would be given I. Outline a walking programme that would be suitable for your patient.


8.3. Reflective activities Consider the mid unit feedback you received last week. A. How does it compare with how you have been rating yourself over the past two weeks? List

any unexpected comments either positive or negative. B. List the positive attributes your tutor mentioned. Were you aware of these? C. List the negative comments your tutor mentioned. Were you aware of these? D. How have you addressed the issues identified last week? E. Have the strategies been effective? Have you discussed this with your tutor? F. Consider the feedback your supervisor has given you this past week. How will you act on this

feedback in your final week?.


9. WEEK 4 ACTIVITIES: SPECIALISED CASES In your last week you will be seeing patients with complex problems. Your problem solving abilities and clinical reasoning skills should enable you to effectively manage these patients. However, remember it is always advantageous to discuss patients with your tutor, peers, and senior staff at any stage of your career.

9.1. Case 1: Chest Trauma A 50 year old man has received a stab wound, # ( R ) Ribs 4 - 7 and a pneumothorax during a fight. PMHx includes smoking 40 / day and a heavy alcohol intake. He is on the surgical ward with 2 ICC’s with UWSD. O/E : Pain 4 / 10 at rest and 6 / 10 with movement PCA pethidine RR 26 b / min BP 150 / 80 HR 90 b / min FIO2 0.35 % via mask SpO2 90 % Ausc - ↓ BS throughout ( R ) lung field No added sounds DAY 2 0800 hrs Patient is tired, agitated and confused ABGs pH 7.47 PaO2 58 PaCO2 32 HCO3 23 RMO orders an increase in the FIO2 to 0.40 % humidified 1000 hrs FIO2 0.40 % humidified SpO2 88 %

Repeat ABG’s pH 7.33 PaO2 65 PaCO2 50 HCO3 24 A. Complete the clinical reasoning sheet (Appendix 1) for this patient B. Discuss the aspects of the patient’s presentation that may impact on assessment and

treatment. C. Outline your concerns in relation to the objective assessment. D. List the precautions relating to ICC’s. E. Discuss what is happening on Day 2. F. How might your Rx options vary on Day 1 or 2?


9.2. Case 2: Post ICU A 75 year old man has returned to your surgical ward from ICU. He has spent 6/52 in ICU, following a repair of a ruptured oesophageal ulcer which required multiple blood transfusions. He was ventilated for 5/52 weeks, with ARDS and difficulty weaning. He was discharged from ICU after 5.5/52, however, deteriorated in the ward due to secretion retention and respiratory muscle fatigue and was readmitted and ventilated overnight. PMHx: COPD (mild), IHD (angina on extreme effort, eg moving house) Peptic ulcer disease Anxiety O/E: Tracheostomy – attached to humidification FiO2 0.28 Thin, frail man, appears anxious Muscle power UL 3+/5, LL - Quads 3-/5, hip extensors 2/5 AE R = L ↓ BS, few transmitted sounds, cleared by huff or suction Vital signs: Blood pressure 150/86mmHg, HR 90beats/min, RR 25b/min, SpO2 94 ABG’s: pH 7.37 PaCO2 45 PaO2 79 HCO3 28 Medications: Ventolin 1ml/5mls NaCl in Nebulizer 6/24 Anginine prn Losec

A. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient

on Day 1. B. What condition, common in long term ICU patients, does this man appear to have

developed? C. What are some signs that this man could be deteriorating? 9.3. Managing a Ward and Prioritizing patients One of your skills as a new graduate will be to decide who you will see and in what priority in your ward(s) each day. The following ward lists are used as an example of a new graduate potential workload in a medical and surgical ward. For each ward 1. Identify the six (6) patients in each ward that would be your highest priority to see.

2. Provide a rationale for your choice e.g. age of patient, type of surgery – upper abdominal or

thoracic – productive cough, potential for complications

3. List any factors that might impact upon your treatment


4. Prioritise these six (6) patients and consider the number of treatments per day that would be required

5. Consider the patients in each ward that would need active treatment

6. List the patients that would require a quick check or supervision SURGICAL WARD Bed

Age Name Condition Co-morbidities/other problems

1 48 Mr News (R) IHR 3/7 PMHx : Nil 2 55 Mr Ord (L) IHR 3/7 PMHx : Nil 3 82 Mrs Bond Ant. Resection 3/7 Mobility problems 4 78 Mr Que Abdominal Pain Diabetic, PVD 5 73 Mr Issacs Abdominal Pain PMHx : Nil 6 32 Mr Crenny Wiring Mandible 6/7 PMHx : Nil 7 45 Mr Board Pancreatitis ETOH++, Smoker 8 81 Mr Louder Bowel Obstruction Old laryngectomy 9 90 Mrs Long (R) Mastectomy 2/7 Lives by self 10 96 Mrs Sanders Inoperable Ca Stomach From nursing home 11 18 Mr. Roberts (L) IHR 1/7 ago. Cystic Fibrosis 12 81 Mr Nelson R/O Wire Mandible Mild COPD 13 22 Mr Brady Spontaneous PNTx (L) ICC Previous Pnx 14 81 Mr Owens Vagotomy and Pyloroplasty 1/7 Rheumatoid arthritis 15 44 Mr Boswell (R) IHR 1/7 PMHx : Nil 16 40 Mrs Roberts Stripping Varicose Veins 2/7 PMHx: Bronchiectatic 17 60 Mrs Hoge Pre-op. Lap. diverticular abcess Chronic GI disease,

smoker 18 28 Mr Phillips Head Injury FI PMHx : Nil 19 56 Mr Rowan Metatastic Melanoma (L) neck Previous melanoma 20 71 Mr Frier Abdominal pain FI Weight loss 4kg 21 56 Mr Emeon Haemorrhoidectomy 1/7 PMHx : Nil 22 81 Mr Crowe Laparotomy with colostomy 1/7 Mild HT 23 76 Mr Jones Diverticular Abscess FI IHD, Diabetes 24 60 Mrs Lang Large Bowel Obstruction PMHx : Nil 25 54 Mrs Ivan Biliary Colic PMHx : Nil 26 60 Mrs Jacobs Exploration cholecystectomy

wound pre-op Obese

27 60 Mrs Kleene Closure of Colostomy 3/7 Previous Ca Bowel 28 70 Mrs Gow High Ant. Resection 2/7 PMHx: Mild HT 29 64 Mr Muir BK amputee 7/7 Mild COPD


MEDICAL WARD Bed Age Name Condition Co-morbidities/other

problems 1 69 Mrs Abbott Social Admission Acopia 2 62 Mrs Blow Rapid AF IHD 3 87 Mr Crawford Melaena for Ix Diverticulitis, Mild HT 4 19 Mr Dawson Acute Asthma PMHx: Chronic asthma 5 66 Mr Enright Unconscious, (R) CVA ? Aspiration pneumonia 6 73 Mrs Faulkner Chest Pain COPD 7 74 Mrs Gibson Rapid AF PMHx: Nil 8 27 Mr Hill AMI Day 4, from CCU 9 91 Mr Ibsen CCF – uncontrolled IHD, PVD 10 60 Mrs Jones PE PMHx: Nil 11 68 Mrs Ernest COPD Acute exacerbation 12 70 Mr Lawson Gout Chronic renal failure 13 54 Mr Mullin AMI Inferior Infarct Day 5, from CCU 14 61 Mr Nolan Acute bronchitis ETOH, Cirrhosis of liver 15 41 Mr Osbourne CAP - Respiratory failure BiPAP 16 34 Mr Powell Hypoglycaemic episode Type I Diabetes 17 81 Mr Quinn CCF – controlled IHD 18 86 Mr Crowley (R) LL Pneumonia, UTI Confused 19 85 Mr Swann Chest pain FI Immobile in nursing home 20 60 Mrs Turner Rheumatoid arthritis Acute exacerbation 21 55 Mrs Ung Acute Asthma Smoker 22 64 Mr Vanps Inflammatory Bowel Disease Previous IBD 23 35 Mr West Joint Inflammation FI PMHx: Nil 24 65 Mrs Youn (L) TIA Controlled HT 25 38 Mrs Anderson (L) DVT Smoker, OCP 26 67 Mr Bowden Peripheral Neuropathy FI PMHx: Nil 27 85 Mr Rogers Vertigo and UTI Frequent falls 28 55 Mrs Douglas CAP - (R) ML PMHx: Nil 29 66 Mrs Kirkland Temporal arteritis Chronic headaches 30 73 Mrs Freer (R) CVA HT


