Acute Stream Cardiorespiratory: Independent Learning Package

ACUTE STREAM
CARDIORESPIRATORY
Independent Learning Package
© Division of Physiotherapy
The University of Queensland
2006
This manual has been compiled by

Dr Angela Chang and Dr Jenny Paratz
© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 2
TABLE OF CONTENTS
1. Acute Stream Program ........................................................................................................... 4

1.1. Welcome to the Acute Stream Clinical Unit.................................................................. 4
1.2. The Independent Learning Package, Computer Assisted Learning (CAL) packages and
Recommended Text ................................................................................................................... 4
1.3. Expectations upon commencing the unit ....................................................................... 4
1.4. Acute unit assessment .................................................................................................... 5
1.5. Acknowledgements........................................................................................................ 5
2. Check list for Further Preparation Required by Facilities for Day 1..................................... 6
3. Revision Test ......................................................................................................................... 8
4. Week 1 Activities: Surgical management............................................................................ 10

4.1. Interpretation of a medical chart .................................................................................. 10
4.2. Patient attachments and their physiotherapy implications........................................... 10
4.3. Surgical case study....................................................................................................... 11
4.4. Reflective activities...................................................................................................... 12
5. Week 2 Activities: Medical management ............................................................................ 13

5.1. Treatment progression ................................................................................................. 13
5.2. Discharge planning ...................................................................................................... 16
5.3. Medical cases - problem solving................................................................................. 16
6. Week 3 Activities: Specialised Surgical management......................................................... 19

6.1. Case 1: Vascular surgery ............................................................................................. 19
6.2. Case 2: CABG.............................................................................................................. 20
7. Week 4 Activities: Specialised cases................................................................................... 23

7.1. Case 1: Chest Trauma .................................................................................................. 23
7.2. Case 2: Post ICU .......................................................................................................... 24
7.3. Managing a Ward and Prioritizing patients ................................................................. 24
7.4. Reflection activity: Professional issues ....................................................................... 27
8. Outline of Answers to revision Exam .................................................................................. 28
9. Outline of Answers to Self-Directed Learning Activities.................................................... 30

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 6. 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
“Revision test” on page 8 prior to commencement of the unit. It is strongly advised that you
attempt this activity within the suggested time frame before referring to the answers. This test
has been designed to reflect a reasonable level of preparedness prior to commencing the Acute
Unit. If you are unable to answer the questions in the appropriate detail, you will need to revise
your pre-clinical lectures and attempt the question again.
1.4. Acute unit assessment
A Cardiothoracic Clinical Reasoning Sheet has been provided in Appendix 1 (page 49) of this
ILP. It is advised that you use this planning sheeting during the first 2 weeks of your unit to
assist giving you supervisor a summary of your treatment plans for new patients. It is also
designed to help you integrate assessment findings and develop clinical reasoning and decision-
making skills. Please discuss this with your clinical educator at the start of your placement.
1.5. Acknowledgements
This Independent Learning Package is the result of the teaching and experience of a number of
past and present cardiothoracic physiotherapy staff, including contributions by Ms Ruth
Dunwoodie, Ms Marie Steer, Mrs Bernadette Pozzi, Ms Julie Adsett and Mrs Robyn Cupit.

2. CHECK LIST FOR FURTHER PREPARATION REQUIRED BY
FACILITIES FOR DAY 1
The following are a list of skills and knowledge that students are expected to complete prior to
commencing their Acute Unit developed with contribution from the clinical educators. This
information has been covered in your pre-clinical cardiothoracic curriculum and you should use
this checklist to monitor your level of understanding of each component. Please revise any areas
in which you are not prepared in prior to your first day.
(Please tick to indicate the areas that you have read and understood)
Background Theory and Interpretation
The student should know;

Spirometry - Definitions of FEV1 , FVC, FEV1 /FVC and interpretation of Volume –Time
curves and Flow-volume loops
Normal values Hb, WBC, Platelets, T, BP, HR, RR, oxygen saturations and BSL’s
Interpretation of arterial blood gases
Names of major abdominal surgeries and respective incision lines
Gravity Assisted Drainage Positions (PD)
Signs symptoms of cardiac disease (including (R) and (L) cardiac failure, IHD, acute
coronary syndromes, ECG recognition and implications)
Contraindications for all techniques eg. especially for osteoporosis
Oxygen therapy – principles, flow rates, effect on hypoxic drive, effect on pulmonary
hypertension
Basic groups of medications including
Beta 2 agonists
Steroids- inhaled, oral, IV
Analgesics
Diuretics
Antibiotics
Anti hypertensives
Cardiac drugs, glycosides, anti-arrhythmics
Appreciate effects of steroid medications – short term and long term
Assessment
The student should be able to:

List respiratory symptoms e.g. SOB, wheeze, pain, cough, sputum and haemoptysis
List accessory muscles of ventilation
Describe and recognise different ventilatory patterns
Know the questions to ask about a patient’s home situation and relevance to situation
Understand the effects of body position on assessment findings
Observe an ICC for swinging, bubbling, draining, understand implications, appreciate correct
handling
Auscultate using surface anatomy landmarks
Describe pre mobilisation checks, including a calf check and the signs of a DVT and checks
when an epidural is in situ
Conduct a 6 minute walk test (6MWT)

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

3. REVISION TEST
You should attempt to complete this test after revising the notes on the following topics:
• Respiratory Assessment and Assessment of the Surgical Patient
• Chest Xray
• Auscultation
• Interpretation of Blood Gases
The suggested time frame is 45 minutes.
Question 1
You are reviewing the chart of a bronchiectatic patient who has been referred to physiotherapy
for treatment of her chest infection.
a. In a table format, discuss the key points or information you would look to obtain from the
patient’s medical chart and indicate why this information is important
Question 2
Your COPD patient is admitted with ↑↑ SOB and an inability to cope at home alone.
His ABG’s are as outlined:
FiO2 - 0.30 via a multi-vent mask

pH - 7.31
pCO2 - 59 mmHg
HCO3 - 30
pO2 - 60 mmHg
a. Interpret the ABG’s
b. Discuss the breathing pattern that your patient may be demonstrating
c. Outline the signs and symptoms of Type I and Type II respiratory failure
Question 3
Mrs Brown is a 76 year old COPD patient admitted with a ( R ) ML bronchopneumonia. As part
of your assessment you are reviewing her chest X Ray.
a. Outline using headings the steps you would take in this review.
b. What classical sign would demonstrate the involvement of the ( R ) ML?
Question 4
Mr Jones has returned to the Ward from the High Dependency Unit (HDU) Day 1 post elective
AAA Repair. He received initial post op physiotherapy in the Unit. He had poor pain control
with pain at rest 6/10 and with movement 8/10. His BP had been in the range 140 – 175/ 75 – 90
mmHg. The APS (Acute Pain Service) reviewed his pain relief and increased the range he was

able to receive via the epidural. He had an episode of chest pain this am and an ECG and serial
cardiac enzymes were ordered
a. Discuss any results or information you would wish to know prior to treating this patient and
the reasons this information is needed
b. Provide the range of normal values for these results
c. Explain the precautions you would take prior to mobilisation of this patient
d. Explain the precautions you would take during mobilisation of this patient
e. Outline the signs that you would monitor that may indicate the patient was having difficulty
during the walk
Once you have completed the test, compare your responses to the answers on page 29.

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

B. What is the patient’s relevant past history?
i. What are the physiotherapy implications of these conditions?
ii. Are there any safety issues you need to consider for this patient?
C. Do you think this patient was at high risk of post operative complications?
i. Why or why not?
ii. Outline the risk factors for post operative complications.
iii. How would you manage a patient who you thought was “high risk”?
D. Summarise the patient’s operation notes.
i. What are some intra-operative events that can occur? What are their
implications for physiotherapy treatment?
ii. What post operative pain relief was the patient prescribed? What are the
iii. What are the other common methods of analgesia delivery? What are the
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?
4.2. 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?

4.3. Surgical case study
Answer the following questions regarding Mr C, a 58 year old man is admitted to a Colorectal
ward prior to surgery. Routine Admission for a ( R ) Hemicolectomy
HPC : 10 kg weight loss over last 4 / 12

PR bleeding / melena
Lethargy
Abdominal pain → “cramping“ sensation, worse at night, worsening over last 1/12
PMHx : Smoker 20 / day for last 40 years

COPD - RFT’s FEV1 / FVC = 1.6 / 2.9
Hypertension
OT : ( R ) Hemicolectomy
Post op orders : NBM

IV fluids
Analgesia via epidural
Hourly UO measures
Routine post op observations
A. What would you include in your pre-operative assessment of this patient?

