PBT 3

1. What is MRSA? What are the modes of transmission? Who is at risk for MRSA?
Public Health Agency of Canada
- Staphylococcus aureus is a bacteria commonly found on the skin and in the noses of
healthy people
o Around 25% of general population carry Staph bacteria on their hands or in their
noses but are not ill
- If left untreated, MRSA infections may develop into infection of the bloodstream, bones,
and/or lungs (e.g. pneumonia)
- Usually spread through direct physical contact or through contact with objects
contaminated with infected bodily fluids
- People with weakened immune systems and chronic conditions are more susceptible to
infection
- On rare occasions an MRSA infection can result in life-threatening illness or death but
most cases are limited to the skin and can be successfully treated with antibiotics other
than methicillin
- To prevent the spread of MRSA skin infections, you must:
o Cover your wound pus or other drainage from the wound can contain MRSA, so
make sure that the bandages and tape used to cover the wound are properly
discarded
o Wash hands frequently especially important after changing bandages or
touching the infected area
o Avoid sharing personal items towels, razors, washcloths; make sure any soiled
clothing is washed water and regular laundry detergent is sufficient
o Using gloves when touching blood or body fluids, masks and gowns during
procedures likely to generate splashes or droplets of body fluids
o Cleansing and sterilization of patient care equipment
o Educating patient, families, and visitors
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CPO website
Arrange treatment times when the clinic is least busy or when patients who are frail and
vulnerable to infection are not attending the clinic. If the clinic is consistently busy or the
patient is unable to attend at the preferred treatment times, try to arrange care in the
patients home
The clinic staff has the responsibility to provide treatment to the MRSA patient, but its
first responsibility is to protect the interest of its current patients. If the clinic staff had
offered the patient the best available appointment times, explained the reasons for the
restriction in appointment times, the benefits of treatment and the impact of not attending
treatment, and the patient still refused the appointment times offered, clinic staff would
have the following choices:
o Contact the referring facility and explore other treatment options
o Provide patient with list of other clinics in the area
o Document all actions taken in attempt to accommodate the patient while trying to
protect the interests of its current patients

2. How do we interpret Andrews chest x-ray report?

- Left lower lobe collapse triangular area of increased density behind the heart shadow
o Auscultation decrease breath sounds bilaterally in lower lobes
o End-inspiratory coarse crackles in left lower lobe
Air bubbling through mucus in large airways
- Atelectasis post-op complication causing hypoxia
o Usually occurs in the first 48 hours following surgery
o In abdominal and thoracic surgery, the normal mechanisms by which mucus is
cleared is impaired by pain, inhibiting deep breathing and coughing
o Mucus retention occurs with resorption of alveolar air, leading to alveolar
collapse
o Management
Assessment of degree of respiratory support required, in general
supplemental oxygen therapy will be sufficient
Assessment of the patients analgesic requirements should be performed to
ensure they can breathe and cough without inhibition
Chest physiotherapy required to ensure clearance of mucus and secretions
and helpful in preventing secondary infection
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Normal body temperature can range from 36.5 to 37.2 degrees Celsius for an adult
o Low grade fever is 37-39 degrees Celsius
o High grade fever is 39 degrees or above
Normal hemoglobin levels in men are from 140g/L to 180 g/L
o Need iron therapy, in the form of oral pills, so blood levels can normalize
Resp rate 22/mins (tachypnea >20/mins) and reduced diaphragmatic excursion
Rapid shallow breathing
Normal value for WBCs in the blood is 4,500 to 10,000 WBC per microliter
o High number of WBC is called leukocytosis
o May be due to: anemia, cigarette smoking, infections, inflammatory disease,
tissue damage
When the bodys CO2 sensor begins to fail (commonly COPD), PO2 falls which triggers
hypoxic drive to increase ventilation
o They require a certain level of hypoxia to keep breathing
o At times, a high flow oxygen mask may be applied to a doctor which may abolish
the hypoxia, causing underventilation which can be fatal
o Oxygen should be controlled to achieve an oxygen saturation between 88% and
92%; at this level, the patient will not die of hypoxia nor will ventilation be
depressed to any significant degree
Productive cough with yellow sputum
o Under normal circumstances, mucus is clear and transparent
o When infected, mucus changes colours and one of the first signs of an infection is
usually yellow mucus discharge from the nose and throat
o Yellow mucus is often a clear hint of bacterial invasion and involvement and it
also indicates that the bodys immune system is fighting against it

