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
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 Check list for Further Preparation Required by Facilities for Day 1 ....................................... 5 Common Medications Guide ................................................................................................... 7 Start Up Test .......................................................................................................................... 10 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 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 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 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 Outline of Answers to Start Up Exam ................................................................................... 30 Outline of Answers to Self-Directed Learning Activities .................................................. 32
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9. 10.
Cardiothoracic Clinical Reasoning Sheet....................................................................................... 51
-Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2007
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 preclinical 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 decisionmaking 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 BSLs 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 patients 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
Narcotics
Product Name
Pethidine Fentanyl Morphine Omnopon Physeptone Endone MS Contin Panadol Solprin Marcain Lignocaine Xylocaine Naprosyn Feldene Brufen Voltaren Hydrocortisone Dexmethsone Depo-medrol Prednisone / Prednisolone Tagamet Zantac Pepcidine / Pepcid Maxalon Stemetil Zofran Losec Zoton Ventolin Bricanyl Serevent Oxis, Foradile Qvar Pulmicort Flixotide Atrovent Spiriva Combivent Seretide Mucomyst Pulmozyme
Generic Name
Analgesics
Simple Analgesics Local Analgesics
Methodone Oxycodone Morphine Paracetamol Asprin Bupivacaine Lignocaine Naproxen Piroxicam Ibuprofen Diclofenac Hydrocortisone Dexamethasone Methylprednisolone Cimetidine Ranitidine Famotidine Metoclopramide Prochlorperazine Ondansetron Omeprazole Iansoprazole Salbutamol Terbutaline Salmeterol Eformoterol Beclomethasone Budesonide Fluticasone Ipratropium Bromide Tiatropium Atrovent + salbutamol Flixotide + serevent Dornase alpha
Antiinflammatory GIT Respiratory
Non Steroidal AntiInflammatories
Steroids
H2 Receptor Antagonist
Anti-emetics
Proton pump inhibitors,
2 Agonists-Short-acting
Long acting Inhaled Corticosteroids
Anticholinergic Combination Medications Mycolytics
Groups
IDDM
Product Name
Actrapid Monotard Mixtard Diabenese Diabex Diaformin Lasix Demadex anginine Transiderm isordil isopten (arrhythmia) cardizem adalet capoten renitec inderal betaloc / lopressor tenormin avapro Amoxycilline Flucloxicillin Keflex Rocephin Vibramycin
Generic Name
Diabetes
Oral Hypoglycaemics NIDDM
Chloropropamide Metformin frusemide Torsemide
Diuretics
Nitrates
Cardiovascular
Calcium Channel Blockers
ACE Inhibitors
Blockers
AngiotensinII Receptor antagonist Penicillins
isosorbide dinitrate verapamil diltiazem nifedipine captopril enalapril propranolol metoprolol atenolol irbesarten Amoxil, Moxacin Cephalexin Ceftriaxone Doxycycline Gentamicin Tobramycin Metronidazole temazepam flunitrazepam nitrazepam
Antibiotics
Cephalosporins Tetracyclines Aminoglycosides Anti fungal
Anti-coagulant
Flagyl normison rohypnol mogadon diazepam Valium heparin warfarin clexane zocor / lipex vastin / lescol pravachol span K, slow K chlorvescent
Other
Sedative s
Hypercholestraemia
Potassium Chloride
streptokinase simvastatin fluvastatin sodium pravastatin
4.
NORMAL VALUES
Pa O2 Pa CO2 pH 85 - 100 mm Hg (11-13 kpa) 35 - 45 mm Hg (4.5 - 6.0 Kpa) 7.35 - 7.45 22 - 28 meq/l HCO3140 - 145 mlq/l 4.0 - 4.5 mlq/l 105 meq/l 20 - 40 mgm % (3.0-7.5) .06 - 0.12 24 - 27 mlq/l
Blood Gases
Serum Electrolytes
Na+ K+ ClUrea Creatinine HC03-
Blood Values Male Hb PCV RBC 14 - 16 gm / 100 ml 40 - 54 % 5 - 6 mill / c. mm. Female 12 - 15 gm / l00 ml 36 - 47 % 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 patients 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 ABGs 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 ABGs 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
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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.
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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 patients 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 patients medical chart, answer the following questions: A. What is the patients main reason for admission? B. What is the patients 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 patients 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?
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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 - RFTs 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?
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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?
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7.
WEEK 2 ACTIVITIES: MEDICAL MANAGEMENT
7.1. Treatment progression As the patients 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 patients 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 patients 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 ABGs on 2 L/min : pH 7.35, pCO2 45, pO 2 67, HCO3 27
Temp 375 Pulse 90 Resp: marked increase RR 30 Ausn Dx Rx scattered exp wheeze, fine basal crackles, soft breath sounds Acute exacerbation of chronic lung disease Oral antibiotics, nebulised Ventolin/Atrovent 2/24, IV hydrocortisone, O2 2 L/min intranasal, AFB x 3, Cytology x 3, M&C x 1