9.4. Reflection activity: Professional issues Have any professional/ethical issues arisen during your clinical unit? Examples of this would be

• Conflict of role between health professionals • Orders for not to treat in a patient where you are still actively treating • A situation where you disagree with the decision of another health professional eg early

discharge before you consider they are safe. • Patient unwilling to have treatment • Patient becomes aggressive/confused • Patent is being placed in a nursing home or similar place when they feel they can still cope

in their own home • Patient has received a bad prognosis and wants to talk about it, but you do not know how

to talk about it with them. If any of these have occurred to either you or another student, discuss:

• The situation • How do you think each of the personnel involved felt? What was their motivation? • What were the professional/ethical issues involved? • How did you resolve this (if you only observed this, state what your actions would have

been). • What was the outcome?


10. OUTLINE OF ANSWERS TO START UP EXAM Question 1:

INFORMATION IMPORTANCE

History of the presenting complaint

Cough ↑ or ↓ or normal SOB ↑ or normal Sputum Change in colour

quantity or quality

Indication of the severity of the infection

Indication of the course of the disease

Process

Exercise Tolerance

Current status compared to usual baseline and an indication of the aim for

discharge regarding mobility

Medications

Regular medications used and any changes with this admission

The need to co-ordinate treatment with use of bronchodilators

Steroid use and the potential for contraindications to physiotherapy techniques

Chest X Ray + / - Report

Specific lung segments involved

Lung changes as a result of the disease process

ABG result

Indication of the patient’s current level of function

Respiratory or Lung Function tests

Indication of either the obstruction or restriction the patient experiences. If a post

bronchodilator test is performed there is an indication of the reversibility of the

obstruction.

Sputum Culture

The organism that has caused the infection and the need for any additional

precautions

Plan of Medical Management

Indication of patient’s LOS

Question 2:

a. Interpretation of ABG’s

pH 7.35 – 7.45 ↓ acidosis PaCO2 35 – 45 mm Hg ↑ acidosis HCO3 22 –28 ↑ alkalosis PaO2 80 – 100 ↓ severe hypoxaemia

Partially Compensated Respiratory Acidosis with severe hypoxaemia

b. The patient would be demonstrating an ↑ in the work of breathing (WOB) with an utilisation of accessory muscles, with elevation of the shoulders and potentially stabilisation of the upper limb to provide fixation for reversed origin and insertion. In

view of his chronic respiratory condition, the lower chest wall movement is likely to be minimal or nil with vertical or piston

movement most obvious – demonstrating rigidity

c. Signs of Type I respiratory failure – agitation, confusion, plucking at air or sheets, decreased PaO2, increased RR, HR and

BP

Signs of Type II respiratory failure – vasodilation, bounding peripheries, flushed, increased PaCO2, drowsy (late sign), coma

Question 3:

a. Review of CXR:

� Patient Information

� Type of film and position

� Exposure

� Centering or rotation

� Soft tissue structures

� Bony structures and outline

� Trachea, mediastinum and hilar region

� Heart size, heart borders and cardiophrenic angles

� Diaphragm border and levels and costophrenic angles

� Lung fields

b. Involvement of (R) ML - loss of the ( R ) heart border such that the margin is not clearly differentiated.


If you were unable to answer this question or need to clarify the aspects being considered in more detail, review the Chest X

Rays CAL program before commencing clinic as this information will be needed DAY 1.

Question 4:

a. Results or information needed prior to treating this patient include:

i. Regarding chest pain – need the interpretation of the ECG by medical officer and serial cardiac enzymes. This is needed as 1)

ECG interpretation - ensure patient has not had an MI; and 2) Serial cardiac enzymes - will reveal changes in enzyme levels

over time if the patient has had an MI. However, as serial enzyme levels may not be available for several days, ECG monitoring

and troponin levels on day 1 can be used to determine whether patient should be mobilised.

ii. BP. This is needed as there may be ↓ with blood loss intra-operatively and is influenced by epidural that can cause vasodilation.

b. Normal range for the above results:

i.ECG - no ST elevation; no T wave changes; no Q waves;

ii. BP - Need to know normal range for the patient, look at the measure obtained on admission or at pre-admission clinic

c. Precautions prior to and during mobilisation of this patient

- Subjectively ask about pins and needles , tingling, numbness or heaviness of their legs - MANDATORY FOR SAFETY

- Objectively

• if needed assess sensation – checking light touch in a dermatomal distribution

• assess muscle strength – repeated inner range quads contraction and hip and knee flexion. Look at the quality,

range and eccentric control of the movement

• vitals signs should have been checked at the beginning of Rx . If indicated BP can be checked prior to transferring

the patient

d. Patient transfer and mobilisation

• Organise the equipment so all attachments are on the one side of the bed

• Organise chair prior to moving the patient if the patient is to sit out of bed and have a forearm support frame (FSF) ready

• First walk have a second person present in view of the large surgery and aiming to minimise patient’s discomfort

• Ensure you are close to the patient to control or facilitate the movement

• Clear instructions to the patient and assistant regarding movement

• Sit the patient on the side of the bed for a few moments to allow BP to settle

• Question the patient regarding light-headedness and encourage the patient to move his ankles to assist the blood return to

the head and some slow deep breaths

• When shoes are being put on ensure one person is responsible for the patient

• Remain close to the patient at all times particularly on standing the patient

• Ensure the patient is stable before organising the FSF into position

• Remain close to the patient and utilise the sacrum as a key point of control

• Talk to the patient while mobilising to monitor their level of awareness

These steps will ensure safety with mobilisation. You must follow them through for safe handling to be demonstrated

e. Signs that indicate the patient may be having difficulty during the walk

- ↑ sweating - Change in colour - patient becomes pale

- ↓ or slowing of verbal response - Staring or fixed gaze prior to rolling eyes back

- ↓ SpO2


11. OUTLINE OF ANSWERS TO SELF-DIRECTED LEARNING ACTIVITIES

4. WEEK 1: SURGICAL MANAGEMENT (SUGGESTED RESPONSES) 4.1 Interpretation of a medical chart

A. This will depend on the patient. E.g. Ca of colon

B. This will depend on the patient’s past medical history. Below are some common conditions and their physiotherapy

implications and safety issues to consider.

Condition Physiotherapy implications Safety issues

IHD Questions in subjective re: Angina - establish history -

stable / unstable. Time of last episode, location of pain,

quality, duration, intensity, precipitating factors.

Expectation re exercise tolerance. Technique selection

Medications - indication of severity

Be mindful of exercise tolerance, limit mobility

Care when mobilising, may need to take nitrates

Monitor chest pain

HT Need to know the baseline BP. HT => inc. risk CVA, MI

Influence technique selection - HDT cautious (not if

unstable) relax the patient, short inspiratory holds not

contraindicated check BP

Think of factors that inc. BP - pain, isometric exercise.