o Soon after a few days, an untreated cold results in yellow to greenish nasal
discharge (bacterial infection)
o This usually results in nasal blockage and breathing difficulties
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Fowlers position
o Standard position commonly used for patients to promote oxygenation via
maximum chest expansion and implemented during events of respiratory distress
by relaxing the tension in the abdominal muscles to improve breathing
o Semi Fowlers position is semi-upright sitting position between 30-45 degrees to
alleviate compression of the chest
o Fluid is allowed to flow in the abdominal cavity and be collected in the pelvic
region - if the patient is lying down without the tube feeding can run into the
lungs

3. Could Andrew have pneumonia?

- Pneumonia is a disorder marked by inflammation of the lungs and alveoli, most
commonly caused by bacteria in post-operative patients
- Lung inflammation prevents adequate gas exchange, despite adequate ventilation and
perfusion
- Progression can lead to segmental bronchial collapse, reducing oxygenation further by
preventing alveolar ventilation
- Colonization of the lung with pathogenic bacteria due to aspiration of contaminated
secretions, combined with relative immunosuppression due to surgery make this a
common post-operative complication
o Hospital acquired pneumonia is defined as pneumonia which occurs after 48
hours in hospital
- Clinical features:
o Presence of 3 or more of the following features without any other obvious cause:
cough, sputum production, dyspnea, chest pain, temperature >38 degrees Celsius
and tachycardia
A controlled trial of intermittent positive pressure breathing, incentive
spirometry, and deep breathing exercises in preventing pulmonary
complications after abdominal surgery 1984 Celli
- Management:
o Initial management is supportive, with administration of oxygen and intravenous
fluid therapy. Physiotherapy is essential to allow the patient to clear secretions
from the lung
o The post-operative patient with pneumonia should be frequently reassessed to
ensure that no further deterioration occurs. If the patients condition worsens
despite full supportive management and he/she appears to be tiring (especially
with worsening tachypnea), input from intensive care should be sought as the
patient may require ventilatory support
4. What are post-op complications after surgery?
- Respiratory depression: opiates and carbon dioxide narcosis

Can present as hypoxia due to reduced ventilation secondary to reduced respiratory drive,
impaired consciousness due to drug toxicity or carbon dioxide narcosis
o Elderly and patients with renal impairment do not excrete opiates effectively and
accumulation can occur
o In toxic concentrations respiratory depression occurs, with hypoventilation
o Respiration in patients with COPD is dependent on hypoxic drive; if a patient is
given high concentrations of oxygen, their respiratory stimulus is lost and
respiratory depression occurs
o Patient can quickly develop carbon dioxide retention, respiratory acidosis and
reduced consciousness, causing hypoventilation and associated hypoxia
May notice pin-point pupils or a bounding pulse (heart is racing, strong)

Bronchospasm: sudden constriction of bronchiolar muscle, stimulated by histamine

release
o Inhibits air entry and exit into the alveoli
o Can occur in post-operative patients with pre-existing pulmonary conditions such
as asthma or COPD with contributing airways hyper-reactivity; also a feature of
anaphylaxis
Clinical features:
o Wheezing on auscultation
NSAIDs are frequently administered as analgesia post-operatively and may have been the
provoking factor for bronchospasm
o A new prescription of aspirin could also contribute

Pulmonary embolus: causes obstruction to the pulmonary vascular tree by an embolus,

usually from a DVT of the pelvic or large leg veins
Inadequate pulmonary perfusion to adequately ventilated areas of the lung occurs,
impairing gas exchange and causing hypoxia
o Immobility, cancer, and surgery are significant risk factors
o Embolus is not always thrombus; air embolism can occur following insertion of
central venous catheters and rarely fat embolism can occur in patients with
sustained long bone fractures
Clinical features:
o Small subclinical emboli can occur without any symptoms
o In general, the larger the embolus, and larger the ventilation/perfusion mismatch,
the more profound the symptoms
o A massive pulmonary embolus classically presents with a collapsed,
hemodynamically unstable patient who may have just visited the toilet (the
straining dislodging the distal thrombus)
o Smaller emboli can present with dyspnea, pleuritic chest pain and hemoptysis
with signs of hypoxia
Others
Tachycardia
Tachypnea
Signs of DVT