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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 Ls 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 Ls 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
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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 Os 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?
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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 patients social history should you consider when planning for discharge? B. What factors regarding the patients 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 Fatigued looking, agitated SOBAR ++ - unable to speak in short sentences Laboured breathing Accessory muscle use ++ Not cyanosed BP - 170 / 90 PR - 130 b / min Hyperinflated, poor inspiratory effort Clear lung fields Quiet chest BS throughout both lung fields
O/E :
RR - 32 b / min
CXR :
Auscultation :
No added sounds
ABGs : On R/A pH - 7.47
PaCO2 - 28
PaO2 - 60
HCO3 - 24
A. Discuss the significance of Mrs Ks 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.
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Three hours later in the Ward on 30% O2 ABGs : pH - 7.33 PaCO2 - 58
PaO2 - 65
HCO3 - 24
E. Discuss the ABGs 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 Amoxil O/E :
Atrovent tds Anginine prn
Pulmicort bd
Barrel shaped chest Cyanosis Clubbing SOBOE Productive cough - production of mucopurulent, slightly blood-stained secretions BS throughout both lung fields Scattered crackles and wheezes throughout lung fields LL > UL No local lesions Fibrosis and peribronchial thickening in the lower lobes
Auscultation :
CXR :
ABGs : On Room Air pH - 7.41 PaCO2 - 37
PaO2 - 68
HCO3 - 25
A. Discuss the significance of this patients past medical history. Consider the medications. B. Complete the clinical reasoning sheet for this patient. (see Appendix 1) C. What are changes in the patients 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?
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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?
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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 PMHx: 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 ABGs: On MVM FiO2 0.35 PaCO2 - 38 PaO2 - 67 HCO3 - 25
PH - 7.46
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?
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8.2. Case 2: CABG A 68-year-old male admitted to the Cardiac Surgery Ward for CABG tomorrow PMHx: HT - 30 years IHD - AMI 1990 with ongoing angina Ex-smoker ceased 2 years ago previously 20 per day for 35 years Echocardiography Angiography LVEF LAD RCA Circumflex 40% 90% blocked 70% blocked 75% blocked
Investigations :
OT Notes : Time in OR 1325 - 1550 hrs 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 :
Time on bypass 60 minutes
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 HR 70 b/min paced BP 100/55mmHg
Orders:
93%
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 O/E
: :
Minimal pain 1/10 at rest and 4/10 with movement Pain in posterior mid thoracic spine Non distressed
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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 patients 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.
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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?.
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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 ICCs with UWSD. O/E : Pain 4 / 10 at rest and 6 / 10 with movement PCA pethidine RR 26 b / min BP 150 / 80 HR SpO2 90 % No added sounds 90 b / min
FIO2 0.35 % via mask
Ausc - BS throughout ( R ) lung field DAY 2 ABGs 0800 hrs Patient is tired, agitated and confused
pH 7.47 PaO2 58 PaCO2 32 HCO3 23
RMO orders an increase in the FIO2 to 0.40 % humidified 1000 hrs Repeat ABGs FIO2 0.40 % humidified SpO2 88 %
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 patients presentation that may impact on assessment and treatment. C. Outline your concerns in relation to the objective assessment. D. List the precautions relating to ICCs. E. Discuss what is happening on Day 2. F. How might your Rx options vary on Day 1 or 2?
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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 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 Blood pressure 150/86mmHg, HR 90beats/min, RR 25b/min, SpO2 94 pH 7.37 PaCO2 45 PaO2 79 HCO3 28
O/E:
Vital signs: ABGs:
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
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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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Age 48 55 82 78 73 32 45 81 90 96 18 81 22 81 44 40 60 28 56 71 56 81 76 60 54 60 60 70 64 Name Mr News Mr Ord Mrs Bond Mr Que Mr Issacs Mr Crenny Mr Board Mr Louder Mrs Long Mrs Sanders Mr. Roberts Mr Nelson Mr Brady Mr Owens Mr Boswell Mrs Roberts Mrs Hoge Mr Phillips Mr Rowan Mr Frier Mr Emeon Mr Crowe Mr Jones Mrs Lang Mrs Ivan Mrs Jacobs Mrs Kleene Mrs Gow Mr Muir Condition (R) IHR 3/7 (L) IHR 3/7 Ant. Resection 3/7 Abdominal Pain Abdominal Pain Wiring Mandible 6/7 Pancreatitis Bowel Obstruction (R) Mastectomy 2/7 Inoperable Ca Stomach (L) IHR 1/7 ago. R/O Wire Mandible Spontaneous PNTx (L) ICC Vagotomy and Pyloroplasty 1/7 (R) IHR 1/7 Stripping Varicose Veins 2/7 Pre-op. Lap. diverticular abcess Head Injury FI Metatastic Melanoma (L) neck Abdominal pain FI Haemorrhoidectomy 1/7 Laparotomy with colostomy 1/7 Diverticular Abscess FI Large Bowel Obstruction Biliary Colic Exploration cholecystectomy wound pre-op Closure of Colostomy 3/7 High Ant. Resection 2/7 BK amputee 7/7 Co-morbidities/other problems PMHx : Nil PMHx : Nil Mobility problems Diabetic, PVD PMHx : Nil PMHx : Nil ETOH++, Smoker Old laryngectomy Lives by self From nursing home Cystic Fibrosis Mild COPD Previous Pnx Rheumatoid arthritis PMHx : Nil PMHx: Bronchiectatic Chronic GI disease, smoker PMHx : Nil Previous melanoma Weight loss 4kg PMHx : Nil Mild HT IHD, Diabetes PMHx : Nil PMHx : Nil Obese Previous Ca Bowel PMHx: Mild HT Mild COPD