B. Mr C asks you to explain what a (R) hemicolectomy is. How would you explain it to
him?
He now presents Day 1 post op :

C/O : Inadequate analgesia pain 7/10 at rest
Itchy
Nausea and vomiting
O/E : Distressed RR - 30/min Accessory muscle use +++

↓↓ lateral costal expansion
BS - absent in the bases with no added sounds
Weak ineffective cough
Calf check √√
Wound - nil ooze
C. Complete the clinical reasoning sheet (see Appendix 1) for your management of this
patient on Day 1.
It is now Day 3 post op and Mr C presents with the following:

Abdominal distension ++
↑ temperature 39 0C
↑↑ WCC - 20
Abdominal pain ++ - 9/10 at rest
D. What do you think is happening? What condition is this?
E. How would you modify your management of Mr C?

4.4. 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?

5. WEEK 2 ACTIVITIES: MEDICAL MANAGEMENT
5.1. Treatment progression
As the patient’s condition progresses, you must also modify your assessment and management of
your patient. During your remaining 3 weeks in the acute unit, you will be asked to consider how
to progress your management of patients, and also consider discharge planning (this will be
addressed in the next section). As part of your continuing assessment of the patient, including
their medical and bed chart, you will notice certain signs and symptoms that demonstrate an
improvement or deterioration of the patient’s condition and need to modify your treatment
accordingly.
For the following cases, consider what signs and symptoms would indicate an improvement or
deterioration in the patient’s condition and how this might impact on your management of the
patient.
Case 1: Mr L, a 64 year old man admitted with acute exacerbation of his COPD
PHx: Emphysema/Asthma
Hiatus Hernia
Medications: Prednisolone 15 mg/day – long standing dose

Serevent bd
Ventolin and Atrovent via nebuliser
Current History:
Thin man
Increased SOB over 1/52
Increased cough and slight increase in yellowish sputum, haemoptysis
Decreased exercise tolerance, able to walk 15m with 1 person assist (previously
independent, no SOB on flat)
Investigations:
CXR Small area patchy consolidation at lung bases
Hyperinflated lung fields, elongated mediastinum
ABG’s on 2 L/min : pH 7.35, pCO2 45, pO 2 67, HCO3 27
Temp 375 Pulse 90

Resp: marked increase RR – 30
Ausn scattered exp wheeze, fine basal crackles, soft breath sounds
Dx Acute exacerbation of chronic lung disease
Rx Oral antibiotics, nebulised Ventolin/Atrovent 2/24, IV hydrocortisone, O2 2 L/min

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

For Mr L, consider the signs and symptoms that would suggest to you an improvement in
his current condition. How could this improvement influence your treatment? With these
improvements in Mr L’s condition, how could you progress his Rx?
Sign/Symptom Improvement Impact on Rx/ Progression
Sputum
Cough
Breathlessness
Exercise tolerance
Mobility
Auscultation
ABGs
CXR
Vital signs
Now, consider what would indicate deterioration in Mr L’s condition and how this might
impact on your management of the patient. How could this deterioration influence your
treatment?
Sign/Symptom Deterioration Impact on Rx/ Progression
Sputum
Cough
Breathlessness
Exercise tolerance
Mobility
Auscultation
ABGs
CXR
Vital signs

Case 2: Mrs O, a 62 year old woman is admitted to a general surgery ward for ? Liver resection /
Biliary Reconstruction for metastatic Ca
PMHx: Transverse Colectomy 6/95 for Ca

Ex-smoker - ceased 6/95 with a 40 pack year history
COPD
IHD
Hypertension
OT: Hemihepatectomy via bilateral subcostal incisions with xiphisternal extension
Post op orders: ICU
Day 1 post op: RTW in pm
C/O: Adequate analgesia via PCA (morphine)

Nil nausea
Dizziness when transferred from bed to chair in ICU
Nil SOB
Productive s/a yellow sputum
O/E: Non distressed, sitting in bed

↓ Lateral costal expansion (R) > (L)
↓ BS (R) base, nil added sounds
Effective productive cough
For Mrs O, consider the signs and symptoms that would suggest to you an improvement in her
current condition. How could this improvement influence your treatment? With these
improvements in Mrs O’s condition, how could you progress her Rx?
A. In a table, outline the following i) Sign/Symptoms; ii) Improvement and iii) Impact on
your treatment and progression of Rx.
On Day 3, Mrs O demonstrates the following signs/symptoms.

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

5.2. Discharge planning
It is important to consider when the patient will be ready to be discharged from your initial
assessment, as it will influence your treatment progression.
A. What factors regarding the patient’s social history should you consider when planning for
discharge?
B. What factors regarding the patient’s mobility should you consider when planning for
discharge?
C. What members of the multidisciplinary team can be involved in the discharge planning of
a patient? What are their roles?
D. When would you refer the patient to outpatient or on going physiotherapy management?
How would you organise these services?
5.3. Medical cases - problem solving
Case 1
Answer the following questions regarding Mrs K, a 50 year old female is admitted to a
Medical Ward via Casualty
PMHx : Asthma since 45 years old - 3 previous hospital admissions, never ventilated
Non-smoker
Nil other relevant
O/E : Fatigued looking, agitated

SOBAR ++ - unable to speak in short sentences
Laboured breathing
Accessory muscle use ++
Not cyanosed
BP - 170 / 90 PR - 130 b / min RR - 32 b / min
CXR : Hyperinflated, poor inspiratory effort

Clear lung fields
Auscultation : Quiet chest

↓ BS throughout both lung fields No added sounds
ABG’s : On R/A
pH - 7.47 PaCO2 - 28 PaO2 - 60 HCO3 - 24
A. Discuss the significance of Mrs K’s past medical history
B. What do the auscultation findings suggest?
C. Interpret the ABGs
D. Consider how your assessment of Mrs. K might be modified.

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

IHD
Current Medications :
Ventolin qid Atrovent tds Pulmicort bd
Amoxil Anginine prn
O/E : Barrel shaped chest

Cyanosis
Clubbing
SOBOE
Productive cough - ↑ production of mucopurulent, slightly
blood-stained secretions
Auscultation : ↓ BS throughout both lung fields

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

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

pH - 7.41 PaCO2 - 37 PaO2 - 68 HCO3 - 25
A. Discuss the significance of this patient’s past medical history. Consider the medications.
B. Complete the clinical reasoning sheet for this patient. (see Appendix 1)
C. What are changes in the patient’s signs and symptoms would indicate an improvement
in his condition?
D. How would you change your treatment plan (from question B) in response to these
improvements?
E. What do you have to consider prior to discharge from hospital?

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?

6. 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.
6.1. 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
ABG’s: On MVM FiO2 0.35
PH - 7.46 PaCO2 - 38 PaO2 - 67 HCO3 - 25
A. What are signs and symptoms of Peripheral Vascular Disease?
B. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient
on Day 1.
C. On Day 2 you approach the patient and she complains of severe pain in her right leg.
On examination it is pale and cold. What could this indicate? What would be your
actions?
D. What are some precautions taken when treating patients post this particular surgery and
with PVD?