Low grade fever

New onset arrhythmia

Pulmonary edema: accumulation of fluid in the lung parenchyma which prevents

effective diffusion of gas between the alveoli and pulmonary circulation, leading to
hypoxia
Can occur readily in post-operative patients, generally cardiogenic as a result of:
o Acute deterioration in cardiac function
Myocardial infarction, acute coronary syndrome or arrhythmia
o Fluid overload
Excessive parenteral fluid therapy can cause left ventricular dilatation
Clinical features: the patient may appear to be in respiratory distress with dyspnea,
tachypnea and signs of hypoxia
o May also have tachycardia, narrow pulse pressure, hypotensive, with an elevated
jugular venous pulse or elevated central venous pressure if there is monitoring
o On auscultation of the chest, inspiratory crackles will be heard

ARDS acute respiratory distress syndrome characterized by inflammation of the lung

parenchyma causing impaired gas diffusion
- Normally presents as a sequel to sever systemic inflammatory response syndrome (SIRS),
when release of pro-inflammatory cytokines causes WBC recruitment in the lung
- Lungs become stiff, reducing ventilator capacity and compounds the effect on respiratory
function
- More likely found in patients with profound sepsis, extensive trauma or massive blood
transfusion
- ARDS should not be diagnosed in a post-operative patient who has had uncomplicated
elective surgery
Fever in the post-operative patient by Fraser and Mangino; Antimicrobe (database for infectious
disease)
- In the first 48 hours of the post-operative period a fever is nearly always non-infectious in
origin
- Tissue damage alone results in the disruption of phospholipids from the cell membrane,
leading to a cascade of prostaglandins and cytokines that eventually lead to a body
temperature elevation
o Fever that persists beyond 96 hours generally warrants further attention
o Post-operative infections include device-related complications such as hospital or
ventilator-associated pneumonia, catheter-related urinary tract infection, catheterrelated bloodstream infection, and surgical site infections
o Other rarer infections can include: sinusitis, odontogenic infections, occult
abdominal abscesses, or infectious sources that were incubating prior to the
surgery
-

Hospital-associated pneumonia (HAP) is the second most common infection after urinary
tract infection and is a frequent cause of infection in the post-operative patient

o Especially surgical procedures requiring general anaesthesia and intubation

o Intubation increases the risk of developing ventilator-associated pneumonia
(VAP) by promoting aspiration and colonization of the endotracheal tube with
endogenous and multi-drug resistance, healthcare-associated pathogens especially
as the duration of intubation increases
Immobility promotes atelectasis and poor clearance of secretions
5. What are physiotherapy interventions after abdominal surgery?
Chest physiotherapy for pneumonia in adults. Yang et al., Cochrane Review. 2013
- RCTs assessed the effectiveness and safety of chest physiotherapy for pneumonia in
adults
- 6 RCTs assessing 434 participants were included. The studies appraised four types of
chest physiotherapy, namely conventional chest physiotherapy, osteopathic manipulative
treatment (including paraspinal inhibition, rib raising, and diaphragmatic or soft
myofascial release), active cycle of breathing techniques (including active breathing
control, thoracic expansion exercises and forced expiration technique) and positive
epiratory pressure. None of these techniques (vs no physiotherapy or placebo therapy)
reduce mortality. Among three of the techniques (conventional chest physiotherapy,
active cycle of breathing techniques and osteopathic manipulative treatment) there is no
evidence to support a better cure rate in comparison with no physiotherapy or placebo
therapy
- Chest physiotherapy should not be recommended as routine additional treatment for
pneumonia in adults
Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery.
Pasquina et al., 2006. Chest
- Examined the efficacy of respiratory physiotherapy for prevention of pulmonary
complications after abdominal surgery
- 35 trials tested respiratory physiotherapy treatments. Of 13 trials with a no intervention
control group, 9 studies (n=883) did not report on significant differences, and 4 studies
(n=528) did: in 1 study, the incidence of pneumonia was decreased from 37.3 to 13.7%
with deep breathing, directed cough, and postural drainage; in 1 study, the incidence of
atelectasis was decreased from 39-15% with deep breathing and directed cough; in 1
study, the incidence of atelectasis was decreased from 77-59% with deep breathing, direct
cough, and postural drainage; in 1 study, the incidence of unspecified pulmonary
complications was decreased from 47.7% to 21.4 to 22.2% with intermittent positive
pressure breathing, or incentive spirometry, or deep breathing with directed cough. 22
trials (n=2,734) compared physiotherapy treatments without no intervention control
subjects; no conclusions could be drawn
- Few trials that supported the usefulness of prophylactic respiratory physiotherapy and the
routine use of respiratory physiotherapy after abdominal surgery does not seem to be
justified
- There are clinical settings, in which the usefulness of respiratory physiotherapy is based
on strong evidence, for instance, therapeutic non-invasive positive pressure ventilation in
patients with acute exacerbations of severe COPD, pulmonary rehabilitation in patients