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MEDICAL WARD Bed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Age Name 69 62 87 19 66 73 74 27 91 60 68 70 54 61 41 34 81 86 85 60 55 64 35 65 38 67 85 55 66 73 Mrs Abbott Mrs Blow Mr Crawford Mr Dawson Mr Enright Mrs Faulkner Mrs Gibson Mr Hill Mr Ibsen Mrs Jones Mrs Ernest Mr Lawson Mr Mullin Mr Nolan Mr Osbourne Mr Powell Mr Quinn Mr Crowley Mr Swann Mrs Turner Mrs Ung Mr Vanps Mr West Mrs Youn Mrs Anderson Mr Bowden Mr Rogers Mrs Douglas Mrs Kirkland Mrs Freer Condition Social Admission Rapid AF Melaena for Ix Acute Asthma Unconscious, (R) CVA Chest Pain Rapid AF AMI CCF uncontrolled PE COPD Gout AMI Inferior Infarct Acute bronchitis CAP - Respiratory failure Hypoglycaemic episode CCF controlled (R) LL Pneumonia, UTI Chest pain FI Rheumatoid arthritis Acute Asthma Inflammatory Bowel Disease Joint Inflammation FI (L) TIA (L) DVT Peripheral Neuropathy FI Vertigo and UTI CAP - (R) ML Temporal arteritis (R) CVA Co-morbidities/other problems Acopia IHD Diverticulitis, Mild HT PMHx: Chronic asthma ? Aspiration pneumonia COPD PMHx: Nil Day 4, from CCU IHD, PVD PMHx: Nil Acute exacerbation Chronic renal failure Day 5, from CCU ETOH, Cirrhosis of liver BiPAP Type I Diabetes IHD Confused Immobile in nursing home Acute exacerbation Smoker Previous IBD PMHx: Nil Controlled HT Smoker, OCP PMHx: Nil Frequent falls PMHx: Nil Chronic headaches HT
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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?
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10.
OUTLINE OF ANSWERS TO START UP EXAM
Question 1: INFORMATION History of the presenting complaint Cough or or normal SOB or normal Sputum Change in colour quantity or quality Exercise Tolerance Medications IMPORTANCE Indication of the severity of the infection Indication of the course of the disease Process Current status compared to usual baseline and an indication of the aim for discharge regarding mobility 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 Specific lung segments involved Lung changes as a result of the disease process Indication of the patients current level of function 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. The organism that has caused the infection and the need for any additional precautions Indication of patients LOS
Chest X Ray + / - Report ABG result Respiratory or Lung Function tests
Sputum Culture Plan of Medical Management
Question 2: a. Interpretation of ABGs 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.
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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 patients 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
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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 patients past medical history. Below are some common conditions and their physiotherapy implications and safety issues to consider. Condition Physiotherapy implications Safety issues IHD Be mindful of exercise tolerance, limit mobility Questions in subjective re: Angina - establish history Care when mobilising, may need to take nitrates stable / unstable. Time of last episode, location of pain, Monitor chest pain quality, duration, intensity, precipitating factors. Expectation re exercise tolerance. Technique selection Medications - indication of severity HT Need to know the baseline BP. HT => inc. risk CVA, MI Short inspiratory holds Influence technique selection - HDT cautious (not if If unstable, limit HDT unstable) relax the patient, short inspiratory holds not contraindicated check BP Think of factors that inc. BP - pain, isometric exercise. PND Paroxysmal nocturnal dyspnoea - breathlessness that Avoid supine position wakes the patient at night Monitor carefully during exercise Causes - Cardiac suggests (L) VF - inc. venous return from LL ==> pooling of blood in lungs ==> breathlessness - Resp - severe asthma - nocturnal bspasm Implications - no HDT, dec. ex. tolerance, care with demand, avoid supine position CCF Establish from the chart if symptoms reflect more (R) HF If cardiac involvement care with demand or (L) VF. Establish cardiac or respiratory involvement If respiratory involvement aim to increase demand and gain control of SOB COPD Questions in subjective cough, sputum (include normal Monitor SpO2 levels), SOB, smoking history Consider SOB when mobilising Check for spirometry results in chart, current management May have hypoxic drive if severe Diabetes Questions in subjective foot care, shoes, sensation in Mobilise with correct footwear feet Care with mobilisation, avoid injury to foot Check circulation, skin for broken areas 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 Larger incision likely to have more pain, respiratory inhibition. becomes open May require assistance to mobilise Day 1 Monitor Hb and BP prior to mobilisation. Large blood loss low Hb post-op 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 Depending on tissue involved will influence mobility, sensation. sacrificed May modify mobility, exercises.