Short inspiratory holds

If unstable, limit HDT

PND Paroxysmal nocturnal dyspnoea - breathlessness that

wakes the patient at night

Causes - Cardiac suggests (L) VF - inc. venous return

from LL ==> pooling of blood in lungs ==> breathlessness

- Resp - severe asthma - nocturnal b’spasm

Implications - no HDT, dec. ex. tolerance, care with

demand, avoid supine position

Avoid supine position

Monitor carefully during exercise

CCF Establish from the chart if symptoms reflect more (R) HF

or (L) VF. Establish cardiac or respiratory involvement

If cardiac involvement – care with demand

If respiratory involvement – aim to increase demand

and gain control of SOB

COPD Questions in subjective – cough, sputum (include normal

levels), SOB, smoking history

Check for spirometry results in chart, current management

Monitor SpO2

Consider SOB when mobilising

May have hypoxic drive if severe

Diabetes Questions in subjective – foot care, shoes, sensation in

feet

Check circulation, skin for broken areas

Mobilise with correct footwear

Care with mobilisation, avoid injury to foot

C. The following are risk factors for post operative complications, consider how many of the following risk factors your patient had:

Elderly; Immunocompromised; Premorbid lung pathology i.e. productive cough, fibrotic changes, restrictive conditions, CAL;

Malnourished; Long procedures i.e. longer than 3 hours → ↑ risk post-op; Upper abdominal or thoracic surgery - particularly if resection of lung tissue is involved; Underlying malignancies; Recent URTI; Immobile; Neurological problems - i.e. spinal cord

injury; Obesity; Smoking history; PMHx respiratory or circulatory complications with previous surgery.

A patient identified as “at risk” would be seen pre-operatively, including respiratory assessment, and given information on post op

presentation, respiratory and circulatory exercises. Post operatively, patients will be seen day 1, at least once, may increase in

Rx sessions as required and monitored daily.

D. i. Some intraoperative events and their implications for physiotherapy management are below:

Event Implications

Change to the planned procedure - laproscopic procedure

becomes open

Larger incision – likely to have more pain, respiratory inhibition.

May require assistance to mobilise Day 1

Large blood loss → low Hb post-op Monitor Hb and BP prior to mobilisation.

Decreased O2 available in system, may become hypoxaemic

during demand activities, e.g. mobilisation

Cardiac complications - ECG changes intra-op, silent MI May limit mobility depending on event. May also have further

investigations and medical management. Check chart.

Labile BP, intra-operative CVA Type of CVA will influence mobility, communication

Contamination of the field e.g. faecal contamination Increased temperature – inflammatory response

Other tissue damage - nerves, tendons, arteries or muscles

sacrificed

Depending on tissue involved will influence mobility, sensation.

May modify mobility, exercises.


GA complications - epidural at wrong level, (R) main bronchus

intubation, epidural / spinal CSF leak

Incorrect level of epidural – can lead to increased pain

(R) main bronchus intubation – may have collapse of (L) lobes

Aspiration Likely to be (R) upper lobe, increased temperature, secretions

may be present.

D. ii and iii. The common types of analgesia used post operatively and their implications are in the table below:

Type of analgesia Implications

Patient controlled analgesia.

Usually narcotic used.

Encourage your patient to provide themselves with some pain relief at the beginning of your

assessment and regularly throughout the Rx to ensure the relief is maximised prior to

mobilization.

Monitor the patient’s RR and SpO2 to ensure their breathing is not becoming depressed.

Patients may require antiemetics to reduce nausea prior to commencing physiotherapy

treatment. Some patients may not be able to mobilise due to severe nausea.

Monitor the patient’s responsiveness, if they are very drowsy and unable to participate in your

physiotherapy treatment, notify the nursing and medical staff as the patient’s medications may

need to be reviewed.

Information regarding the type of narcotic used, base rate, bolus dose and lock out period is

available in the medication chart.

Epidural analgesia. Can also

be patient controlled epidural

analgesia.

Ask in subjective questioning about pins and needles, numbness, weakness or heaviness

THIS IS AN ISSUE OF SAFETY - THESE QUESTIONS MUST BE ASKED �

If numbness or pins and needles are present - an objective assessment of light touch in a

dermatomal distribution must be undertaken to define the level involved�

If weakness or heaviness is present - an objective evaluation of muscle strength must

be performed. i) Static quads and inner range knee extension over your arm with an

isometric hold - look at the quality of the movement, the range, the ability to hold and the

eccentric control. ii) Hip and knee flexion - ensure you are supporting the limb for safety.

Look at the quality of the movement through the range, the range of movement and eccentric

control.

Numbness may not prevent the patient from mobilising, but the effect of weakness on

movement control may delay mobilisation

Hypotension may be an adverse effect. Check BP prior to mobilising. Check sitting BP if

available to see if postural hypotension is present. Care with mobilisation if PB less than

90/60.

If there is a progressive loss of motor function report to medical staff immediately as this may

indicate inflammation of the epidural site and compression of the spinal cord.

Opiods Monitor patient for adverse effects of narcotics - Respiratory depression; Nausea and vomiting;

Sedation; Itchiness; Urinary retention.

May need to check pain levels prior to mobilising. If patient reports high levels of pain, check

bed chart if pain relief medication is available. Consult nursing staff if further analgesia is

required. Optimum pain relief will be achieved 20-30 minutes post administration (depends on

medication and route).

E. Other sections of the medical chart that are important to review prior to seeing a surgical patient may include:

Section Possible change in management

Spirometry – idea of the severity of

patient’s respiratory condition

Investigations – such as bloods. E.g.

post op Hb levels, platelets If low Hb, look at trend. With decreased Hb, activity requiring effort may → ↑ breathlessness, patient may be lethargic, patient may feel light-headed on standing

or faint during the walk, a blood transfusion may be planned. If Hb < 8 gm / 100 ml

patient will not be mobilised due to the reasons outlined above.

If platelets < 20 don’t percuss patient, if platelets < 40 don’t vibrate patient.

Operation notes Any change to operation, intraoperative events or events in recovery. These have

been outlined in question C.

4.2 Patient attachments and their physiotherapy implications

Item and function Implications Working properly?

Oxygen Mask – provides

supplemental oxygen to

patient.

Check the correct concentration is being delivered

to the patient.

Keep O2 on during Rx

Mobilise post-op pts with O2 (if appropriate)

Check connected to oxygen port and

turned to correct flow rate.


Replace O2 mask or nasal prongs if removed to

mobilise pt.

Wound drain – remove fluid

from wound site following

operation. Consider the 3

types of wounds. Which do

you see most often?

Do not pull out during the course of your treatment

Ensure safe, appropriate handling to avoid

infection.

Can mobilise patients with drainage bag, keep

below level of wound.

Check level – ensure not too full as it

may rupture.

Check wound, ensure wound drain still

attached.

Nasogastric tube – drain bile or

gastric contents from stomach

Often pinned to pillow - do not pull out when sitting

pt forward.

Ensure tube is well secured to pts nose with

appropriate tape, and will not slip out when

mobilising.

Switch off NG feeds when tipping or suctioning

your pt. to avoid aspiration.

NG feeds can often be disconnected to mobilise

the pt. – be sure to reconnect them once the pt

has returned to the bed or chair.

Check below level of nose.

Can be on free drainage, regular

aspiration or suction.

Urinary catheter –

Remove urine from bladder into

an external bag.

Used when patients cannot

mobilise to toilet

Monitors urinary output

(important when narcotic

analgesia is used for pain

relief)

Ensure bag is not too full prior to mobilising

Don’t pull catheter out when mobilising

Keep bag below level of the catheter

Check level – ensure not too full, if so

ask nursing staff to empty prior to

mobilising.

IV drip - Peripheral venous line

inserted for post-op

administration of maintenance /

replacement fluids and

medications.

Ensure burette is not empty - esp. prior to

mobilising pt.

Do not fill / adjust IVAC - call N/staff

Care with arm exercises when there is a problem

with patency of the drip - only then is backflow

likely to occur.