6.2. 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
Investigations : Echocardiography LVEF - 40%

Angiography LAD - 90% blocked
RCA - 70% blocked
Circumflex - 75% blocked
OT Notes : Time in OR 1325 - 1550 hrs Time on bypass 60 minutes

CABG x 3 vessels
IMAG for LAD and OM1
SVG for RCA and Circumflex
Temp 32 0 C
CPB - 56 minutes
Pacing wires inserted
3 drains on low suction
Post op orders :
Remain ventilated
IV fluids as charted
Omnopon / Morphine (IM)
Dopamine infusion at 5 mcg /kg/min
Tridil infusion 1.5mcg/kg/min
Keflex 3 doses
Hourly UO measures → notify if > 30 mls per hour
Patient weaned and extubated at 0600hrs
Registrar Review at 0800hrs

Patient drowsy but rousable
FIO2 6 litres via mask SpO2 93%
HR 70 b/min paced
BP 100/55mmHg
Orders:
Leave paced
Gradually wean tridil leave dopamine for present
Remove one pericardial drain
Continue IV fluids pain relief and medications as ordered
Your examination:
C/O : Minimal pain 1/10 at rest and 4/10 with movement

Pain in posterior mid thoracic spine
O/E : Non distressed
O2 2 litres via nasal prongs, SpO2 95%

Obs. ↓ Bibasal expansion
Palp. ↓ Lateral costal expansion ↓ (L) > (R) base
Ausc. ↓ BS (L)LL anterior, lateral and posterior basal segments
A. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient
on Day 1.
B. Discuss your pre-operative management of a patient undergoing cardiac surgery. What

information is it necessary to give?
C. Outline the pathophysiological effects of the surgery on the respiratory system.
D. What are the pulmonary complications that can occur after cardiac surgery?
E. Describe the patient’s presentation when you see him post extubation.
F. Discuss the medications that the patient is requiring post operatively. What effect will
this have on your management?
G. What factors would you consider prior to mobilising this patient?
H. Discuss progression of this patient and the discharge advice that would be given
I. Outline a walking programme that would be suitable for your patient.

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?.

7. 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.
7.1. Case 1: Chest Trauma
A 50 year old man has received a stab wound, # ( R ) Ribs 4 - 7 and a pneumothorax during a
fight.
PMHx includes smoking 40 / day and a heavy alcohol intake.
He is on the surgical ward with 2 ICC’s with UWSD.
O/E : Pain 4 / 10 at rest and 6 / 10 with movement
PCA pethidine
RR 26 b / min BP 150 / 80 HR 90 b / min
FIO2 0.35 % via mask SpO2 90 %
Ausc - ↓ BS throughout ( R ) lung field No added sounds
DAY 2 0800 hrs Patient is tired, agitated and confused
ABGs pH 7.47 PaO2 58 PaCO2 32 HCO3 23
RMO orders an increase in the FIO2 to 0.40 % humidified
1000 hrs FIO2 0.40 % humidified SpO2 88 %
Repeat ABG’s pH 7.33 PaO2 65 PaCO2 50 HCO3 24
A. Complete the clinical reasoning sheet (Appendix 1) for this patient
B. Discuss the aspects of the patient’s presentation that may impact on assessment and
treatment.
C. Outline your concerns in relation to the objective assessment.
D. List the precautions relating to ICC’s.
E. Discuss what is happening on Day 2.
F. How might your Rx options vary on Day 1 or 2?

7.2. Case 2: Post ICU
A 75 year old man has returned to your surgical ward from ICU. He has spent 6/52 in ICU,
following a repair of a ruptured oesophageal ulcer which required multiple blood transfusions.
He was ventilated for 5/52 weeks, with ARDS and difficulty weaning. He was discharged from
ICU after 5.5/52, however, deteriorated in the ward due to secretion retention and respiratory
muscle fatigue and was readmitted and ventilated overnight.
PMHx: COPD (mild),

IHD (angina on extreme effort, eg moving house)
Peptic ulcer disease
Anxiety
O/E: Tracheostomy – attached to humidification FiO2 0.28

Thin, frail man, appears anxious
Muscle power UL 3+/5, LL - Quads 3-/5, hip extensors 2/5
AE R = L ↓ BS, few transmitted sounds, cleared by huff or suction
Vital signs: Blood pressure 150/86mmHg, HR 90beats/min, RR 25b/min, SpO2 94
ABG’s: pH 7.37 PaCO2 45 PaO2 79 HCO3 28
Medications: Ventolin 1ml/5mls NaCl in Nebulizer 6/24

Anginine prn
Losec
A. Complete the clinical reasoning sheet (Appendix 1) for your management of this patient
on Day 1.
B. What condition, common in long term ICU patients, does this man appear to have
developed?
C. What are some signs that this man could be deteriorating?
7.3. Managing a Ward and Prioritizing patients
One of your skills as a new graduate will be to decide who you will see and in what priority in
your ward(s) each day. The following ward lists are used as an example of a new graduate
potential workload in a medical and surgical ward.
For each ward
1. Identify the six (6) patients in each ward that would be your highest priority to see.
2. Provide a rationale for your choice e.g. age of patient, type of surgery – upper abdominal or
thoracic – productive cough, potential for complications
3. List any factors that might impact upon your treatment
4. Prioritise these six (6) patients and consider the number of treatments per day that would be
required

5. Consider the patients in each ward that would need active treatment
6. List the patients that would require a quick check or supervision
SURGICAL WARD
Bed Age Name Condition Co-morbidities/other

problems
1 48 Mr News (R) IHR 3/7 PMHx : Nil
2 55 Mr Ord (L) IHR 3/7 PMHx : Nil
3 82 Mrs Bond Ant. Resection 3/7 Mobility problems
4 78 Mr Que Abdominal Pain Diabetic, PVD
5 73 Mr Issacs Abdominal Pain PMHx : Nil
6 32 Mr Crenny Wiring Mandible 6/7 PMHx : Nil
7 45 Mr Board Pancreatitis ETOH++, Smoker
8 81 Mr Louder Bowel Obstruction Old laryngectomy
9 90 Mrs Long (R) Mastectomy 2/7 Lives by self
10 96 Mrs Sanders Inoperable Ca Stomach From nursing home
11 18 Mr. Roberts (L) IHR 1/7 ago. Cystic Fibrosis
12 81 Mr Nelson R/O Wire Mandible Mild COPD
13 22 Mr Brady Spontaneous Pnx (L) ICC Previous Pnx
14 81 Mr Owens Vagotomy and Pyloroplasty 1/7 Rheumatoid arthritis
15 44 Mr Boswell (R) IHR 1/7 PMHx : Nil
16 40 Mrs Roberts Stripping Varicose Veins 2/7 PMHx: Bronchiectatic
17 60 Mrs Hoge Pre-op. Lap. diverticular abcess Chronic GI disease,
smoker
18 28 Mr Phillips Head Injury FI PMHx : Nil
19 56 Mr Rowan Metatastic Melanoma (L) neck Previous melanoma
20 71 Mr Frier Abdominal pain FI Weight loss 4kg
21 56 Mr Emeon Haemorrhoidectomy 1/7 PMHx : Nil
22 81 Mr Crowe Laparotomy with colostomy 1/7 Mild HT
23 76 Mr Jones Diverticular Abscess FI IHD, Diabetes
24 60 Mrs Lang Large Bowel Obstruction PMHx : Nil
25 54 Mrs Ivan Biliary Colic PMHx : Nil
26 60 Mrs Jacobs Exploration cholecystectomy Obese
wound pre-op
27 60 Mrs Kleene Closure of Colostomy 3/7 Previous Ca Bowel
28 70 Mrs Gow High Ant. Resection 2/7 PMHx: Mild HT
29 64 Mr Muir BK amputee 7/7 Mild COPD

MEDICAL WARD
Bed Age Name Condition Co-morbidities/other

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

7.4. 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?

8. OUTLINE OF ANSWERS TO REVISION EXAM
Question 1:
INFORMATION IMPORTANCE
History of the presenting complaint Indication of the severity of the infection
Cough ↑ or ↓ or normal
SOB ↑ or normal Indication of the course of the disease
Sputum Change in colour Process
quantity or quality
Current status compared to usual baseline and an indication of the aim for
Exercise Tolerance discharge regarding mobility
Regular medications used and any changes with this admission
Medications The need to co-ordinate treatment with use of bronchodilators
Steroid use and the potential for contraindications to physiotherapy techniques
Specific lung segments involved
Chest X Ray + / - Report Lung changes as a result of the disease process
Indication of the patient’s current level of function
ABG result
Indication of either the obstruction or restriction the patient experiences. If a post
Respiratory or Lung Function tests 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
Sputum Culture precautions
Plan of Medical Management Indication of patient’s LOS
Question 2:
a. Interpretation of ABG’s
pH 7.35 – 7.45 ↓ acidosis
PaCO2 35 – 45 mm Hg ↑ acidosis
HCO3 22 –28 ↑ alkalosis
PaO2 80 – 100 ↓ severe hypoxaemia
Partially Compensated Respiratory Acidosis with severe hypoxaemia
b. The patient would be demonstrating an ↑ in the work of breathing (WOB) with an utilisation of accessory muscles, with
elevation of the shoulders and potentially stabilisation of the upper limb to provide fixation for reversed origin and insertion. In
view of his chronic respiratory condition, the lower chest wall movement is likely to be minimal or nil with vertical or piston
movement most obvious – demonstrating rigidity
c. Signs of Type I respiratory failure – agitation, confusion, plucking at air or sheets, decreased PaO2, increased RR, HR and
BP
Signs of Type II respiratory failure – vasodilation, bounding peripheries, flushed, increased PaCO2, drowsy (late sign), coma
Question 3:
a. Review of CXR:
Patient Information
Type of film and position
Exposure
Centering or rotation
Soft tissue structures
Bony structures and outline
Trachea, mediastinum and hilar region
Heart size, heart borders and cardiophrenic angles
Diaphragm border and levels and costophrenic angles
Lung fields
b. Involvement of (R) ML - loss of the ( R ) heart border such that the margin is not clearly differentiated.

