Post Operative Assessment & Rehabilitation of abdominal surgeries

 POST OPERATIVE ASSESSMENT & REHABILITATION OF ABDOMINAL SURGERIES:

POST OPERATIVE ASSESSMENT

1.     Surgery notes reading

·        Type of incision

·        Type of anaesthesia

·        Duration of surgery

2.      Vital signs checking

·        Tidal volume-2ml/kg

·        Body weight Minute volume-100ml/kg

·        Body weight FVC-70ml/kg FEV1-70-90%of FVC

·        PaO2-not less than 70mm/hg

·        Paco2-not more than 50mm/hg

·        RR-12-16/min ABG analysis

·        Pulse oxymetry

·        PR

·        ECG

·        Heart sounds

·        Systemic arterial blood pressure

·        CVP

·        TPR chart Ventilator support

3.     Understanding the attachments

·        Iv lines

·        Nasogastric tube

·        Catheter

·        PCA

·        Drains

4.     Orientation assessment

·        Communication ability

·        Alertness

·        Perceptual ability to follow instructions

5.     Objective assessment

·        Respiratory

·        Circulatory

·        ROM/MUSCLE POWER

·        Mobility/functional

·        Balance

·        Coordination

6.     Respiratory assessment

·        Painful breathing

·        Difficulty in coughing

·        Impaired respiration

·        Accumulation of secretions

·        Palpation

·        Auscultation

7.     Circulatory assessment

·        Homan’s sign

·        Oedema

8.       Posture & mobility

·        Kypho scoliosis

·        Bed mobility

9.     Pain assessment

·        VAS

·        MPQ

AIM OF PHYSIOTHERAPY TREATMENT

·        Prevention of early post-operative complication

·        Prevention of post-operative pulmonary complications

·        Prevention of post-operative  circulatory complication

·        Prevention of post-operative postural deformity

·        Prevention of muscle wasting and joint immobility

·        Reducing length of hospitalisation and

·        Maximising the patient's functional ability and degree of independence. 

Day 1 onwards

A.   PREVENTION OF EARLY POST-OPERATIVE COMPLICATION

o   Pain: Pain:  It is normal to have some pain in the days immediately following the surgery. However, excessive pain can delay mobility and/or prevent coughing which can lead to chest complications.

o   Pressure sore

B.   PREVENTION OF PULMONARY COMPLICATIONs

o   Due to anaesthesia, patient may find it difficult to take deep breaths and to cough up secretions.

o   Pain causes reflex inhibition of the diaphragm and therefore breathing is difficult.

o   Due to affected abdominal muscles the patient tends to avoid using them because of pain or fear of pain and this again hampers respiratory movements. 

Chest complications are most likely to occur in the first 48 hours after surgery. It is therefore important to do regular breathing exercises to expand  all parts of the lungs and to clear any build-up of secretions, decreasing the risk of infection.

1.     Breathing exercises–The aim of the deep breaths is to loosen any secretions which you may feel have moved into throat and upper airways.

It should be given to all parts of the chest but particularly the lower costal and posterior basal areas. Breathing should be as deep as possible with emphases on the expiratory movements as this helps to loosen the secretions and stimulate the cough reflex.

Position: Sitting as upright as possible in bed or in a chair.

Technique:

o   Relax the shoulders and upper chest

o   Take a slow deep breath in through the nose if possible

o   Hold the breath for 3 seconds

o   Breath out slowly through the  mouth

           Repetition: Take four deep breaths as described every hour.

2.     Huffing: If the patient feels these secretions moving, performing a huff will often help to move these sections to the back of throat, and from there, patient should be able to clear them with a less vigorous cough. When huffing, it is important to tilt the chin up, and keep the  mouth open. Take a medium sized breath in and a short, sharp breath out, as if fogging up a mirror. Repeat this step two to three times. For an effective huff/cough, use a rolled up towel/pillow to support the tummy/abdomen and wound.

3.     Coughing: The patient must be encouraged to cough and try to clear any secretions. It is important to give as much support as possible when the patient attempts to cough. It helps if the patient places his hands over or around the wound as the pressure helps to prevent stretching of the wound as the patient coughs. In abdominal surgery it may help if the patient can bend his knees up, as this relaxes the abdominal wall and decreases the stretch on it as the patient coughs. Remember fewer strong coughs have more effect than a lot of weak ones.

4.      Inhalation: If the secretions are very sticky the patient may need an inhalation to loosen them.

5.     Postural drainage and Vibration: If secretions cannot be removed it may be necessary to use other techniques such as postural drainage and vibrations.

C.   PREVENTION OF CIRCULATORY COMPLICATIONS:

Circulatory exercises: These are important to help relieve any swelling, prevent blood clots and increase the circulation. These can be done either lying in bed or sitting in the chair.

·        Ankles:

o   Move the feet up and down briskly 10-20 times every 30 minutes.

o   Move the ankles in circles

·        Knees:

o   In bed – pull up the toes towards the hip, then push the back of the knee down into the bed. Hold for five seconds then relax. Repeat five times on each leg.

o   Sitting in a chair – straighten the knee out in front of the body. Hold for five seconds then relax. Repeat five times on each leg.

·        Buttocks: Tighten the buttocks regularly to relieve pressure from the bottom (repeat five times).