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GA complications - epidural at wrong level, (R) main bronchus intubation, epidural / spinal CSF leak Aspiration
Incorrect level of epidural can lead to increased pain (R) main bronchus intubation may have collapse of (L) lobes 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. Encourage your patient to provide themselves with some pain relief at the beginning of your Usually narcotic used. assessment and regularly throughout the Rx to ensure the relief is maximised prior to mobilization. Monitor the patients 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 patients responsiveness, if they are very drowsy and unable to participate in your physiotherapy treatment, notify the nursing and medical staff as the patients 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 Ask in subjective questioning about pins and needles, numbness, weakness or heaviness be patient controlled epidural THIS IS AN ISSUE OF SAFETY - THESE QUESTIONS MUST BE ASKED analgesia. 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 patients respiratory condition Investigations such as bloods. E.g. If low Hb, look at trend. With decreased Hb, activity requiring effort may post op Hb levels, platelets 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 dont percuss patient, if platelets < 40 dont 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 Oxygen Mask provides Check the correct concentration is being delivered supplemental oxygen to to the patient. patient. Keep O2 on during Rx Mobilise post-op pts with O2 (if appropriate)
Working properly? Check connected to oxygen port and turned to correct flow rate.
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Wound drain remove fluid from wound site following operation. Consider the 3 types of wounds. Which do you see most often? Nasogastric tube drain bile or gastric contents from stomach
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) IV drip - Peripheral venous line inserted for post-op administration of maintenance / replacement fluids and medications.
Replace O2 mask or nasal prongs if removed to mobilise pt. 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. 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. Ensure bag is not too full prior to mobilising Dont pull catheter out when mobilising Keep bag below level of the catheter
Check level ensure not too full as it may rupture. Check wound, ensure wound drain still attached. Check below level of nose. Can be on free drainage, regular aspiration or suction.
Check level ensure not too full, if so ask nursing staff to empty prior to mobilising.
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.
Epidural catheter inserted into epidural space used for post op analgesia
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). 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 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 the IV is not alarming if so call Nursing staff, dont adjust IVAC. Check if patient reports pain at IV site inform nursing staff as thrombophlebitis may occur.
Assess whether swinging with patient breaths; draining fluid or bubbling.
Check epidural is not alarming. Check sensation and muscle function in your assessment.
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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 IHs 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 - physiotherapists 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 Reduced respiratory compromise, may have increased secretion production. Need to ask re cough, sputum, and exercise tolerance in pre-op Ax. Heavy Smoker 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.
HTN (R) hemicolectomy, no complications in theatre or during recovery
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 Inadequate pain relief. Impaired cough Itchy, nausea and vomiting Adverse effects of analgesia.
Epidural analgesia
Increased RR, increased accessory muscle use. Due to increased pain, anxiety. Decreased BS in bases, no added sounds. Atelectasis due to pain as above Limited lateral costal expansion Risk of secretion retention due to poor cough Ineffective 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 optimise pain relief prior to PT Rx Need to check sensation and muscle strength prior to Ensure epidural isnt affecting sensation/muscle power.
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mobilising Position: High sitting Ventilation: SBE or DBex
Increase FRC Needs slow laminar flow and collateral ventilation hold to reexpand atelectasis. This breathing pattern will also help surfactant release If poor understanding of SBE or Dbex. Need for feedback.
Incentive spirometer 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 Support is needed due to pain Cough is needed to make sure chest is clear Circulation exercises are needed to prevent DVTs
Secretion removal: Supported cough abdominal support with pillow/towel Mobility/Ambulation: Leg exercises Ambulation with rollator, 2 assist, O2 as required.
2 people needed as patient has epidural analgesia Ambulate if patients 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, ABGs, 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 patients condition pre-operatively a long-term re-conditioning programme would be appropriate.