If you were unable to answer this question or need to clarify the aspects being considered in more detail, review the Chest X
Rays CAL program before commencing clinic as this information will be needed DAY 1.
Question 4:
a. Results or information needed prior to treating this patient include:
i. Regarding chest pain – need the interpretation of the ECG by medical officer and serial cardiac enzymes. This is needed as 1)
ECG interpretation - ensure patient has not had an MI; and 2) Serial cardiac enzymes - will reveal changes in enzyme levels
over time if the patient has had an MI. However, as serial enzyme levels may not be available for several days, ECG monitoring
and troponin levels on day 1 can be used to determine whether patient should be mobilised.
ii. BP. This is needed as there may be ↓ with blood loss intra-operatively and is influenced by epidural that can cause
vasodilation.
b. Normal range for the above results:

i.ECG - no ST elevation; no T wave changes; no Q waves;
ii. BP - Need to know normal range for the patient, look at the measure obtained on admission or at pre-admission clinic
c. Precautions prior to and during mobilisation of this patient

- Subjectively ask about pins and needles , tingling, numbness or heaviness of their legs - MANDATORY FOR SAFETY
- Objectively
• if needed assess sensation – checking light touch in a dermatomal distribution
• assess muscle strength – repeated inner range quads contraction and hip and knee flexion. Look at the quality,
range and eccentric control of the movement
• vitals signs should have been checked at the beginning of Rx . If indicated BP can be checked prior to transferring
the patient
d. Patient transfer and mobilisation

• Organise the equipment so all attachments are on the one side of the bed
• Organise chair prior to moving the patient if the patient is to sit out of bed and have a forearm support frame (FSF) ready
• First walk have a second person present in view of the large surgery and aiming to minimise patient’s discomfort
• Ensure you are close to the patient to control or facilitate the movement
• Clear instructions to the patient and assistant regarding movement
• Sit the patient on the side of the bed for a few moments to allow BP to settle
• Question the patient regarding light-headedness and encourage the patient to move his ankles to assist the blood return to
the head and some slow deep breaths
• When shoes are being put on ensure one person is responsible for the patient
• Remain close to the patient at all times particularly on standing the patient
• Ensure the patient is stable before organising the FSF into position
• Remain close to the patient and utilise the sacrum as a key point of control
• Talk to the patient while mobilising to monitor their level of awareness
These steps will ensure safety with mobilisation. You must follow them through for safe handling to be demonstrated
e. Signs that indicate the patient may be having difficulty during the walk
- ↑ sweating
- Change in colour - patient becomes pale
- ↓ or slowing of verbal response
- Staring or fixed gaze prior to rolling eyes back
- ↓ SpO2

9. OUTLINE OF ANSWERS TO SELF-DIRECTED LEARNING
ACTIVITIES
4. WEEK 1: SURGICAL MANAGEMENT (SUGGESTED RESPONSES)
4.1 Interpretation of a medical chart
A. This will depend on the patient. E.g. Ca of colon
B. This will depend on the patient’s past medical history. Below are some common conditions and their physiotherapy
implications and safety issues to consider.
Condition Physiotherapy implications Safety issues
IHD Questions in subjective re: Angina - establish history - Be mindful of exercise tolerance, limit mobility
stable / unstable. Time of last episode, location of pain, Care when mobilising, may need to take nitrates
quality, duration, intensity, precipitating factors. Monitor chest pain
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 b’spasm
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
Large blood loss → low Hb post-op Monitor Hb and BP prior to mobilisation.
Decreased O2 available in system, may become hypoxaemic
during demand activities, e.g. mobilisation
Cardiac complications - ECG changes intra-op, silent MI May limit mobility depending on event. May also have further
investigations and medical management. Check chart.
Labile BP, intra-operative CVA Type of CVA will influence mobility, communication
Contamination of the field e.g. faecal contamination Increased temperature – inflammatory response
Other tissue damage - nerves, tendons, arteries or muscles Depending on tissue involved will influence mobility, sensation.
sacrificed May modify mobility, exercises.
GA complications - epidural at wrong level, (R) main bronchus Incorrect level of epidural – can lead to increased pain

intubation, epidural / spinal CSF leak (R) main bronchus intubation – may have collapse of (L) lobes
Aspiration Likely to be (R) upper lobe, increased temperature, secretions
may be present.
D. ii and iii. The common types of analgesia used post operatively and their implications are in the table below:
Type of analgesia Implications
Patient controlled analgesia. 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 patient’s RR and SpO2 to ensure their breathing is not becoming depressed.
Patients may require antiemetics to reduce nausea prior to commencing physiotherapy
treatment. Some patients may not be able to mobilise due to severe nausea.
Monitor the patient’s responsiveness, if they are very drowsy and unable to participate in your
physiotherapy treatment, notify the nursing and medical staff as the patient’s medications may
need to be reviewed.
Information regarding the type of narcotic used, base rate, bolus dose and lock out period is
available in the medication chart.
Epidural analgesia. Can also 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
patient’s 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 don’t percuss patient, if platelets < 40 don’t vibrate patient.
Operation notes Any change to operation, intraoperative events or events in recovery. These have
been outlined in question C.
4.2 Patient attachments and their physiotherapy implications

Item and function Implications Working properly?
Oxygen Mask – provides Check the correct concentration is being delivered Check connected to oxygen port and
supplemental oxygen to to the patient. turned to correct flow rate.
patient. Keep O2 on during Rx
Mobilise post-op pts with O2 (if appropriate)
Replace O2 mask or nasal prongs if removed to
mobilise pt.

Wound drain – remove fluid Do not pull out during the course of your treatment Check level – ensure not too full as it
from wound site following Ensure safe, appropriate handling to avoid may rupture.
operation. Consider the 3 infection. Check wound, ensure wound drain still
types of wounds. Which do Can mobilise patients with drainage bag, keep attached.
you see most often? below level of wound.
Nasogastric tube – drain bile or Often pinned to pillow - do not pull out when sitting Check below level of nose.
gastric contents from stomach pt forward. Can be on free drainage, regular
Ensure tube is well secured to pts nose with aspiration or suction.
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.
Urinary catheter – Ensure bag is not too full prior to mobilising Check level – ensure not too full, if so
Remove urine from bladder into Don’t pull catheter out when mobilising ask nursing staff to empty prior to
an external bag. Keep bag below level of the catheter mobilising.
Used when patients cannot
mobilise to toilet
Monitors urinary output
(important when narcotic
analgesia is used for pain
relief)
IV drip - Peripheral venous line Ensure burette is not empty - esp. prior to Check the IV is not alarming – if so call
inserted for post-op mobilising pt. Nursing staff, don’t adjust IVAC.
administration of maintenance / Do not fill / adjust IVAC - call N/staff Check if patient reports pain at IV site –
replacement fluids and Care with arm exercises when there is a problem inform nursing staff as thrombophlebitis
medications. with patency of the drip - only then is backflow may occur.
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).
ICC - A flexible tube inserted Do not pull out during the course of your treatment Assess whether swinging with patient
into the pleural space, Check whether the fluid is swinging, draining or breaths; draining fluid or bubbling.
connected to a system of bubbling.
underwater seals and suction. Keep bottle system below level of insertion into
Further information about ICCs patients chest wall so no danger of fluid entering
see lecture notes. 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
Epidural – catheter inserted Ask in subjective questioning about pins and Check epidural is not alarming.
into epidural space used for needles, numbness, weakness or heaviness Check sensation and muscle function in
post op analgesia If numbness or pins and needles are present - an your assessment.
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
4.3 Surgical case study
A. What would you include in your pre-operative assessment of this patient?
• Check chart, patient history, investigations

