Independent Learning PackageAcute2005

• Other symptoms Day 4 The low ABP (which is requiring inotropic support) and peripheral shut down, would likely indicate sepsis in this gentlman. • Treatment changes Day 4 ¾ no disconnection from the ventilator ¾ position flat rather than sitting up ¾ emphasis should be on passive/ active exercises ¾ secretion clearance techniques on the ventilator if appropriate. ¾ no antiembolic stockings secondary to peripheral shut down ¾ vigilant skin care • Progression of treatment as condition improves: ¾ Increase active exercise component ¾ Position more upright as haemodynamics allow ¾ SOOB and mobilize as soon as haemodynamically stable N.B. MHI in an ARDS patient can have significant detrimental effects -> mobility and positioning should become the emphasis to optimize ventilation • If respiratory function further deteriorates - mode of ventilation: Pressure controlled ventilation (PCV) may be commenced if lung compliance continues to decline. In this mode, a preset pressure is set, minimizing the risk of barotrauma. Inspiratory volumes will thus vary depending on airway resistance. PATIENT 3 • Major effect of physiotherapy on the acute HI patient Potential to increase ICP • Additional equipment for 23 year old acute HI patient • Extraventricular drain (EVD) / ICP monitor • End Tidal CO2 monitor • Underwater seal drainage - UWSD 144 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Precautions necessary with equipment: ¾ R/V precautions associated with ICCs and UWSD ¾ EVD - provides an indication of changing intracranial dynamics before they are clinically evident. Drainage system will be set at a height recommended by the Medical staff. This is usually 10cm above the tragus, though will vary dependent upon the patient. ÎIf sitting patient up/ SOOB, this needs to be adjusted to control CSF drainage ie if too low -> excess CSF will be drained if too high -> less CSF will be drained which may contribute to ↑ ICP In some ICUs, it is requested by the medical staff that the drain be closed during Physiotherapy treatment to avoid uncontrollable volumes of CSF being drained during moments of increased ICP eg suctioning. Check with the staff in the unit that you are working, to confirm their protocol. When the drain is on free drainage, the ICP measurement will be less accurate and no waveform will appear on the monitor. ¾ End tidal CO2 (ETCO2) monitor Provides a continuous measure of CO2 levels to detect changes that may be dangerous or missed with ABG analysis (intermittent). ♦ Best placed as near to the airway as possible. ♦ Used in patients with CHI due to the relationship between CO2 and ICP - > R/V this relationship When bagging a patient with ETCO2 monitoring in situ, be sure to keep the attachment in the circuit to enable ongoing monitoring during treatment. Rapid drops in CO2 with bagging may result in arrhythmias and rebound hyperaemia. Therefore aim to keep the ETCO2 constant during treatment. 145 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• CPP definition, calculation and level: ¾ Cerebral perfusion pressure provides a clinical estimate of cerebral perfusion. CPP = MAP – ICP The goal CPP will be recommended by the Medical staff though usually should be kept above 70mmHg. CPP below 60mmHg has been associated with cerebral ischaemia. • Minimise the effect of physiotherapy in increasing ICP ¾ Keep treatment sessions short ¾ Patient is usually positioned 30degrees head up with head in the midline - not rotated as may occlude jugular drainage ¾ Quick suction not stimulating prolonged cough effort ¾ Treatment immediately post IV sedation ¾ No tipping and maybe not even bed flat ¾ Avoid prolonged sessions of manual hyperinflation ¾ Adjust MHI rate and volumes to maintain ETCO2 at a constant level ¾ Monitor vital signs ¾ Nursing staff may drain CSF prior to or during treatment • CPP drops during treatment: ¾ Monitor other parameters including ABP and HR ¾ Increase rate of MHI to decrease CO2 and thus decrease ICP ¾ If able to sustain CO2 and ICP at appropriate levels -> continue ¾ If continued decline in CPP -> reconnect to ventilator and cease treatment • Paralysing agents and effects on respiratory function: ¾ Patients may be paralysed to prevent shivering if they are being actively cooled to manage their ICP - cooling decreases metabolic requirements and thus is neuroprotective. ¾ When paralysed, the patient will be unable to cough and is thus at a much higher risk of secretion retention and subsequent infection. Vigilant chest Physiotherapy is thus necessary during this time if tolerated by the patient. 