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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 Ls condition, how could you progress his Rx? Sign/Symptom Improvement Impact on Rx/ Progression Sputum Decreased amount, no longer yellow Increase duration of Rx, decrease frequency of treatment or blood stained Continue secretion mobilisation and removal techniques e.g. if using PEP may need to reassess resistance. Cough Decreased amount of coughing May decrease use of assisted coughing techniques May progress positioning from high supported positions Breathlessness Decreased to nil SOBAR to more supine positions, modified gravity assisted positioning. Exercise tolerance Increased distance mobilised Progress ambulation decrease O2 required (monitor Mobility Independently mobile, not requiring 1 with SpO2), decrease assistance, increase distance. Progress to stairs person assist Encourage independent mobilisation Auscultation Decreased wheeze, decreased fine Progress secretion mobilisation and removal to crackles independent treatment sessions monitor performance. ABGs Reduced respiratory acidosis CXR Vital signs Resolution of changes in bases Decreased RR
Now, consider what would indicate deterioration in Mr Ls 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. Shorter more frequent treatment sessions to reduce green), increased thickness (e.g. fatigue. plugs), more blood stained Positioning in high sitting, high side lying May use humidification to help loosen secretions Cough Increased amount, weaker May use positive pressure devices e.g. IPPB to reduce work of breathing increase ventilation Breathlessness Increased SOB now SOBAR More passive techniques to mobilise secretions e.g. percussion instead of flutter, if patient fatiguing Exercise tolerance Unable to mobilise 15m, confined to Assisted cough to remove secretions if cough impaired bed area only. may need to use suction. Mobility Mobilising with rollator, 2 assist Auscultation ABGs CXR Vital signs Increased wheezes, crackles. Increased acidosis, increased hypoxaemia Greater changes in lung bases, more changes throughout lungs Increased temp, HR, RR. 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 Increase duration of Rx, decrease frequency of treatment or blood stained Continue breathing exercises may increase number of repetitions. Cough Strong, effective, non productive Continue supported coughing minimal pain May progress positioning sit out of bed Nausea Nil in bed, and with mobilisation Progress ambulation decrease O2 required (monitor with SpO2), decrease assistance, increase distance. Dizziness Nil during transfers, mobilisation Progress to stairs
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Mobility Auscultation Palpation
Independently mobile, no dizziness, nausea Improved BS in (R) base, nil added sounds 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 patients 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 patients mobility should you consider when planning for discharge? Walking aid May not be able to use in patients 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 patients 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
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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 Ks 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 ABGs reflect hyperventilation i.e. blowing off their CO2 and severe hypoxaemia Uncompensated respiratory alkalosis with a severe hypoxaemia
D. C/O: O/E:
Consider how your assessment of Mrs K might be modified. Limited or impossible due to fatigue and SOB Observation - no assessment of response to verbal instruction Palpation - assess response to tactile input Auscultation - limited due to patients shallow breathing pattern, stretch facilitation to encourage deeper breaths Ensure O2 is kept on at all times. E. Discuss the ABGs that were taken three (3) hours later. pH alkalosis alkalosis PaCO2 HCO3 normal Hypoxemia even with supplemental oxygen PaO2 Uncompensated respiratory acidosis with moderate to severe hypoxaemia What condition is now evident? TYPE II RESPIRATORY FAILURE PaCO2 > Fatigued with shallow breathing CO2
F.
50 mmHg
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 patients 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: Main Findings Implications for PT Ax and Rx Ischaemic heart disease Will need to find out what exacerbates angina, what relieves it Bronchectasis 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 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes
39
Barrel shaped chest Productive cough mucopurulent, sl blood stained Scattered crackles/wheezes CXR fibrosis and peribronchial thickening in lower lobes ABGs - Hypoxaemia 3. What is the prioritised problem list for this patient? Retained secretions Increased work of breathing Decreased exercise tolerance
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
4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations: What exacerbates angina? Amount of blood in sputum Streaks of blood through purulent sputum are common => Rx would not cease but results recorded in the patients file. Frank haemoptysis is a sign of erosion of pulmonary vessel needs to be monitored. Dont treat with percussion and vibrations for 5 10 days to allow healing. Timing of Rx with bronchodilator (Ventolin) Treat 20-30mins post, when maximal bronchodilation occurs Could use humidifier prior to Rx 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. Secretion mobilisation: PEP mouthpiece/Flutter Use of collateral ventilation, mobilise secretions, keeps airways open ACBT with percussion and vibration Use of FET to mobilise secretions and remove. Secretion removal: Assisted cough - AP Mobility/Ambulation: Leg exercises Ambulate around ward with if required O2 (check SpO2)
May need supported cough if weak. No bibasal expansion present
Circulation exercises are needed to prevent circulatory complications Will assist circulation and ventilation. Can also assist with secretion mobilisation.