Care with bed mobility - limit movements of joints

close to insertion of IV as there is an increased

risk of tissuing (rupture vein wall).

Check the IV is not alarming – if so call

Nursing staff, don’t adjust IVAC.

Check if patient reports pain at IV site –

inform nursing staff as thrombophlebitis

may occur.

ICC - A flexible tube inserted

into the pleural space,

connected to a system of

underwater seals and suction.

Further information about ICCs

see lecture notes.

Do not pull out during the course of your treatment

Check whether the fluid is swinging, draining or

bubbling.

Keep bottle system below level of insertion into

patients chest wall so no danger of fluid entering

pleural cavity

If the bottle breaks: If previously no bubbling –

double clamp, quickly change bottles

If previously bubbling –do not clamp, quickly

change the bottle.

Chest tube accidentally disconnected, reconnect

and assess system

Assess whether swinging with patient

breaths; draining fluid or bubbling.

Epidural – catheter inserted

into epidural space used for

post op analgesia

Ask in subjective questioning about pins and

needles, numbness, weakness or heaviness

If numbness or pins and needles are present - an

objective assessment of light touch in a

dermatomal distribution must be undertaken to

define the level involved

If weakness or heaviness is present - an

objective evaluation of muscle strength must

be performed (Inner range knee extension, Hip

and knee flexion, dorsiflexion).

Check sitting BP if available to see if postural

hypotension is present. Care with mobilisation if

BP less than 90/60

Check epidural is not alarming.

Check sensation and muscle function in

your assessment.


4.3 Surgical case study A. What would you include in your pre-operative assessment of this patient?

• Check chart, patient history, investigations

• Chest assessment and institute chest treatment if indicated

• Teach

- appropriate breathing exercises - SBE with IH’s or RDB (depending on chest wall compliance)

- circulation exercises

- supported cough or huff

- bed mobility and transfers - with assistance and independently

- specific exercises for procedures - UL exercises for thoracic surgery

• Explain

- physiotherapist’s role regarding chest, circulation, mobilisation, specific exercises

- post-operative presentation / incision(s)

- rationale for breathing and circulation exercises hourly post-op

- early mobilisation programme i.e. generally Day 1 post-op

- need for adequate post-op pain relief for effective physiotherapy treatment

Provide TED stockings pre-op depending on hospital protocol

B. Mr C asks you to explain what a (R) hemicolectomy is. How would you explain it to him?

It is an operation that removes part of the large bowel (or colon) and stitches it back together.

C. Complete the clinical reasoning sheet for your management of this patient on Day 1. Part 1. After reading the Medical and Bedside Charts:

Main Findings Implications for PT Ax and Rx

COPD

Heavy Smoker

HTN

(R) hemicolectomy, no complications in

theatre or during recovery

Epidural analgesia

Reduced respiratory compromise, may have increased secretion production.

Need to ask re cough, sputum, and exercise tolerance in pre-op Ax.

Will affect cilial function, more risk of post-operative complications

More risk of post-operative complications

Check if controlled – check medications. May have higher resting BP.

Ask re pain levels, pin+needles, numbness, heaviness or weakness in C/O.

May also include neurological assessment.

2. What are the key assessment findings? List the pathophysiological causes for these findings.

Main Findings Pathophysiological Causes

Wound pain – 7/10 at rest

Impaired cough

Itchy, nausea and vomiting

Increased RR, increased accessory muscle use.

Decreased BS in bases, no added sounds.

Limited lateral costal expansion

Ineffective cough

Inadequate pain relief.

Adverse effects of analgesia.

Due to increased pain, anxiety.

Atelectasis – due to pain as above

Risk of secretion retention due to poor cough

3. What is the prioritised problem list for this patient?

1. Poor pain control

2. Respiratory distress

3. Hypoventilation

4. Risk of retained secretions – due to inhibited cough

5. Risk of circulatory complications

4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected.

Treatment Plan Rationale

Special considerations:

Pain management – need to get pain team review.

Need to check sensation and muscle strength prior to

Need to optimise pain relief prior to PT Rx

Ensure epidural isn’t affecting sensation/muscle power.


mobilising

Position:

High sitting

Increase FRC

Ventilation:

SBE or DBex

Incentive spirometer

Needs slow laminar flow and collateral ventilation hold to re-

expand atelectasis. This breathing pattern will also help

surfactant release

If poor understanding of SBE or Dbex. Need for feedback.

Secretion mobilisation:

Not required

There is no indication of secretion retention at present. Monitor

closely, as patient may retain secretions if pain not well

controlled, and has Hx of smoking

Secretion removal:

Supported cough – abdominal support with pillow/towel

Support is needed due to pain

Cough is needed to make sure chest is clear

Mobility/Ambulation:

Leg exercises

Ambulation – with rollator, 2 assist, O2 as required.

Circulation exercises are needed to prevent DVTs

2 people needed as patient has epidural analgesia

Ambulate if patient’s pain and respiratory distress is improved

with pain relief. Will help increase ventilation.

5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate?

Patient has poor pain control and this needs to be addressed first. Pain is affecting ventilation and ability to cough, so

may lead to atelectasis and retained secretions.

If after reassessment treatment is not appropriate – ventilation remains decreased, could try other methods of

increasing ventilation – incentive spirometry, IPPB. If pain not controlled – contact Pain team

6. Discuss any factors that may influence your treatment plan. Why are they important to consider?

Patient is in respiratory distress due to the pain – need to ensure this is improved prior to commencing Rx.

Patient has been lethargic and had poor mobility/exercise tolerance prior to surgery – need to progress ambulation

accordingly.

7. What are the safety considerations for your treatment of this patient (e.g. contraindications). How could you manage these?

Monitoring of pain levels, sensation, muscle power is important (epidural)

Need to also monitor BP, as it can be decreased with epidural analgesia

8. What outcome measures will you use to determine the effect of your treatment?

Auscultation, palpation, SpO2, cough, ABG’s, walking distance Part 3. After treatment:

9. When would you like to see this patient again? Why?

In afternoon (approx 3-4 hours later) as patient requires frequent treatment, ensure pain well controlled and not

inhibiting ventilation.

10. What is your plan for the next treatment?

Reassess, increase level of management (e.g. IPPB) if worse BS or has not improved. May SOOB or mobilise further if

improved.

D. What do you think is happening? What condition is this?

On Day 3 the signs reflect PERITONITIS - Inflammation or irritation of the peritoneal cavity with associated infection. E. How would you modify your management of Mr C?

• Time treatment with pain relief or encourage use of PCA throughout Rx

• Maintain pulmonary function and prevent complications

• Short frequent treatments

• Positioning may be difficult - may not tolerate high supported sitting, may prefer standing

• Increase ambulation distance as tolerated.

• In view of patient’s condition pre-operatively a long-term re-conditioning programme would be appropriate.


5. WEEK 2: MEDICAL MANAGEMENT (SUGGESTED RESPONSES) 5.1 Treatment progression

For Mr L, consider the signs and symptoms that would suggest to you an improvement in his current condition. How could this

improvement influence your treatment? With these improvements in Mr L’s condition, how could you progress his Rx?

Sign/Symptom Improvement Impact on Rx/ Progression

Sputum

Decreased amount, no longer yellow

or blood stained

Cough

Decreased amount of coughing

Breathlessness

Decreased to nil SOBAR

Exercise tolerance

Increased distance mobilised

Mobility

Independently mobile, not requiring 1

person assist

Auscultation

Decreased wheeze, decreased fine

crackles

ABGs

Reduced respiratory acidosis

CXR

Resolution of changes in bases

Vital signs Decreased RR

Increase duration of Rx, decrease frequency of treatment

Continue secretion mobilisation and removal techniques

– e.g. if using PEP may need to reassess resistance.