146 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Contraindicated techniques post extubation ¾ BOS # provides a direct connection between the nasopharynx and brain, thus introducing a high potential for infection and trauma. ¾ BiPAP or IPPB via mask, as well as nasopharyngeal suction are therefore contraindicated in this patient group. The only positive pressure possible will be IPPB via a mouth piece ( patient will usually need to be cooperative for this). ¾ stretch facilitation, percussion and vibes on the right secondary to rib #s • Post extubation treatment As the patient is drowsy and poorly cooperative, techniques for treatment might include: ¾ Positioning eg L sidelying, high sitting, SOOB ¾ Facilitated DBEs ¾ Stretch facilitation on the left ¾ Passive limb movements for demand ¾ Secretion removal techniques on the left if warrented ¾ Tilt tabling ¾ Stimulate cough with tracheal pressure ¾ If ineffective ⇒ Suction via Guedels • Mobilization: ¾ SOOB - choice of chair will be dependent upon the presence of tonal changes ¾ Tilt tabling - R/V benefits of tilt tabling ¾ Progress to more active mobilization when patient is less drowsy and better able to cooperate ¾ SOOB and tilt tabling should be commenced in the ICU as soon as the patient is haemodynamically and neurolically stable. 147 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

MEDICATIONS The following exercises with simulated drug sheets aim to provide you with the opportunity to test your current knowledge of drugs as well as your ability to interpret drug sheets. It will provide you with a guide as to the questions you should be asking yourself with each new patient. You may well be surprised as to the amount of information that can be gained from the drug sheets alone. It would be ideal to do this section without reference to your drug list. If however you use your list it may be beneficial to repeat the exercises towards the end of the unit to assess your progress. 148 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 1 : 3 pages of Medications PRESCRIPTION Date 1/2 2/2 3/2 4/2 5/2 6/2 Time LD LD CJ CJ WS WS Drug Route 0800 Perindopril O (Coversyl) Dose Freq Start Daily 2mg 1/2/99 Drug Route Chlorvescent O 0800 LD LD CJ CJ WS WS WS WS Effervescent 1400 LD LD CJ CJ PJ PJ K+ ES ES Dose Freq Start 2200 JA JA JA PJ WS WS LM LM II Tds 1/2/99 ES ES Drug Route LM LM Ampicillin IV 0600 BT BT BT ES WS WS LM LM 1200 LD LD CJ CJ LM LM Dose Freq Start 1800 RP RP KT KT 149 1gm Q6hr 1/2/99 2400 BT BT BT ES Drug Route Gentamicin IV 2100 RP RP KT KT In 100mls Start over 30 mins Dose Freq 280m Nocte 1/2/99 g Route Drug Metoprolol 0800 LD LD CJ CJ Betaloc Dose Freq Start 50 mg Bd 2/2/99 2000 RP RP KT KT Drug Route Simvastatin O 2000 RP RP KT KT Start Lipex / Zocor Dose Freq 10 mg Nocte 2/2/99 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PRESCRIPTION Date 1/2 2/2 3/2 4/2 5/2 6/2 Time Drug Route Aspirin O 0800 LD LD CJ CJ WS WS Dose Freq Start 150m Daily 1/2/99 g Route Drug Anginine S/L Dose Freq Start CJ 1210 I Prn 1/2/99 Drug Route Morphine IV Dose Freq Start CJ 1220 2.5- q4hr 1/2/99 5mg Prn Drug Route Maxalon IV Metochlopram Start ide Dose Freq Qid/pr 1/2/99 n Drug Route Frusemide O / IV 0600 BT BT BT ES ES ES Dose Freq Start WS WS 40mg Bd 1/2/99 1200 LD LD CJ CJ LM LM 150 Drug Route Nitrolate Paste Top 0600 Dose Freq Start 1000 1400 15mg q4hr 1/2/99 1800 RP RP KT KT © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PRESCRIPTION Date 1/2 2/2 3/2 4/2 5/2 6/2 Time LD LD CJ CJ WS WS Drug Route Phenytoin O 1000 Dilantin Dose Freq Start 1/2/99 30mg Mane SINGLE DOSE MEDICATIONS Administration DRUG ROUTE DOSE DOCTOR’S Administered SIGNATURE DATE 10mg Initial Tim 40mg Smith e TIME Chang KT 2400 4/2/99 O/C Diazepam O LM 1725 6/2/99 1715 Frusemide IV QUESTIONS relating to Patient 1 : 1) Outline the group to which each medication belongs, their primary actions and uses. 2) From this list, what are the primary medical conditions of this patient? 3) Why is the patient receiving chlorvescent? 4) Why is the patient written up for maxalon? 