5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate? Main problem is secretion retention due to bronchiectasis affecting the lower lobes. 6. Discuss any factors that may influence your treatment plan. Why are they important to consider? 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 8. What outcome measures will you use to determine the effect of your treatment? Auscultation, palpation, sputum (amount, colour, consistency) SpO2, ABGs, walking distance Part 3. After treatment: 9. When would you like to see this patient again? Why?
40
4 hours later needs frequent treatment for his productive chest. 10. What is your plan for the next treatment? Reassess, change secretion mobilisation technique if not effective, promote exercise/mobility C. What are changes in the patients 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 patients 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 patients 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: Main Findings Implications for PT Ax and Rx Severe PVD 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 Heavy Smoker Will affect cilial function, more risk of post-operative complications More risk of post-operative complications Obese Lower FRC particularly in supine Increased work of breathing at rest Large incision Will impact on pain diaphragm function and respiratory mechanics 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes
Ischaemic heart disease
41
Subjective You will have more information re what exacerbates angina Objective Decreased breath sounds ++
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
ABGs Hypoxaemia 3. What is the prioritised problem list for this patient? Atelectasis causing hypoxaemia Potential for Angina
4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations: What exacerbates angina? Patient is at risk of respiratory failure i.e. obese, atelectasis, major surgery Position: Sitting > 60o upright will compress graft Sitting < 60o upright Partial upright sitting will FRC Ventilation: SBE, IH, Needs slow laminar flow and collateral ventilation hold to reexpand atelectasis. This breathing patter will also help surfactant release Incentive spirometer As they are an at risk patient I would provide an incentive spirometer ? Arm exercises to increase demand Arm exercises may increase ventilation, however check what exacerbates angina and how unstable it was prior to surgery Secretion mobilisation: There is no indication of secretion retention at present Secretion removal: Supported cough Mobility/Ambulation: Leg exercises
Support is needed due to pain Cough is needed to make sure chest is clear
Circulation exercises are needed, however be careful with limb handling, check pulses Walk> 24 hours Wait 24 hours before 1st walk to make sure graft is stable Walk will assist circulation and demand ventilation 5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate? Major problem is atelectasis. Treatment needs to be frequent and altered if not effective 6. Discuss any factors that may influence your treatment plan. Why are they important to consider? Exacerbation of angina may be a factor. Position following vascular surgery is also important 7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these? Monitoring of angina is important Care of skin on legs is important 8. What outcome measures will you use to determine the effect of your treatment? Auscultation, palpation, SpO2, CXR, ABGs, walking distance Part 3. After treatment: 9. When would you like to see this patient again? Why? 3 hours later needs frequent treatment 10. What is your plan for the next treatment? Reassess, increase level of management (eg CPAP) if worse AE or has not improved
42
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 Ps 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 patients 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 Surgeons 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, dont 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?) Main Findings Implications for PT Ax and Rx Heavy smoker before quitting Will have caused lung damage Check if he is has a productive cough Low ejection fraction 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
IMAG during surgery
Part 2. After completion of subjective/objective assessment: 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes
43
Decreased gas exchange (SpO2 93%) on 2l/min
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
Drowsy
Blood pressure low requiring Dopamine
Pain score 4/10 on movement
Decreased BE and AE in (L) LL
3. What is the prioritised problem list for this patient? 1. Decreased gas exchange 2. Drowsiness, decreased ability to co-operate 3. Decreased blood pressure 4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations: 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 This will increase laminar flow, assist collateral ventilation and stability of alveoli Use CPAP if no improvement CPAP will increase FRC Secretion mobilisation: 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 Mobility/Ambulation: Walk would assist lungs, however BP still low and As still dependent on Dopamine need to delay walk. Could result in drowsy. decreased cardiac output at present. 5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate? This patient needs intensive treatment to reverse atelectasis and potential chest infection, however they are not suitable for mobilization yet 6. Discuss any factors that may influence your treatment plan. Why are they important to consider? Low blood pressure and dependency on Dopamine is important. Drowsiness also indicates they are unsafe to mobilize 7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these? Dont walk at present 8. What outcome measures will you use to determine the effect of your treatment? Auscultation, SpO2, CXR, arterial blood gases, alertness