May decrease use of assisted coughing techniques

May progress positioning – from high supported positions

to more supine positions, modified gravity assisted

positioning.

Progress ambulation – decrease O2 required (monitor

with SpO2), decrease assistance, increase distance.

Progress to stairs

Encourage independent mobilisation

Progress secretion mobilisation and removal to

independent treatment sessions – monitor performance.

Now, consider what would indicate deterioration in Mr L’s condition and how this might impact on your management of the

patient. How could this deterioration influence your treatment?

Sign/Symptom Deterioration Impact on Rx/ Progression

Sputum

Increased amount, darker colour (e.g.

green), increased thickness (e.g.

plugs), more blood stained

Cough

Increased amount, weaker

Breathlessness

Increased SOB – now SOBAR

Exercise tolerance

Unable to mobilise 15m, confined to

bed area only.

Mobility

Mobilising with rollator, 2 assist

Auscultation

Increased wheezes, crackles.

ABGs

Increased acidosis, increased

hypoxaemia

CXR

Greater changes in lung bases, more

changes throughout lungs

Vital signs

Increased temp, HR, RR.

Shorter more frequent treatment sessions to reduce

fatigue.

Positioning in high sitting, high side lying

May use humidification to help loosen secretions

May use positive pressure devices e.g. IPPB to reduce

work of breathing – increase ventilation

More passive techniques to mobilise secretions e.g.

percussion instead of flutter, if patient fatiguing

Assisted cough to remove secretions – if cough impaired

may need to use suction.

Monitor closely, patient may move into respiratory failure.

Case 2: Mrs O A. In a table, outline the following i) Sign/Symptoms; ii) Improvement and iii) Impact on your treatment and progression of Rx.

Sign/Symptom Improvement Impact on Rx/ Progression

Sputum

Decreased amount, no longer yellow

or blood stained

Cough

Strong, effective, non productive

minimal pain

Nausea

Nil in bed, and with mobilisation

Dizziness

Nil during transfers, mobilisation

Increase duration of Rx, decrease frequency of treatment

Continue breathing exercises – may increase number of

repetitions.

Continue supported coughing

May progress positioning – sit out of bed

Progress ambulation – decrease O2 required (monitor

with SpO2), decrease assistance, increase distance.

Progress to stairs


Mobility

Independently mobile, no dizziness,

nausea

Auscultation

Improved BS in (R) base, nil added

sounds

Palpation

Improved lateral costal expansion on

(R), so R=L

Encourage independent mobilisation

B. What condition is this? What is the medical management?

PARALYTIC ILEUS - Cessation of movement of the gut / peristalsis not regained for a prolonged period post-op. Maybe due to

rough or excessive handling intraop or with peritonitis.

Medical management includes - NBM with N/G tube; IV fluids and Parentral nutrition

C. How will your physiotherapy management be modified?

• Abdominal distention - high sitting may not be comfortable and may prefer to stand for Rx.

• Encourage mobility as this decreases basal collapse and provides gravity to stimulate gut function.

• Some patients gain relief from massage to promote gut motility. 5.2 Discharge planning A. What factors regarding the patient’s social history should you consider when planning for discharge?

• Home environment – house, hostel, nursing home

� House – number of stairs, rail

� Hostel – distance to dining area, any stairs, ramps, gutters

� Nursing home – any mobility requirements, distance to dining area.

• Level of support at home – spouse, family, living alone

• Level of assistance required for ADLs – house cleaning, meals, transport, bathing, nursing care

B. What factors regarding the patient’s mobility should you consider when planning for discharge?

• Walking aid

� May not be able to use in patient’s home environment due to furniture, size of home. May need to involve home

visit or OT involvement.

� If patient has stairs, will need to be able to use single stick or crutches. Will not be able to use hopper or

wheeliwalker/rollator independently. If patient does have person to assist with moving the walking aid and with

stairs, will be able to move aid to top/bottom of stairwell.

� Patient may need to purchase or hire the aid – will depend on duration required, financial assistance available.

• Level of assistance required – supervision/1person/2 person assist

� May not have assistance available eg lives alone, family works during the day

� May have minimum requirements to return to hostel/nursing home/facilities eg must only be supervision to mobilise

• Distance mobilised

� Consider functional activities the patient needs to be able to complete independently, eg walk to toilet, kitchen.

� May know distance to dining area, recreational area in hostel/facility

C. What members of the multidisciplinary team can be involved in the discharge planning of a patient? What are their roles?

• Occupational therapist – may require home visit, modifications, assistance with ADL tasks, assistive devices.

• Social worker – may require assistance with organising placement (hostel or nursing home)

• Nurse – may organise domiciliary nursing care for wounds, medications, and assistance with bathing/dressing, meals.

• Medical staff – may organise following reviews, referral to other medical specialists, and letter to GP.

D. When would you refer the patient to outpatient or on going physiotherapy management? How would you organise these services?

This may depend on the patient’s presentation:

- If patient has retained secretions, and is not independent in airway clearance, may need a referral for outpatient respiratory

treatment.

- If respiratory patient – eg COPD, patient may benefit from referral to pulmonary rehabilitation following discharge from the

hospital.

- If cardiac surgery patient – may be referred for cardiac rehabilitation following discharge (may be physiotherapy or nursing

role depending on unit)

- If patient has a falls risk – may refer to falls clinic, outpatient physiotherapy exercise programs

- If amputee – will be referred to amputee clinic


The organisation of such services differs with each institution, so consult your clinical educator for the specific information about

your institution. During your placement, consider the outpatient or on going physiotherapy management of your patients and what

services the institution provides.

5.3 Medical cases – problem solving Case 1 A. Discuss the significance of Mrs K’s past medical history

Mrs K has a history of asthma, with only three (3) hospital admissions. Therefore her asthma is usually well controlled and the

fact that she has never been ventilated reflects the severity of the disease.

B. What do the auscultation findings suggest?

Reflect the lack of movement of air and that the patient is fatiguing. C. Interpret the ABGs

pH - ↑ - alkalosis PaCO2 - ↓ - alkalosis HCO3 - - normal

PaO2 - ↓ - severe hypoxaemia ABG’s reflect hyperventilation i.e. blowing off their CO2 and severe hypoxaemia Uncompensated respiratory alkalosis with a severe hypoxaemia

D. Consider how your assessment of Mrs K might be modified.

C/O: Limited or impossible due to fatigue and SOB

O/E: Observation - no assessment of response to verbal instruction

Palpation - assess response to tactile input

Auscultation - limited due to patient’s shallow breathing pattern, stretch facilitation to encourage deeper breaths

Ensure O2 is kept on at all times.

E. Discuss the ABG’s that were taken three (3) hours later.

pH - ↑ alkalosis PaCO2 - ↓ alkalosis HCO3 - normal

PaO2 - ↓ Hypoxemia even with supplemental oxygen Uncompensated respiratory acidosis with moderate to severe hypoxaemia

F. What condition is now evident?

TYPE II RESPIRATORY FAILURE PaCO2 > 50 mmHg

Fatigued with shallow breathing ⇒ ↑ CO2

G. Outline the aims of treatment and techniques that may be appropriate at this stage?

- Need to talk to the Medical Staff

- Positioning - high supported sitting or forward lean sit - Supportive therapy

- Humidification - to assist with the supplemental O2 DO NOT RELAX THE ACCESSORY MUSCLES AS THE PATIENT IS RELIANT ON THEM Case 2 A. Discuss the significance of this patient’s past medical history. Consider the medications.

The patient is only on anginine, a short acting coronary artery vasodilator, for his IHD. As there are no long acting agents used

the IHD is less severe.