From day 2 onwards

A.   ABDOMINAL EXERCISES

Start: Day 2 after the surgery. Here are 3 exercises to do twice daily for approximately 3 months. Increase repetitions as able:

Why: Help strengthen the deep abdominal muscles, enhance blood flow to the area and promote healing.

Position: Lie on the bed with the head on a pillow, knees bent and feet flat on the bed.

1) Static abdominals: Place the hands on the lower tummy. Breathe in through the nose and as to breathe out, gently pull the belly button down towards the spine. Aim to hold this for 5 seconds. Repeat 5 times.

 2) Pelvic tilting: Pull in the tummy muscles. Then push the lower part of the spine down into the bed and curl the bottom up. Hold for 3 seconds and then release gently. Repeat 5 times.

3) Knee rolling: Keeping the knees together, gently move the knees down towards each side as far as is comfortable. Repeat 5 times each side.

·        Does each of these exercises three times a day and repeat each one five times. Do more repetitions as you feel able.

·        Discontinue the exercises if they cause any pain and seek advice from the physiotherapist.

B.   MOBILITY : It is important to mobilize as early as possible post-surgery. This will help to facilitate a speedier recovery and in turn assist with your chest care. You will be instructed in how to get out of bed on the first morning after the operation. Try to stay out for a minimum of 30 – 40 minutes.

1.     To get out of bed:

•         When: It is important to sit out of bed as soon as possible following your operation.

•         Why: The upright position is the best position for your lungs and it will help you improve your circulation and general function.

•         How to get out of bed: Bend your knees up, roll onto your side (This avoids twisting the abdomen and incision).Bring your legs over the edge of the bed and lower your feet to the floor using your elbow to push yourself into a sitting position.

•         Sitting out of bed: It is important that you sit out for as long as you can tolerate each day following your surgery. Try to increase the time spent out each day.

Getting out of bed for the first time may make you feel light-headed or nauseous. This can be a side effect of the general anaesthetic and can be helped by sitting at the bedside for a few minutes and taking deep breaths. If necessary, an injection may be given to control nausea. Most patients will have connections such as an arm-drip, a wound-drain or a urinary catheter. These are usually removed within 2-3 days. Care should be taken that they are not pulled during mobility.

2.     Walking :

Role of walking:

·        Promotes independence

·        Prevents chest infections

·        Reduced risk of blood clots

·        Increases your strength, fitness and endurance

How much: Try to gradually increase the amount of walking you do each day. Regular short walks are recommended. For example, walk around the bed space, to the toilet and to look out of the window. Try to walk about five metres on the first day with the physiotherapist. Increase this distance gradually. The aim should be that by discharge, the patient can walk a minimum of 40 - 50 metres with ease.

C.   PREVENTION OF POSTURAL DEFORMITY:

1.     Posture: It is very important to be aware of the  posture and take special care for about six weeks after the surgery. A good posture will help to prevent backache.

2.     Sitting posture: Sit upright in a supportive chair, if possible, with both feet on the floor. Do not slouch. Place a small cushion or rolled towel in the small of the back.

3.     Standing or walking posture: Avoid holding the tummy with the hands and slouching forwards. Stand upright with shoulders back; keep bottom and tummy tucked in.

4.     Lifting: Do not lift heavy objects for at least six weeks. When the patient need to lift or pick something up, bend his knees and keep his back straight. Hold larger objects close to the body.

D.   PREVENTION OF MUSCLE WASTING AND JOINT IMMOBILITY
Muscle weakness and joint stiffness are particularly likely to occur in the elderly if they remain in bed for any length of time before or after surgery. The physiotherapist may need to give general mobilizing and strengthening exercises to enable the patient to regain independence.

ADVICE ON DISCHARGE

·        Exercises: Continue with the exercises for at least six weeks, preferably three months, if you are returning to a physical job.

·        Rest: The body is using energy to heal itself so the patient will feel more tired than normal. Do not try to do too much too soon, and allow some rest time each day to aid the recovery.

·        Walking: Try to walk for about five to 10 minutes at least once a day. Hills and stairs are quite safe but build up speed and distance gradually. Walking is a very valuable exercise; try to increase your walking time and distance each week.

·        Driving: Do not drive for about four to six weeks, depending on the surgery. Make sure that the patient can wear a seatbelt comfortably and perform manoeuvres and an emergency stop without undue pain.

·        Work and sports: Always get approval from the doctor to return to work. Gradually build up your level of physical activity.

·        Also get approval to return to the normal exercise routine e.g. swimming, cycling, aerobics and other sports.

Do’s
Independent personal hygiene; light housework; making drinks; washing and drying dishes; preparing light meals.

Don’ts
Decorating; heavy lifting; shaking the duvet or heavy bedding; cooking a large meal using the oven; heavy housework; gardening; D.I.Y.

Week 1:

·        Regular short walks

·        Abdominal exercises

·        Rest during the day

·        Avoid heavy lifting

Week 2-5:

·        Continue with exercises and walking: Increase distance as able and as feels comfortable

·        Regular rest: Pacing activity

·        Light housework – light meals and cleaning

·        Still no heavy lifting

Week 6:

·        Driving (practice emergency stop)

·        Cycling on the flat

·        Low impact aerobics

Week 12:

·        Normal activities

·        Preferred exercise should be resumed gradually especially high intensity/competitive sports

·        Tennis, running, cycling up hills