44
Part 3. After treatment: 9. When would you like to see this patient again? Why? 2 hours after previous treatment, as requires frequent treatment 10. What is your plan for the next 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 patients presentation when you see him post extubation. Usually nursed in supine / 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 Surgeons 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 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.
F.
45
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, 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 surgeons 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 special questions to include in C/O or specific points to check in the O/E?) Main Findings Implications for PT Ax and Rx
46
Aggressive nature, confused, heavy alcohol intake
May undergo DTs, confused because of hypoxia, may be very difficult to manage during treatment Cilial function decreased, maybe some chronic damage to lung
Heavy smoker
Serious chest injury, large number of rib fractures and Potential for worsening of respiratory condition pneumothorax Part 2. After completion of subjective/objective assessment: 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes Day 1 Pain ++ Decreased gas exchange++ 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
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
A rise in PaCO2 signifies exhaustion
3. What is the prioritised problem list for this patient? Pain Hypoxaemia, Type I Respiratory failure Confusion, aggression 4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations: Deterioration, confusion, agitation, pain Position: Upright sitting Increase FRC Ventilation: CPAP, BiPAP, IPPB, SBE, IH Increase FRC, increase collateral ventilation, maybe too Improve pain relief confused to do breathing exercises When PaCO2 increases needs intubation and ventilation Secretion mobilisation: CPAP Increased air entry will mobilise secretions Secretion removal: Supported cough Need to remove secretions, pain needs support Mobility/Ambulation: Day 1 difficult to mobilize on this level of oxygen, could try but use pulse oximeter Too confused to mobilize Day 2 5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate? Patient at critical level, needs effective urgent treatment as going into respiratory failure 6. Discuss any factors that may influence your treatment plan. Why are they important to consider? Lack of co-operation 7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these? Care with aggression Patient could go into respiratory failure very quickly 8. What outcome measures will you use to determine the effect of your treatment? SpO2, ABGs, Level of confusion, auscultation Part 3. After treatment:
47
9. When would you like to see this patient again? Why? See every hour or give CPAP/BiPAP continuously with ABGs after an hour 10. What is your plan for the next treatment? May need ventilation B. Discuss the aspects of the patients presentation that may impact on assessment and treatment. Smoking history Alcohol intake potential for DTs, 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 Consultants 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. ABGs 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.
48
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 special questions to include in C/O or specific points to check in the O/E?) Main Findings Implications for PT Ax and Rx COPD Has had long stay and extended ventilation in ICU Liable to experience respiratory muscle fatigue again Been readmitted to ICU once Tendency towards secretion retention IHD 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
Anxious This will further increase the risk of readmission to ICU Part 2. After completion of subjective/objective assessment: 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes Tracheostomy Due to long ventilation. Will need to ensure patient airway Muscle weakness 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
Gas exchange still low
HR, BP RR all increased
3. What is the prioritised problem list for this patient? Tendency towards secretion retention and respiratory muscle fatigue Exhaustion Anxiety 4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations: Will become exhausted quickly Position: SOOB, Tilt table Ventilation: Could benefit from CPAP or BiPAP especially during Will assist in prevention of respiratory muscle fatigue treatment Secretion mobilisation: 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 Need to ensure trachae remains patent Ensure nursing staff are skilled in this care Mobility/Ambulation: Tilt table, sit to stand Lower limb weakness, needs rehabilitation Could use BiPAP, CPAP during this 5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate? The patient needs effective treatment to prevent secretion retention and respiratory failure, also active rehabilitation, however do not exhaust patient during treatment 6. Discuss any factors that may influence your treatment plan. Why are they important to consider? Treatment needs to be effective without exhausting patient
49
7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these? Recognition of respiratory muscle fatigue and/or deterioration Correct management of trachae Ask re angina 8. What outcome measures will you use to determine the effect of your treatment? SpO2, observe respiratory muscles during treatment Muscle strength and mobility RR, Anxiety Part 3. After treatment: 9. When would you like to see this patient again? Why? 2 x day needs frequent treatments 10. What is your plan for the next treatment? 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.
50
CARDIOTHORACIC CLINICAL REASONING SHEET