B. Complete the clinical reasoning sheet for this patient. (See appendix 1) Part 1. After reading the Medical and Bedside Charts:


Ischaemic heart disease

Bronchectasis

Will need to find out what exacerbates angina, what relieves it

Consider the pathological changes with bronchiectasis

Need to check normal sputum production, current management, ex tolerance

Ask re blood stained sputum – streaks or frank amounts




Barrel shaped chest

Productive cough – mucopurulent, sl blood stained

Scattered crackles/wheezes

CXR – fibrosis and peribronchial thickening in lower lobes

ABG’s - Hypoxaemia

Long Hx of obstructive respiratory disease – limited bibasal

expansion.

Increased secretion production, exacerbation of bronchiectasis

Bronchiectasis, affecting lower lobes more than upper.

Increased secretions resulting in V/Q mismatch and reduced

gas exchange


Retained secretions

Increased work of breathing

Decreased exercise tolerance




What exacerbates angina?

Amount of blood in sputum

Timing of Rx with bronchodilator (Ventolin)

Could use humidifier prior to Rx

Streaks of blood through purulent sputum are common => Rx would not

cease but results recorded in the patient’s file.

Frank haemoptysis is a sign of erosion of pulmonary vessel – needs to be

monitored. Don’t treat with percussion and vibrations for 5 – 10 days to

allow healing.

Treat 20-30mins post, when maximal bronchodilation occurs

Loosen secretions, assist in mobilisation

Position:

HDT

If patient tolerates – IHD is not severe, but check for any chest pain and

SOB

Gravity assisted drainage of lower lobes

Ventilation:

Deep breathing exercises

Decreased ventilation is not a problem at present, but will help in

mobilisation of secretions. No inspiratory hold as patient hyperinflated.


PEP mouthpiece/Flutter

ACBT with percussion and vibration

Use of collateral ventilation, mobilise secretions, keeps airways open

Use of FET to mobilise secretions and remove.

Secretion removal:

Assisted cough - AP

May need supported cough if weak. No bibasal expansion present


Leg exercises

Ambulate around ward – with if required O2

(check SpO2)

Circulation exercises are needed to prevent circulatory complications

Will assist circulation and ventilation. Can also assist with secretion

mobilisation.


Main problem is secretion retention due to bronchiectasis affecting the lower lobes.


Amount of blood in sputum – as discussed above. May influence use of treatment techniques.

Chest pain – will need to modify positioning, to supine or head up position

7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these?

Monitor angina


Auscultation, palpation, sputum (amount, colour, consistency) SpO2, ABG’s, walking distance Part 3. After treatment:



4 hours later – needs frequent treatment for his productive chest.


Reassess, change secretion mobilisation technique if not effective, promote exercise/mobility C. What are changes in the patient’s signs and symptoms would indicate an improvement in his condition?

- Decreased sputum, becomes clearer (closer to normal amount), less blood stained.

- Improved crackles and wheezes on auscultation in lower lobes

- Improved breath sounds

- Increased PaO2

- Decreased SOBOE – able to mobilise greater distance prior to becoming SOB (increased exercise tolerance) D. How would you change your treatment plan (from question B) in response to these improvements?

- Increase duration of treatment

- Introduce independent airway clearance (eg PEP) to Rx, and monitor during Rx sessions. May need to check resistance

levels (as pressure may change with changes in patient’s condition)

- Progress mobility include stairs

- Develop home program for airway clearance – check patient is independent.

- Start resistance exercises for upper and lower limbs

E. What do you have to consider prior to discharge from hospital?

- Home situation – house, stairs

- Mobility aids required

- Any assistance for ADLs, meals etc eg domiciliary care

- Need for continuing respiratory care - ?follow up for chest care if continues to be productive but not independent with airway

clearance.

- Referral for pulmonary rehabilitation program or develop patient’s own walking program with 6MWD results. (may not be

able to access PR) 6. WEEK 3: SPECIALISED SURGICAL MANAGEMENT (SUGGESTED RESPONSES) 6.1 Case 1: Vascular surgery A. What are signs and symptoms of Peripheral Vascular Disease?

• Intermittent Claudication distance, eases with rest. • Resting Pain - ischaemia in peripheral nerves -severe may require morphine • Paraesthesia - altered sensation • Trophic skin changes - dec. hair & nail growth - hairless, smooth shiny nail bed • Brown patches - melanosis • Absent or decreased peripheral pulses - DP PT • Slow or absent capillary return • Decreased temperature - Cool • Ulcers - poor wound healing • Cyanosis Ruborous cyanosis on foot becoming dependent • Wasting • Gangrenous Changes

B. Clinical Reasoning sheet Part 1. After reading the Medical and Bedside Charts:


Severe PVD

Ischaemic heart disease

Heavy Smoker

Obese

Large incision

Will need to take precautions with lower limbs, skin care, handling

Will need to find out what exacerbates angina, what relieves it NB May occur

more easily following stress of surgery

Will affect cilial function, more risk of post-operative complications

More risk of post-operative complications

Lower FRC particularly in supine

Increased work of breathing at rest

Will impact on pain diaphragm function and respiratory mechanics




Subjective

You will have more information re what exacerbates angina

Objective

Decreased breath sounds ++

ABG’s Hypoxaemia

Stress of surgery, demand ventilation or increased activity may

exacerbate angina

Atelectasis – due to ↓ FRC (obesity, position) pain (lack of sighs → decreased surfactant release), absorption atelectasis

from ↑ inspired oxygen, anaesthetic gases

Atelectasis causing ↓ V/Q mismatch 3. What is the prioritised problem list for this patient?

Atelectasis causing hypoxaemia

Potential for Angina




What exacerbates angina?

Patient is at risk of respiratory failure i.e. obese, atelectasis,

major surgery

Position:

Sitting < 60o upright

Sitting > 60o upright will compress graft

Partial upright sitting will ↑ FRC Ventilation:

SBE, IH,

Incentive spirometer

? Arm exercises to increase demand

Needs slow laminar flow and collateral ventilation hold to re-

expand atelectasis. This breathing patter will also help

surfactant release

As they are an “at risk “ patient I would provide an incentive

spirometer

Arm exercises may increase ventilation, however check what

exacerbates angina and how unstable it was prior to surgery


There is no indication of secretion retention at present

Secretion removal:

Supported cough

Support is needed due to pain

Cough is needed to make sure chest is clear


Leg exercises

Walk> 24 hours

Circulation exercises are needed, however be careful with limb

handling, check pulses

Wait 24 hours before 1st walk to make sure graft is stable

Walk will assist circulation and demand ventilation


Major problem is atelectasis. Treatment needs to be frequent and altered if not effective


Exacerbation of angina may be a factor. Position following vascular surgery is also important


Monitoring of angina is important

Care of skin on legs is important


Auscultation, palpation, SpO2, CXR, ABG’s, walking distance Part 3. After treatment:


3 hours later – needs frequent treatment


Reassess, increase level of management (eg CPAP) if worse AE or has not improved


C. On Day 2 you approach the patient and she complains of severe pain in her right leg. On examination it is pale and cold. What could this indicate? What would be your actions?

These are signs of Acute Ischaemia - The “6” P’s

• Pallor,

• Polar

• Pulseless

• Paralysis

• Paraesthesia

• Pain

Action

• Nursing Staff and Medical Staff notified immediately as the ischaemia needs to be reversed to preserve the limb. • Document findings in patient’s medical record

D. What are some precautions taken when treating patients post vascular surgery and with PVD? � Modifications to physiotherapy treatment for Vascular Procedures:

Vary with Surgeon’s preference – check hospital protocol May include

• Avoid hip F > 60o due to position of grafts for first 24 hours

• Log roll to auscultate posterior chest

• If femoral Popliteal bypass, don’t stretch under knee eg Homans test

• Sitting no higher than 60o

• Lower bedhead to do active hip flexion to 60o.

• Care with handling of vascular leg.

• Assisted leg exercises.