with COPD, chest physical therapy in patients with cystic fibrosis, or CPAP for the
treatment of post-operative hypoxemia. Yet, routine use of respiratory physiotherapy in
patients after abdominal surgery does not seem to be justified
o In line with a meta-analysis in 1993 by Thomas looking at the conflicting body of
literature concerning the efficacy of incentive spirometry, intermittent positive
pressure breathing, and deep breathing exercises in the prevention of postoperative pulmonary complications in patients undergoing upper abdominal
surgery. There was no evidence to support a significant difference between any of
the three modalities
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Princess Alexandra Hospital in English physiotherapy advice following abdominal

surgery
o Improving lung function: breathing exercises, the huff, coughing
o Getting back on their feet:
Bed exercises (foot and ankle PF/DF and circular motion; 10 reps with
each foot per exercise)
Buttock squeezes: for either sitting in a chair or in bed (hold for 5 seconds
and then release for 10 reps)
Knee bending: either sitting up or lying down in bed (10 reps with each
leg)
Sitting out of bed: physiotherapy staff will help to get patients out of bed
on the same day of the surgery and continue to assist until patient can get
out of bed independently
Aim to sit out of bed every day, aiming for 2 hours on the day of
the surgery and 6 hours on day one
Knee bending: sitting in a chair
Straighten leg and put foot on floor (10 reps with each leg)
Walking
Start walking (about 5 metres) on the first day after surgery
Most people are moving freely within 3-5 days after surgery
Short walks 2-3 times per day are best
Start by walking to the bathroom and back or in the corridor
outside your room and increase the distance as you feel safe to
Stairs
Physiotherapist may request to see patient ascend and descend a
flight of stairs before discharge
Return to exercise
Gradual and controlled and PT will give a rough guide as to the
amount and level to perform based on previous level of exercise
Walking is the best exercise for the first 2-6 weeks
Dos and dont
o Avoid heavy lifting and pushing
o Avoid repetitive bending especially with associated lifting

o Delegate heavy housekeeping chores (vacuuming or

laundry)
o Do sit in a chair that is easy to rise out of
o Avoid carrying children for long periods
o Rest
The quantity of early upright mobilisation performed following upper abdominal surgery
is low: an observational study. Browning et al., Australian Journal of Physiotherapy.
2007.
o 50 patients with upper abdominal surgery after receiving physiotherapy
intervention on the first post-operative day
29 of which were male, mean age of 61, 7 were current smokers
o Activity logger recorded uptime continuously for the first 4 post-operative days
and collected information on post-operative pulmonary complications, surgical
attachments, pain relief, duration of anaesthesia, and intensive care admission
o Total median uptime was 3, 7.6, 13.2 and 34.4 minutes for the first four postoperative days
Morning uptime was greater than both afternoon and evening uptime
o Given that uptime predicted length of stay, increasing early upright mobilization
may have a positive effect on reducing length of stay following upper abdominal
surgery

6. What is Andrews plan of care?

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Ottaway hospital booklet on open abdominal aortic aneurysm repair (revised 2013)
After surgery, patients can expect to spend approximately 2 days in the ICU and many
patients need a mechanical ventilator with a tube placed into the trachea right after
surgery and usually removed on the first day following surgery
Plan to stay in hospital for 9 days including day of surgery
Post op day 1: deep breathing and coughing, range of motion, dangle at edge of bed with
assistance if off ventilator
Post op day 2: transfer out of ICU, deep breathing and coughing, range of motion, up in
chair
Post op day 3: deep breathing and coughing exercises, ankle exercises, activity frequency,
up in chair, up walking, smoking cessation
Post op day 4: progress to ambulating independently till discharge