• Chest assessment and institute chest treatment if indicated
• Teach
- appropriate breathing exercises - SBE with IH’s or RDB (depending on chest wall compliance)
- circulation exercises
- supported cough or huff
- bed mobility and transfers - with assistance and independently
- specific exercises for procedures - UL exercises for thoracic surgery
• Explain
- physiotherapist’s role regarding chest, circulation, mobilisation, specific exercises
- post-operative presentation / incision(s)
- rationale for breathing and circulation exercises hourly post-op
- early mobilisation programme i.e. generally Day 1 post-op
- need for adequate post-op pain relief for effective physiotherapy treatment
Provide TED stockings pre-op depending on hospital protocol
B. Mr C asks you to explain what a (R) hemicolectomy is. How would you explain it to him?
It is an operation that removes part of the large bowel (or colon) and stitches it back together.
C. Complete the clinical reasoning sheet for your management of this patient on Day 1.
Part 1. After reading the Medical and Bedside Charts:
Main Findings Implications for PT Ax and Rx
COPD 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
HTN Check if controlled – check medications. May have higher resting BP.
(R) hemicolectomy, no complications in

theatre or during recovery
Epidural analgesia 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.
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 isn’t affecting sensation/muscle power.
mobilising
Position:
High sitting Increase FRC
Ventilation:

SBE or DBex Needs slow laminar flow and collateral ventilation hold to re-
expand atelectasis. This breathing pattern will also help
surfactant release
Incentive spirometer If poor understanding of SBE or Dbex. Need for feedback.
Secretion mobilisation:
Not required There is no indication of secretion retention at present. Monitor
closely, as patient may retain secretions if pain not well
controlled, and has Hx of smoking
Secretion removal:
Supported cough – abdominal support with pillow/towel Support is needed due to pain
Cough is needed to make sure chest is clear
Mobility/Ambulation:
Leg exercises Circulation exercises are needed to prevent DVTs
Ambulation – with rollator, 2 assist, O2 as required. 2 people needed as patient has epidural analgesia
Ambulate if patient’s pain and respiratory distress is improved
with pain relief. Will help increase ventilation.
5. Why is the above treatment plan appropriate for this patient? How would you modify the treatment if not appropriate?
Patient has poor pain control and this needs to be addressed first. Pain is affecting ventilation and ability to cough, so
may lead to atelectasis and retained secretions.
If after reassessment treatment is not appropriate – ventilation remains decreased, could try other methods of
increasing ventilation – incentive spirometry, IPPB. If pain not controlled – contact Pain team
6. Discuss any factors that may influence your treatment plan. Why are they important to consider?
Patient is in respiratory distress due to the pain – need to ensure this is improved prior to commencing Rx.
Patient has been lethargic and had poor mobility/exercise tolerance prior to surgery – need to progress ambulation
accordingly.
7. What are the safety considerations for your treatment of this patient (e.g. contraindications). How could you manage these?
Monitoring of pain levels, sensation, muscle power is important (epidural)
Need to also monitor BP, as it can be decreased with epidural analgesia
8. What outcome measures will you use to determine the effect of your treatment?
Auscultation, palpation, SpO2, cough, ABG’s, walking distance
Part 3. After treatment:

9. When would you like to see this patient again? Why?
In afternoon (approx 3-4 hours later) as patient requires frequent treatment, ensure pain well controlled and not
inhibiting ventilation.
10. What is your plan for the next treatment?

Reassess, increase level of management (e.g. IPPB) if worse BS or has not improved. May SOOB or mobilise further if
improved.
D. What do you think is happening? What condition is this?

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

• Time treatment with pain relief or encourage use of PCA throughout Rx
• Maintain pulmonary function and prevent complications
• Short frequent treatments
• Positioning may be difficult - may not tolerate high supported sitting, may prefer standing
• Increase ambulation distance as tolerated.
• In view of patient’s condition pre-operatively a long-term re-conditioning programme would be appropriate.
5. WEEK 2: MEDICAL MANAGEMENT (SUGGESTED RESPONSES)

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

Sputum Decreased amount, no longer yellow Increase duration of Rx, decrease frequency of treatment
or blood stained Continue secretion mobilisation and removal techniques
Cough Decreased amount of coughing – e.g. if using PEP may need to reassess resistance.
May decrease use of assisted coughing techniques
Breathlessness Decreased to nil SOBAR May progress positioning – from high supported positions
to more supine positions, modified gravity assisted
Exercise tolerance Increased distance mobilised positioning.
Progress ambulation – decrease O2 required (monitor
Mobility Independently mobile, not requiring 1 with SpO2), decrease assistance, increase distance.
person assist Progress to stairs
Auscultation Decreased wheeze, decreased fine Encourage independent mobilisation
crackles Progress secretion mobilisation and removal to
ABGs Reduced respiratory acidosis independent treatment sessions – monitor performance.
CXR Resolution of changes in bases
Vital signs Decreased RR
Now, consider what would indicate deterioration in Mr L’s condition and how this might impact on your management of the
patient. How could this deterioration influence your treatment?
Sign/Symptom Deterioration Impact on Rx/ Progression
Sputum Increased amount, darker colour (e.g. Shorter more frequent treatment sessions to reduce
green), increased thickness (e.g. fatigue.
plugs), more blood stained Positioning in high sitting, high side lying
Cough Increased amount, weaker May use humidification to help loosen secretions
May use positive pressure devices e.g. IPPB to reduce
Breathlessness Increased SOB – now SOBAR work of breathing – increase ventilation
More passive techniques to mobilise secretions e.g.
Exercise tolerance Unable to mobilise 15m, confined to percussion instead of flutter, if patient fatiguing
bed area only. Assisted cough to remove secretions – if cough impaired
Mobility Mobilising with rollator, 2 assist may need to use suction.
Auscultation Increased wheezes, crackles. Monitor closely, patient may move into respiratory failure.
ABGs Increased acidosis, increased

hypoxaemia
CXR Greater changes in lung bases, more
changes throughout lungs
Vital signs Increased temp, HR, RR.
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.
Sputum Decreased amount, no longer yellow Increase duration of Rx, decrease frequency of treatment
or blood stained Continue breathing exercises – may increase number of
Cough Strong, effective, non productive repetitions.
minimal pain Continue supported coughing
Nausea Nil in bed, and with mobilisation May progress positioning – sit out of bed
Progress ambulation – decrease O2 required (monitor
Dizziness Nil during transfers, mobilisation with SpO2), decrease assistance, increase distance.
Progress to stairs
Mobility Independently mobile, no dizziness, Encourage independent mobilisation
nausea
Auscultation Improved BS in (R) base, nil added
sounds
Palpation Improved lateral costal expansion on
(R), so R=L

B. What condition is this? What is the medical management?
PARALYTIC ILEUS - Cessation of movement of the gut / peristalsis not regained for a prolonged period post-op. Maybe due to
rough or excessive handling intraop or with peritonitis.
Medical management includes - NBM with N/G tube; IV fluids and Parentral nutrition
C. How will your physiotherapy management be modified?