• Avoid tipping a patient with recently grafted aorta.

• Podiatrist and well fitting shoes

• No garters and no tight socks

• Dry skin, particularly between toes

• Seek medical advice early with cut/abrasions

• PAC – regular checks and care with sensory loss • Care during treatment with regard to foot exercises, scraping of heel.

• Correct footwear when walking.

• Mobilise with reference to claudication distance.

• Make sure a patient with PVD has sheepskin or bootees during their stay in hospital.

• Electrotherapy precautions.

• Infection control. 6.2 Case 2: Cardiac surgery A. Complete the clinical reasoning sheet for your management of this patient on Day 1.

1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx? (Are there any

special questions to include in C/O or specific points to check in the O/E?)


Heavy smoker before quitting

Low ejection fraction

IMAG during surgery

Will have caused lung damage

Check if he is has a productive cough

This is a risk factor for cardiac surgery and often results in

increased risk of pulmonary problems

Increases risk, more pain, extra drain, lower lung volumes

Check pain scores

Part 2. After completion of subjective/objective assessment:




Decreased gas exchange (SpO2 93%) on 2l/min

Drowsy

Blood pressure low requiring Dopamine

Pain score 4/10 on movement

Decreased BE and AE in (L) LL

This may be due to atelectasis, increased fluid (possible due to low

ejection fraction), causing decreased V/Q ratio and decreased ability of

gas to transfer across alveoli

Able to be roused, but still drowsy. May be due to effect of anaesthetic still

in system, or pain relief drugs. Check respiratory rate and pupils as well to

ensure not overdose of pain relief. Check patient has not had CVA

Check peripheral perfusion and pulses, if cold and pulses low, can

indicate decreased CO. Delay mobilization

Check sitting balance before mobilizing

Arterial system vasodilated. Needs to be weaned off Dopamine before

Mobilization

Pain score on movement is slightly high, but as drowsy and BP low, would

be unwilling to increase pain relief

This is a normal finding in a patient who has had bypass. Abnormal

findings would be changes in the ® side or fine crackles form increased

fluid

However the fact that his SpO2 is low, he is drowsy and he has reduced

ejection fraction demonstrates he at risk of further chest infection


1. Decreased gas exchange

2. Drowsiness, decreased ability to co-operate

3. Decreased blood pressure




Decreased gas exchange

Blood pressure low, still on cardiac support drugs

Drowsy

Position:

Upright sitting – use bed rope

Will increase FRC, improve ventilation and arousal

Ventilation:

SBE, IH, Incentive spirometer

Use CPAP if no improvement

This will increase laminar flow, assist collateral ventilation and stability of

alveoli

CPAP will increase FRC


No formal techniques required yet, use ACBT

No evidence of retained secretions. Need to increase airflow and

expansion of alveoli at present

Secretion removal:

Supported cough

Need to support sternum, and check no secretions


Walk would assist lungs, however BP still low and

drowsy.

As still dependent on Dopamine need to delay walk. Could result in

decreased cardiac output at present.


This patient needs intensive treatment to reverse atelectasis and potential chest infection, however they are not suitable

for mobilization yet


Low blood pressure and dependency on Dopamine is important. Drowsiness also indicates they are unsafe to mobilize


Don’t walk at present


Auscultation, SpO2, CXR, arterial blood gases, alertness


Part 3. After treatment:


2 hours after previous treatment, as requires frequent treatment


If not requiring Dopamine could mobilize. Continue chest treatment if not improved after this treatment consider CPAP

B. Discuss your pre-operative management of a patient undergoing cardiac surgery. What information is it necessary

to give?

• Check chart / patient history / investigations

• Assessment - chest - treatment should be instituted if indicated by findings, including exercise tolerance, circulation,

home situation

• ROM of neck and shoulder and thoracic mobility

• Observation of posture

• Discussion re post-op course i.e. ICU post op, overnight ventilation, extubation and the commencement of

physiotherapy

• Explain mobility programme, management of musculoskeletal pain and progression of exercises as a home

programme C. Outline the pathophysiological effects of the surgery on the respiratory system.

• CPB - capillary leakage similar to ARDS, destruction of red blood cells

• Destruction of surfactant due to 100% O2

• Inadequate humidity, bypass or hypothermia

• Phrenic nerve paralysis from cardioplegia

• Pain from wound and drain sites

• Harvesting of IMA

• Retraction and deflation of lung during surgery

• Major ↓ in lung volumes eg FRC, VC and TLC • Parenchymal damage ↓ lung and chest wall compliance • Chest Wall instability due to wired sternum

• Work of breathing ↑

D. What are the pulmonary complications that can occur after cardiac surgery?

Pulmonary Complications occur in 40-60 % of patients

• Atelectasis - particularly of the (L) Lower Lobe

• Lower respiratory infection

• Pulmonary oedema

• ARDS E. Describe the patient’s presentation when you see him post extubation.

• Usually nursed in supine / ¼ turn from supine / high sitting

• Position for Rx usually high sitting

• Incisions - median sternotomy

� Uni / bilateral LL wounds with compression bandages (if utilised)

� Wrist incisions if RAG

� Usually no TED stockings (depending on the Surgeon’s protocol)

Equipment

• Peripheral line + Arterial line, CVP line, ECG leads, O2 mask or nasal prongs, pulse oximeter, IDC,

temporary pacing wires

• x3 wound drains - retrosternal (pleural), mediastinal and pericardial with UWSD + / - low pressure

suction

• Assistive devices such as an intra-aortic balloon pump (IABP) may be used to augment cardiac function

in more unstable patients.

• Bed rope to assist independent mobility F. Discuss the medications that the patient is requiring post operatively. What effect will this have on your

management?

• Tridil - GTN - Coronary Artery Vasodilators • Dopamine - providing inotropic support.


• Other inotopes / vasopressors - digoxin, dobutamine, adrenaline. (Dopamine can be used for renal support in low doses)

• Keflex - prophylactic antibiotics • Omnopon - for sedation and pain relief whilst ventilated • Morphine for pain relief once extubated. (IM, NSAIDS are used also) • Peripheral vasodilators e.g. hydrallazine, ß blockers – decrease blood pressure and work of heart

• Diuretics - lasix

• Anti-arrhythmics

• Anti platelet aggregation - aspirin

If patient is still on cardiac support drugs eg dopamine, he may not be suitable to mobilise

G. What factors would you consider prior to mobilising this patient?

• Pain control needs to be looked at closely as movement results in a score of 4/10

• Patient still requiring Dopamine

• Familiar with the particular surgeon’s protocol

• Check the cardiac rhythm to ensure stability before the stress of mobilisation

• Care disconnecting the suction from the drainage bottles

• Assess the need for O2 - generally utilised Day 1 H. Discuss progression of this patient and the discharge advice that would be given

At all times a problem solving approach based on assessment findings must be utilised.

• Positioned in high supported sitting - patient able to position self independently using the bed rope as

demonstrated pre-op.