Student Name: Tutors Initials: Date: Patients 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?) Main Findings Implications for PT Ax and Rx
Part 2. After completion of subjective/objective assessment: 2. What are the key assessment findings? List the pathophysiological causes for these findings. Main Findings Pathophysiological Causes
3. What is the prioritised problem list for this patient?
51
4. What is your treatment plan for this patient today? Briefly outline the aim of each technique selected. Treatment Plan Rationale Special considerations:
Position:
Ventilation:
Secretion mobilisation:
Secretion removal:
Mobility/Ambulation:
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?
8. What outcome measures will you use to determine the effect of your treatment?
Part 3. After treatment: 9. When would you like to see this patient again? Why?
10. What is your plan for the next treatment?
52

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ACUTE STREAM

Independent Learning Package

Modified by Dr Angela Chang in 2007

Cardiothoracic Clinical Reasoning Sheet....................................................................................... 51

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

ACUTE STREAM PROGRAM

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

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

CHECK LIST FOR FURTHER PREPARATION REQUIRED BY FACILITIES FOR DAY 1

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

COMMON MEDICATIONS GUIDE

Simple Analgesics Local Analgesics

Antiinflammatory GIT Respiratory

Non Steroidal AntiInflammatories

Anticholinergic Combination Medications Mycolytics

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

Oral Hypoglycaemics NIDDM

Chloropropamide Metformin frusemide Torsemide

Calcium Channel Blockers

Cephalosporins Tetracyclines Aminoglycosides Anti fungal

streptokinase simvastatin fluvastatin sodium pravastatin

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

Na+ K+ ClUrea Creatinine HC03-

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

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

WEEK 1 ACTIVITIES: SURGICAL MANAGEMENT

C. Are they mainly positive or negative?

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

WEEK 2 ACTIVITIES: MEDICAL MANAGEMENT

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

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

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

ABGs : On R/A pH - 7.47

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

Three hours later in the Ward on 30% O2 ABGs : pH - 7.33 PaCO2 - 58

Current Medications : Ventolin qid Amoxil O/E :

Atrovent tds Anginine prn

ABGs : On Room Air pH - 7.41 PaCO2 - 37

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

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

WEEK 3 ACTIVITIES: SPECIALISED SURGICAL MANAGEMENT

A. What are signs and symptoms of Peripheral Vascular Disease?

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

Time on bypass 60 minutes

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

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

D. How have you addressed the issues identified last week?

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

WEEK 4 ACTIVITIES: SPECIALISED CASES

FIO2 0.35 % via mask

pH 7.47 PaO2 58 PaCO2 32 HCO3 23

pH 7.33 PaO2 65 PaCO2 50 HCO3 24

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

Vital signs: ABGs:

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

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

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

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

OUTLINE OF ANSWERS TO START UP EXAM

Chest X Ray + / - Report ABG result Respiratory or Lung Function tests

Sputum Culture Plan of Medical Management

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

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

OUTLINE OF ANSWERS TO SELF-DIRECTED LEARNING ACTIVITIES