• Abdominal distention - high sitting may not be comfortable and may prefer to stand for Rx.
• Encourage mobility as this decreases basal collapse and provides gravity to stimulate gut function.
• Some patients gain relief from massage to promote gut motility.
5.2 Discharge planning

A. What factors regarding the patient’s social history should you consider when planning for discharge?
• Home environment – house, hostel, nursing home
House – number of stairs, rail
Hostel – distance to dining area, any stairs, ramps, gutters
Nursing home – any mobility requirements, distance to dining area.
• Level of support at home – spouse, family, living alone
• Level of assistance required for ADLs – house cleaning, meals, transport, bathing, nursing care
B. What factors regarding the patient’s mobility should you consider when planning for discharge?
• Walking aid
May not be able to use in patient’s home environment due to furniture, size of home. May need to involve home
visit or OT involvement.
If patient has stairs, will need to be able to use single stick or crutches. Will not be able to use hopper or
wheeliwalker/rollator independently. If patient does have person to assist with moving the walking aid and with
stairs, will be able to move aid to top/bottom of stairwell.
Patient may need to purchase or hire the aid – will depend on duration required, financial assistance available.
• Level of assistance required – supervision/1person/2 person assist
May not have assistance available eg lives alone, family works during the day
May have minimum requirements to return to hostel/nursing home/facilities eg must only be supervision to mobilise
• Distance mobilised
Consider functional activities the patient needs to be able to complete independently, eg walk to toilet, kitchen.
May know distance to dining area, recreational area in hostel/facility
C. What members of the multidisciplinary team can be involved in the discharge planning of a patient? What are
their roles?
• Occupational therapist – may require home visit, modifications, assistance with ADL tasks, assistive devices.
• Social worker – may require assistance with organising placement (hostel or nursing home)
• Nurse – may organise domiciliary nursing care for wounds, medications, and assistance with bathing/dressing, meals.
• Medical staff – may organise following reviews, referral to other medical specialists, and letter to GP.
D. When would you refer the patient to outpatient or on going physiotherapy management? How would you
organise these services?
This may depend on the patient’s presentation:
- If patient has retained secretions, and is not independent in airway clearance, may need a referral for outpatient respiratory
treatment.
- If respiratory patient – eg COPD, patient may benefit from referral to pulmonary rehabilitation following discharge from the
hospital.
- If cardiac surgery patient – may be referred for cardiac rehabilitation following discharge (may be physiotherapy or nursing
role depending on unit)
- If patient has a falls risk – may refer to falls clinic, outpatient physiotherapy exercise programs
- If amputee – will be referred to amputee clinic
The organisation of such services differs with each institution, so consult your clinical educator for the specific information about
your institution. During your placement, consider the outpatient or on going physiotherapy management of your patients and
what services the institution provides.
5.3 Medical cases – problem solving

Case 1
A. Discuss the significance of Mrs K’s past medical history
Mrs K has a history of asthma, with only three (3) hospital admissions. Therefore her asthma is usually well controlled and the
fact that she has never been ventilated reflects the severity of the disease.

B. What do the auscultation findings suggest?
Reflect the lack of movement of air and that the patient is fatiguing.
C. Interpret the ABGs

pH - ↑ - alkalosis
PaCO2 - ↓ - alkalosis
HCO3 - - normal
PaO2 - ↓ - severe hypoxaemia
ABG’s reflect hyperventilation i.e. blowing off their CO2 and severe hypoxaemia
Uncompensated respiratory alkalosis with a severe hypoxaemia
D. Consider how your assessment of Mrs K might be modified.

C/O: Limited or impossible due to fatigue and SOB
O/E: Observation - no assessment of response to verbal instruction
Palpation - assess response to tactile input
Auscultation - limited due to patient’s shallow breathing pattern, stretch facilitation to encourage deeper breaths
Ensure O2 is kept on at all times.
E. Discuss the ABG’s that were taken three (3) hours later.
pH - ↑ alkalosis
PaCO2 - ↓ alkalosis
HCO3 - normal
PaO2 - ↓ Hypoxemia even with supplemental oxygen
Uncompensated respiratory acidosis with moderate to severe hypoxaemia
F. What condition is now evident?

TYPE II RESPIRATORY FAILURE PaCO2 > 50 mmHg
Fatigued with shallow breathing ⇒ ↑ CO2
G. Outline the aims of treatment and techniques that may be appropriate at this stage?
- Need to talk to the Medical Staff
- Positioning - high supported sitting or forward lean sit - Supportive therapy
- Humidification - to assist with the supplemental O2
DO NOT RELAX THE ACCESSORY MUSCLES AS THE PATIENT IS RELIANT ON THEM
Case 2
A. Discuss the significance of this patient’s past medical history. Consider the medications.
The patient is only on anginine, a short acting coronary artery vasodilator, for his IHD. As there are no long acting agents used
the IHD is less severe.
B. Complete the clinical reasoning sheet for this patient. (See appendix 1)
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
Barrel shaped chest Long Hx of obstructive respiratory disease – limited bibasal
expansion.
Productive cough – mucopurulent, sl blood stained Increased secretion production, exacerbation of bronchiectasis
Scattered crackles/wheezes
CXR – fibrosis and peribronchial thickening in lower lobes Bronchiectasis, affecting lower lobes more than upper.
ABG’s - Hypoxaemia Increased secretions resulting in V/Q mismatch and reduced

gas exchange

Retained secretions
Increased work of breathing
Decreased exercise tolerance
What exacerbates angina?
Amount of blood in sputum Streaks of blood through purulent sputum are common => Rx would not
cease but results recorded in the patient’s file.
Frank haemoptysis is a sign of erosion of pulmonary vessel – needs to be
monitored. Don’t treat with percussion and vibrations for 5 – 10 days to
allow healing.
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.
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 May need supported cough if weak. No bibasal expansion present
Leg exercises Circulation exercises are needed to prevent circulatory complications
Ambulate around ward – with if required O2 Will assist circulation and ventilation. Can also assist with secretion
(check SpO2) mobilisation.
Main problem is secretion retention due to bronchiectasis affecting the lower lobes.
Amount of blood in sputum – as discussed above. May influence use of treatment techniques.
Chest pain – will need to modify positioning, to supine or head up position
7. What are the safety considerations for your treatment of this patient (eg contraindications). How could you manage these?
Monitor angina
Auscultation, palpation, sputum (amount, colour, consistency) SpO2, ABG’s, walking distance

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

Reassess, change secretion mobilisation technique if not effective, promote exercise/mobility
C. What are changes in the patient’s signs and symptoms would indicate an improvement in his condition?
- Decreased sputum, becomes clearer (closer to normal amount), less blood stained.
- Improved crackles and wheezes on auscultation in lower lobes
- Improved breath sounds
- Increased PaO2
- Decreased SOBOE – able to mobilise greater distance prior to becoming SOB (increased exercise tolerance)

D. How would you change your treatment plan (from question B) in response to these improvements?
- Increase duration of treatment
- Introduce independent airway clearance (eg PEP) to Rx, and monitor during Rx sessions. May need to check resistance
levels (as pressure may change with changes in patient’s condition)
- Progress mobility include stairs
- Develop home program for airway clearance – check patient is independent.
- Start resistance exercises for upper and lower limbs
E. What do you have to consider prior to discharge from hospital?

- Home situation – house, stairs
- Mobility aids required
- Any assistance for ADLs, meals etc eg domiciliary care
- Need for continuing respiratory care - ?follow up for chest care if continues to be productive but not independent with airway
clearance.
- Referral for pulmonary rehabilitation program or develop patient’s own walking program with 6MWD results. (may not be
able to access PR)
6. WEEK 3: SPECIALISED SURGICAL MANAGEMENT (SUGGESTED RESPONSES)
6.1 Case 1: Vascular surgery

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

Severe PVD Will need to take precautions with lower limbs, skin care, handling
Ischaemic heart disease 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
Subjective
You will have more information re what exacerbates angina Stress of surgery, demand ventilation or increased activity may
exacerbate angina
Objective
Decreased breath sounds ++ Atelectasis – due to ↓ FRC (obesity, position) pain (lack of
sighs → decreased surfactant release), absorption atelectasis
from ↑ inspired oxygen, anaesthetic gases
ABG’s Hypoxaemia Atelectasis causing ↓ V/Q mismatch

Atelectasis causing hypoxaemia

Potential for Angina
What exacerbates angina?
Patient is at risk of respiratory failure i.e. obese, atelectasis,
major surgery
Position:
Sitting < 60o upright Sitting > 60o upright will compress graft
Partial upright sitting will ↑ FRC
Ventilation:
SBE, IH, Needs slow laminar flow and collateral ventilation hold to re-
expand 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 Support is needed due to pain
Cough is needed to make sure chest is clear
Leg exercises 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
Major problem is atelectasis. Treatment needs to be frequent and altered if not effective
Exacerbation of angina may be a factor. Position following vascular surgery is also important
Monitoring of angina is important
Care of skin on legs is important
Auscultation, palpation, SpO2, CXR, ABG’s, walking distance

3 hours later – needs frequent treatment

Reassess, increase level of management (eg CPAP) if worse AE or has not improved
C. On Day 2 you approach the patient and she complains of severe pain in her right leg. On examination it is pale and
cold. What could this indicate? What would be your actions?
These are signs of Acute Ischaemia - The “6” P’s
• Pallor,
• Polar
• Pulseless
• Paralysis
• Paraesthesia
• Pain
Action
• Nursing Staff and Medical Staff notified immediately as the ischaemia needs to be reversed to preserve the limb.