• Mobilise if cardiovascularly stable i.e. check if still requiring Dopamine, if arrhythmias

5-10% of patients in studies developed chest infections. Clinically patients who develop respiratory complications post

cardiac surgery apart from the expected (L) LL collapse, need intensive respiratory management

This may include

• Sputum clearance techniques

• Breathing exercises +/- BiPAP/ CPAP

Day 2 - 2nd / 3rd drains removed

Day 3 – 5 - Management of musculoskeletal pain and progression of exercise walking programme

NB. - Progressions will differ with individual patients depending on presentation and assessment findings

DISCHARGE ADVICE:

Home programme

� Thoracic mobility, neck and shoulder exercises

� Lifelong walking programme / aerobic training General Advice:

• Ergonomics, posture and back care

• Modification of risk factors - cease smoking, regular aerobic exercise

• If appropriate referral to Cardiac Rehab programme / exercise class

• OT - Lifestyle modification and planning ADL

• Dietician - diet modification

• Nursing Staff - wound care

7. WEEK 4: SPECIALISED CASES (SUGGESTED RESPONSES) 7.1 Case 1 Chest Trauma

A. Complete the clinical reasoning sheet for this patient

1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx? (Are there any




Aggressive nature, confused, heavy alcohol intake

Heavy smoker

Serious chest injury, large number of rib fractures and

pneumothorax

May undergo DT’s, confused because of hypoxia, may be very

difficult to manage during treatment

Cilial function decreased, maybe some chronic damage to lung

Potential for worsening of respiratory condition




Day 1

Pain ++

Decreased gas exchange++

Day 2

Actually in Type I respiratory failure

Increased agitation, BP, HR and RR all signify Type I

respiratory failure

PaO2 ↓ PaCO2 ↓

Then goes into Type II respiratory failure

PaO2 ↓ PaCO2 ↑

Abnormal mechanics of rib cage and pleura,

Possible secretion retention, decreased FRC see all pathological

mechanisms post chest trauma

Sympathetic system causing increases in vital signs in response to

hypoxia

A rise in PaCO2 signifies exhaustion


Pain

Hypoxaemia, Type I Respiratory failure

Confusion, aggression




Deterioration, confusion, agitation, pain

Position:

Upright sitting

Increase FRC

Ventilation:

CPAP, BiPAP, IPPB, SBE, IH

Improve pain relief

When PaCO2 increases needs intubation and ventilation

Increase FRC, increase collateral ventilation, maybe too

confused to do breathing exercises


CPAP

Increased air entry will mobilise secretions

Secretion removal:

Supported cough

Need to remove secretions, pain needs support


Day 1 – difficult to mobilize on this level of oxygen, could try

but use pulse oximeter

Too confused to mobilize Day 2


Patient at critical level, needs effective urgent treatment as going into respiratory failure


Lack of co-operation


Care with aggression

Patient could go into respiratory failure very quickly


SpO2, ABG’s, Level of confusion, auscultation Part 3. After treatment:



See every hour or give CPAP/BiPAP continuously with ABG’s after an hour


May need ventilation B. Discuss the aspects of the patient’s presentation that may impact on assessment and treatment.

• Smoking history

• Alcohol intake → potential for DT’s, Effect on pain perception

C. Objective Assessment

• Concern re appropriate use of PCA as pain rating remains high

• ↑ Inspired O2 but SpO2 remains low

• Need to encourage use of PCA throughout Rx session

• Auscultation - with the high pain rating is the patient able to take deep breaths sufficient for added sounds to be heard

D. ICC Precautions: In bed

• Note the swinging (S), bubbling (B) and draining (D) with tidal breathing, deeper breaths and cough

• Check the insertion site - ensure there is no ooze and the extent of the dressing

• Check the tube is not kinked by the taping or the bed

Moving - Whether clamps are to be with the patient depends on Consultant’s protocol

1. Keep the bottle below the level of insertion – ensure fluid does not flow back into the chest - potential for empyema

2. Keep the bottle level when mobilising – ensures tube remains underwater and accurate measures of drainage can be

gained

3. If the bottle breaks / disconnected kink the tubing, alternatively if the tube is dislodged apply pressure over insertion site

E. Discuss what is happening on Day 2

At 0800hrs the patient is demonstrating signs of TYPE I RESPIRATORY FAILURE.

Signs and symptoms of Type I Respiratory Failure:

• ↓ pO2 < 60 mmHg

• ↑ Vital signs - ↑ RR ↑ PR ↑ BP • Hypoxaemia

• Restless

• Confused and agitated

• Plucking at sheets

At 1000 hrs the patient has deteriorated despite an ↑ in inspired O2, and the SpO2 is less. This indicates that the patient is tiring.

ABG’s indicate Type II Respiratory Failure with an ↑ pCO2, as he is tiring.

Signs and symptoms of Type II Respiratory Failure

• Drowsiness

• Flushed face

• Peripheral vasodilation

• Bounding pulse

• Eventual coma

F. How might your Rx options vary on Day 1 or 2?

At the review at 0800 hrs consideration of the introduction of BiPAP.

Possible starting pressures - IPAP - 10 cm H2O pressure

- EPAP - 5 cm H2O pressure

At 1000hrs with Type II Respiratory Failure evident, medical reviews would be ongoing and ventilation would be under

consideration.


7.2 Case 2 Post intensive care

A. Complete the clinical reasoning sheet for your management of this patient on Day 1.

1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx. (Are there any



COPD

Has had long stay and extended ventilation in ICU

Been readmitted to ICU once

Tendency towards secretion retention

IHD

Anxious

Liable to experience respiratory muscle fatigue again

Will need active measures to prevent this

Even though usually only develops angina on extreme effort,

the stress of surgery, blood loss, exhaustion may cause angina

to occur more easily, therefore question patient during

treatment

This will further increase the risk of readmission to ICU




Tracheostomy

Muscle weakness

Gas exchange still low

HR, BP RR all increased

Due to long ventilation. Will need to ensure patient airway

Critical care weakness syndrome from extended ventilation,

drugs

Due to lung disease, lack of normal breathing pattern,

secretions

Due to anxiety and exhaustion

Could exacerbate angina


Tendency towards secretion retention and respiratory muscle fatigue

Exhaustion

Anxiety




Will become exhausted quickly

Position:

SOOB, Tilt table

Ventilation:

Could benefit from CPAP or BiPAP especially during

treatment

Will assist in prevention of respiratory muscle fatigue


Will require exercise, ACBT, percussion

Need to actively prevent secretion retention or will develop

respiratory muscle fatigue again

Secretion removal:

Huffing and suction of trachae

Ensure nursing staff are skilled in this care

Need to ensure trachae remains patent


Tilt table, sit to stand

Lower limb weakness, needs rehabilitation Could use BiPAP,

CPAP during this


The patient needs effective treatment to prevent secretion retention and respiratory failure, also active rehabilitation,

however do not exhaust patient during treatment


Treatment needs to be effective without exhausting patient



Recognition of respiratory muscle fatigue and/or deterioration

Correct management of trachae

Ask re angina


SpO2, observe respiratory muscles during treatment

Muscle strength and mobility

RR, Anxiety



2 x day needs frequent treatments


Continue the above, reassess, and aim to have patient standing by self without tilt table

B. What condition, common in long-term ICU patients, does this man appear to have developed?

This man has weakness in several limbs lower > upper. He appears to have critical illness weakness syndrome C. What could be some signs of deterioration in this man?

The man already has a high respiratory rate and a SpO2 of 95 on FiO2 of 0.28. He should be receiving CPAP or BiPAP to

help his work of breathing particularly with any rehabilitation eg tilt table. He should be reviewed regularly by intensive care staff,

still be having arterial blood gases checked and BiPAP applied more continuously if he deteriorates.


CARDIOTHORACIC CLINICAL REASONING SHEET Student Name: Date:

Tutor’s Initials: Patient’s Initials: Part 1. After reading the Medical and Bedside Charts:

1. What are the relevant findings from the medical chart and the implications for the

Physiotherapy Ax and Rx. (Are there any special questions to include in C/O or specific

points to check in the O/E?)



2. What are the key assessment findings? List the pathophysiological causes for these

findings.




4. What is your treatment plan for this patient today? Briefly outline the aim of each

technique selected.



Position:

Ventilation:


Secretion removal:


5. Why is the above treatment plan appropriate for this patient? How would you modify

the treatment if not appropriate?

6. Discuss any factors that may influence your treatment plan. Why are they important to

consider?

7. What are the safety considerations for your treatment of this patient (eg

contraindications). How could you manage these?





ILP Acute 2007

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Transcript of ILP Acute 2007