• Document findings in patient’s medical record
D. What are some precautions taken when treating patients post vascular surgery and with PVD?
Modifications to physiotherapy treatment for Vascular Procedures:

Vary with Surgeon’s preference – check hospital protocol
May include
• Avoid hip F > 60o due to position of grafts for first 24 hours
• Log roll to auscultate posterior chest
• If femoral Popliteal bypass, don’t stretch under knee eg Homans test
• Sitting no higher than 60o
• Lower bedhead to do active hip flexion to 60o.
• Care with handling of vascular leg.
• Assisted leg exercises.
• Avoid tipping a patient with recently grafted aorta.
• Podiatrist and well fitting shoes
• No garters and no tight socks
• Dry skin, particularly between toes
• Seek medical advice early with cut/abrasions
• PAC – regular checks and care with sensory loss
• Care during treatment with regard to foot exercises, scraping of heel.
• Correct footwear when walking.
• Mobilise with reference to claudication distance.
• Make sure a patient with PVD has sheepskin or bootees during their stay in hospital.
• Electrotherapy precautions.
• Infection control.
6.2 Case 2: Cardiac surgery
A. Complete the clinical reasoning sheet for your management of this patient on Day 1.
1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx? (Are there any
special questions to include in C/O or specific points to check in the O/E?)
Heavy smoker before quitting 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
IMAG during surgery Increases risk, more pain, extra drain, lower lung volumes
Check pain scores
Part 2. After completion of subjective/objective assessment:

Decreased gas exchange (SpO2 93%) on 2l/min 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
Drowsy 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
Blood pressure low requiring Dopamine Check peripheral perfusion and pulses, if cold and pulses low, can
indicate decreased CO. Delay mobilization
Pain score 4/10 on movement 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
Decreased BE and AE in (L) LL This is a normal finding in a patient who has had bypass. Abnormal
findings would be changes in the ® side or fine crackles form increased
fluid
However the fact that his SpO2 is low, he is drowsy and he has reduced
ejection fraction demonstrates he at risk of further chest infection

1. Decreased gas exchange
2. Drowsiness, decreased ability to co-operate
3. Decreased blood pressure
Decreased gas exchange
Blood pressure low, still on cardiac support drugs
Drowsy
Position:
Upright sitting – use bed rope Will increase FRC, improve ventilation and arousal
Ventilation:
SBE, IH, Incentive spirometer This will increase laminar flow, assist collateral ventilation and stability of
alveoli
Use CPAP if no improvement CPAP will increase FRC
No formal techniques required yet, use ACBT No evidence of retained secretions. Need to increase airflow and
expansion of alveoli at present
Secretion removal:
Supported cough Need to support sternum, and check no secretions
Walk would assist lungs, however BP still low and As still dependent on Dopamine need to delay walk. Could result in
drowsy. decreased cardiac output at present.
This patient needs intensive treatment to reverse atelectasis and potential chest infection, however they are not suitable
for mobilization yet
Low blood pressure and dependency on Dopamine is important. Drowsiness also indicates they are unsafe to mobilize
Don’t walk at present
Auscultation, SpO2, CXR, arterial blood gases, alertness

2 hours after previous treatment, as requires frequent treatment

If not requiring Dopamine could mobilize. Continue chest treatment if not improved after this treatment consider CPAP
B. Discuss your pre-operative management of a patient undergoing cardiac surgery. What information is it necessary
to give?
• Check chart / patient history / investigations

• Assessment - chest - treatment should be instituted if indicated by findings, including exercise tolerance, circulation,
home situation
• ROM of neck and shoulder and thoracic mobility
• Observation of posture
• Discussion re post-op course i.e. ICU post op, overnight ventilation, extubation and the commencement of
physiotherapy
• Explain mobility programme, management of musculoskeletal pain and progression of exercises as a home
programme
C. Outline the pathophysiological effects of the surgery on the respiratory system.

• CPB - capillary leakage similar to ARDS, destruction of red blood cells
• Destruction of surfactant due to 100% O2
• Inadequate humidity, bypass or hypothermia
• Phrenic nerve paralysis from cardioplegia
• Pain from wound and drain sites
• Harvesting of IMA
• Retraction and deflation of lung during surgery
• Major ↓ in lung volumes eg FRC, VC and TLC
• Parenchymal damage ↓ lung and chest wall compliance
• Chest Wall instability due to wired sternum
• Work of breathing ↑
D. What are the pulmonary complications that can occur after cardiac surgery?
Pulmonary Complications occur in 40-60 % of patients
• Atelectasis - particularly of the (L) Lower Lobe
• Lower respiratory infection
• Pulmonary oedema
• ARDS
E. Describe the patient’s presentation when you see him post extubation.
• Usually nursed in supine / ¼ turn from supine / high sitting
• Position for Rx usually high sitting
• Incisions - median sternotomy
Uni / bilateral LL wounds with compression bandages (if utilised)
Wrist incisions if RAG
Usually no TED stockings (depending on the Surgeon’s protocol)
Equipment
• Peripheral line + Arterial line, CVP line, ECG leads, O2 mask or nasal prongs, pulse oximeter, IDC,
temporary pacing wires
• x3 wound drains - retrosternal (pleural), mediastinal and pericardial with UWSD + / - low pressure
suction
• Assistive devices such as an intra-aortic balloon pump (IABP) may be used to augment cardiac function
in more unstable patients.
• Bed rope to assist independent mobility
F. Discuss the medications that the patient is requiring post operatively. What effect will this have on your
management?
• Tridil - GTN - Coronary Artery Vasodilators
• Dopamine - providing inotropic support.
• Other inotopes / vasopressors - digoxin, dobutamine, adrenaline. (Dopamine can be used for renal support in low
doses)
• Keflex - prophylactic antibiotics
• Omnopon - for sedation and pain relief whilst ventilated
• Morphine for pain relief once extubated. (IM, NSAIDS are used also)
• Peripheral vasodilators e.g. hydrallazine, ß blockers – decrease blood pressure and work of heart
• Diuretics - lasix
• Anti-arrhythmics
• Anti platelet aggregation - aspirin
If patient is still on cardiac support drugs eg dopamine, he may not be suitable to mobilise

G. What factors would you consider prior to mobilising this patient?
• Pain control needs to be looked at closely as movement results in a score of 4/10
• Patient still requiring Dopamine
• Familiar with the particular surgeon’s protocol
• Check the cardiac rhythm to ensure stability before the stress of mobilisation
• Care disconnecting the suction from the drainage bottles
• Assess the need for O2 - generally utilised Day 1
H. Discuss progression of this patient and the discharge advice that would be given
At all times a problem solving approach based on assessment findings must be utilised.
• Positioned in high supported sitting - patient able to position self independently using the bed rope as
demonstrated pre-op.
• Mobilise if cardiovascularly stable i.e. check if still requiring Dopamine, if arrhythmias
5-10% of patients in studies developed chest infections. Clinically patients who develop respiratory complications post
cardiac surgery apart from the expected (L) LL collapse, need intensive respiratory management
This may include
• Sputum clearance techniques
• Breathing exercises +/- BiPAP/ CPAP
Day 2 - 2nd / 3rd drains removed

Day 3 – 5 - Management of musculoskeletal pain and progression of exercise walking programme
NB. - Progressions will differ with individual patients depending on presentation and assessment findings
DISCHARGE ADVICE:
Home programme
Thoracic mobility, neck and shoulder exercises
Lifelong walking programme / aerobic training
General Advice:
• Ergonomics, posture and back care
• Modification of risk factors - cease smoking, regular aerobic exercise
• If appropriate referral to Cardiac Rehab programme / exercise class
• OT - Lifestyle modification and planning ADL
• Dietician - diet modification
• Nursing Staff - wound care
7. WEEK 4: SPECIALISED CASES (SUGGESTED RESPONSES)
7.1 Case 1 Chest Trauma
A. Complete the clinical reasoning sheet for this patient

1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx? (Are there any
Aggressive nature, confused, heavy alcohol intake May undergo DT’s, confused because of hypoxia, may be very
difficult to manage during treatment
Heavy smoker Cilial function decreased, maybe some chronic damage to lung
Serious chest injury, large number of rib fractures and Potential for worsening of respiratory condition
pneumothorax

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
Day 2
Actually in Type I respiratory failure Sympathetic system causing increases in vital signs in response to
Increased agitation, BP, HR and RR all signify Type I hypoxia
respiratory failure
PaO2 ↓ PaCO2 ↓
Then goes into Type II respiratory failure A rise in PaCO2 signifies exhaustion
PaO2 ↓ PaCO2 ↑
Pain
Hypoxaemia, Type I Respiratory failure
Confusion, aggression
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
CPAP Increased air entry will mobilise secretions
Secretion removal:
Supported cough Need to remove secretions, pain needs support
Day 1 – difficult to mobilize on this level of oxygen, could try
but use pulse oximeter
Too confused to mobilize Day 2
Patient at critical level, needs effective urgent treatment as going into respiratory failure
Lack of co-operation
Care with aggression
Patient could go into respiratory failure very quickly
SpO2, ABG’s, Level of confusion, auscultation

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

May need ventilation
B. Discuss the aspects of the patient’s presentation that may impact on assessment and treatment.
• Smoking history
• Alcohol intake → potential for DT’s, Effect on pain perception
C. Objective Assessment

• Concern re appropriate use of PCA as pain rating remains high
• ↑ Inspired O2 but SpO2 remains low
• Need to encourage use of PCA throughout Rx session
• Auscultation - with the high pain rating is the patient able to take deep breaths sufficient for added sounds to be heard
D. ICC Precautions:
In bed
• Note the swinging (S), bubbling (B) and draining (D) with tidal breathing, deeper breaths and cough
• Check the insertion site - ensure there is no ooze and the extent of the dressing
• Check the tube is not kinked by the taping or the bed
Moving - Whether clamps are to be with the patient depends on Consultant’s protocol
1. Keep the bottle below the level of insertion – ensure fluid does not flow back into the chest - potential for empyema
2. Keep the bottle level when mobilising – ensures tube remains underwater and accurate measures of drainage can be
gained
3. If the bottle breaks / disconnected kink the tubing, alternatively if the tube is dislodged apply pressure over insertion site
E. Discuss what is happening on Day 2
At 0800hrs the patient is demonstrating signs of TYPE I RESPIRATORY FAILURE.

Signs and symptoms of Type I Respiratory Failure:
• ↓ pO2 < 60 mmHg
• ↑ Vital signs - ↑ RR ↑ PR ↑ BP
• Hypoxaemia
• Restless
• Confused and agitated
• Plucking at sheets
At 1000 hrs the patient has deteriorated despite an ↑ in inspired O2, and the SpO2 is less. This indicates that the patient is tiring.
ABG’s indicate Type II Respiratory Failure with an ↑ pCO2, as he is tiring.

Signs and symptoms of Type II Respiratory Failure
• Drowsiness
• Flushed face
• Peripheral vasodilation
• Bounding pulse
• Eventual coma
F. How might your Rx options vary on Day 1 or 2?

At the review at 0800 hrs consideration of the introduction of BiPAP.
Possible starting pressures - IPAP - 10 cm H2O pressure
- EPAP - 5 cm H2O pressure
At 1000hrs with Type II Respiratory Failure evident, medical reviews would be ongoing and ventilation would be under
consideration.
7.2 Case 2 Post intensive care
A. Complete the clinical reasoning sheet for your management of this patient on Day 1.
1. What are the relevant findings from the medical chart and the implications for the Physiotherapy Ax and Rx. (Are there any

COPD
Has had long stay and extended ventilation in ICU Liable to experience respiratory muscle fatigue again
Been readmitted to ICU once
Tendency towards secretion retention Will need active measures to prevent this
IHD 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

Tracheostomy Due to long ventilation. Will need to ensure patient airway
Muscle weakness Critical care weakness syndrome from extended ventilation,

drugs
Gas exchange still low Due to lung disease, lack of normal breathing pattern,
secretions
HR, BP RR all increased Due to anxiety and exhaustion

Could exacerbate angina
Tendency towards secretion retention and respiratory muscle fatigue
Exhaustion
Anxiety
Will become exhausted quickly
Position:
SOOB, Tilt table
Ventilation:
Could benefit from CPAP or BiPAP especially during Will assist in prevention of respiratory muscle fatigue
treatment
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
Tilt table, sit to stand Lower limb weakness, needs rehabilitation Could use BiPAP,
CPAP during this
The patient needs effective treatment to prevent secretion retention and respiratory failure, also active rehabilitation,
however do not exhaust patient during treatment
Treatment needs to be effective without exhausting patient
Recognition of respiratory muscle fatigue and/or deterioration
Correct management of trachae
Ask re angina

SpO2, observe respiratory muscles during treatment
Muscle strength and mobility
RR, Anxiety
2 x day needs frequent treatments

Continue the above, reassess, and aim to have patient standing by self without tilt table
B. What condition, common in long-term ICU patients, does this man appear to have developed?
This man has weakness in several limbs lower > upper. He appears to have critical illness weakness syndrome
C. What could be some signs of deterioration in this man?

The man already has a high respiratory rate and a SpO2 of 95 on FiO2 of 0.28. He should be receiving CPAP or BiPAP
to help his work of breathing particularly with any rehabilitation eg tilt table. He should be reviewed regularly by intensive care
staff, still be having arterial blood gases checked and BiPAP applied more continuously if he deteriorates.

CARDIOTHORACIC CLINICAL REASONING SHEET
Student Name: Date:
Tutor’s Initials: Patient’s Initials:

1. What are the relevant findings from the medical chart and the implications for the
Physiotherapy Ax and Rx. (Are there any special questions to include in C/O or specific
points to check in the O/E?)

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

4. What is your treatment plan for this patient today? Briefly outline the aim of each
technique selected.
Position:
Ventilation:
Secretion removal:
5. Why is the above treatment plan appropriate for this patient? How would you modify
the treatment if not appropriate?
6. Discuss any factors that may influence your treatment plan. Why are they important to
consider?
7. What are the safety considerations for your treatment of this patient (eg
contraindications). How could you manage these?


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ACUTE STREAM

This manual has been compiled by

1. Acute Stream Program ........................................................................................................... 4

3. Revision Test ......................................................................................................................... 8

4. Week 1 Activities: Surgical management............................................................................ 10

5. Week 2 Activities: Medical management ............................................................................ 13

6. Week 3 Activities: Specialised Surgical management......................................................... 19

7. Week 4 Activities: Specialised cases................................................................................... 23

8. Outline of Answers to revision Exam .................................................................................. 28

9. Outline of Answers to Self-Directed Learning Activities.................................................... 30

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 3

1.1. Welcome to the Acute Stream Clinical Unit

1.3. Expectations upon commencing the unit

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 4

1.4. Acute unit assessment

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 5

Background Theory and Interpretation

The student should know;

The student should be able to:

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 6

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 7

The suggested time frame is 45 minutes.

FiO2 - 0.30 via a multi-vent mask

a. Interpret the ABG’s

b. Discuss the breathing pattern that your patient may be demonstrating

b. What classical sign would demonstrate the involvement of the ( R ) ML?

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b. Provide the range of normal values for these results

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4.1. Interpretation of a medical chart

A. What is the patient’s main reason for admission?

4.2. Patient attachments and their physiotherapy implications

© -Division of Physiotherapy, The University of Queensland - Acute Stream ILP 2006 10

HPC : 10 kg weight loss over last 4 / 12

PMHx : Smoker 20 / day for last 40 years

Post op orders : NBM

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

He now presents Day 1 post op :

O/E : Distressed RR - 30/min Accessory muscle use +++

It is now Day 3 post op and Mr C presents with the following:

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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C. Are they mainly positive or negative?

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5.1. Treatment progression

Medications: Prednisolone 15 mg/day – long standing dose

ABG’s on 2 L/min : pH 7.35, pCO2 45, pO 2 67, HCO3 27

Temp 375 Pulse 90

Dx Acute exacerbation of chronic lung disease

Rx Oral antibiotics, nebulised Ventolin/Atrovent 2/24, IV hydrocortisone, O2 2 L/min

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PMHx: Transverse Colectomy 6/95 for Ca

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)