5) Is the patient’s IHD stable? 6) What precautions would you take with this patient? 151 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 1 : MEDICATION 1. See next page for Table of medications 2. CONDITION Cardiac / IHD Perindopril, Metoprolol, Aspirin, Anginine, Nitrolate paste, Simvastatin, Morphine, Frusemide, Chlorvescent ? HT Perindopril, Metoprolol, Frusemide ? Heart Failure Frusemide + Chlorvescent, Perindopril Moderate to severe Coronary Nitrolate paste, Metoprolol Artery Disease Severe chest pain Morphine required Chest infection Ampicillin, Gentamicin Epilepsy Phenytoin 3. Chlorvescent , a potassium supplement is given due to the use of diuretics 4. Maxalon is prescribed to counter the potential side effects of nausea and vomiting associated with narcotics 5. The patient’s IHD is not stable as anginine was required on 3/2/99 and this did not relieve the pain and morphine was required to control the pain 6. Precautions in treating this patient : • Care with demand • No isometrics, triflo, inspiratory holds, tipping, prone or TEDs MEDICATIONS - Patient 1 1. Perindopril ACE Inhibitor Action Prevents conversion Angiotensin I to II Angiotensin II – powerful vasoconstrictor, acts on the kidneys to retain fluid and water Causes vasodilitation and ↓afterload by action as a diuretic Conditions Heart Failure; HT 2. Chlorvescent K+ supplement 152 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Action Replaces potassium lost with use of diuretic Conditions Where a non K+ diuretic is used e.g. with HT, Heart Failure 3. Ampicillin Penicillin Action Antibiotic to treat infection Conditions Infection 4. Gentamicin Aminoglycoside Action Antibotic Conditions Infection 5. Metoprolol Beta Blocker Action Blocks Beta 1 channels that are located in nodes and arteries Causes slowing of the heart and vasodilation Conditions Angina; HT; Tachycardia 6. Simvastatin Cholesterol lowering agent Action ↓ Cholesterol Conditions Patients with high cholesterol; adjunct to low fat diet 7. Aspirin Action Anti-platelet aggregation Conditions Prophylactic with IHD or post MI 8. Anginine Glyceryl trinitrate GTN used Sublingual (S/L) Action Shortacting Coronary Artery vasodilator Conditions Angina; Acute ischaemia 9. Morphine Narcotic analgesia Action Pain relief Conditions Used for chest pain or MI 10. Maxalon Anti-emetic Action Prevent or treat nausea or vomiting associated associated with narcotics Conditions Nausea or vomiting 11. Frusemide Non K+sparing diuretic Action Fast acting diuretic Conditions Heart Failure; HT; Fluid overload 12. Nitrolate Paste Nitrate Action Systemic vasodilation ⇒ ↓peripheral vascular resistance Conditions Moderate to severs CAD 13. Phenytoin Anticonvulsant Action Control of grand mal and psychomoter seizures Conditions Epilepsy; Fitting 153 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 2 : 2 pages of medications PRESCRIPTION Date 1/2 2/2 3/2 4/2 5/2 6/2 Time IR IR FJ FJ FJ MT MT HK HK SJ Drug Route 0600 IR T/H Pulmicort Dose Freq Start 1800 EF II Bd 1/2/99 x400 Route Drug Calcitriol O 0800 SJ SJ JW JW JW EF Start 2000 EF MT MT HK HK SJ Dose Freq 1/2/99 IR IR IR FJ FJ FJ 0.25m Bd SJ SJ JW JW JW EF g Route EF MT MT HK HK SJ EF MT MT HK HK SJ Drug 0600 Neb 1200 IR IR IR FJ FJ FJ Ventolin SJ SJ JW JW JW EF Salbutamol Start 1800 EF MT MT HK HK SJ EF MT MT HK HK SJ Dose Freq 1/2/99 2200 5mg QID Route Drug 0600 Neb 1200 Atrovent Ipatropium Start 1800 Bromide 1/2/99 2200 Dose Freq 500m QID g Route Drug Coloxyl & O 0800 SJ SJ JW JW JW EF Senna Dose Freq Start EF MT MT HK HK SJ II Bd 1/2/99 2000 IR IR IR FJ FJ FJ SJ SJ JW JW JW EF Drug Route EF MT MT HK HK SJ EF MT MT HK HK SJ Keflex O 0600 Start 154 Dose Freq 1200 QID 1800 500m g 3/2/99 2200 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PRESCRIPTION Date 1/2 2/2 3/2 4/2 5/2 6/2 Time SJ SJ JW JW JW EF Drug Route EF MT MT HK HK SJ Ranitidine IV 0800 Zantac 20mls over 20 mins Start 2000 Dose Freq 3/2/99 50mg Tds DRUGS WITH VARIABLE DOSE DRUG Prednisolone ROUTE IV DATE TIME DOSE DOCTOR NURSE 1/2/99 1000 200mg Smith SJ 2/2/99 1000 120mg Smith SJ 3/2/99 1000 80mg Smith JW 4/2/99 1000 40mg Smith JW 5/2/99 1000 20mg Smith JW QUESTIONS relating to Patient 2 : 1) For each of the medications outline the group to which they belong, their action and the route of administration. 2) What is the primary condition affecting this patient? 3) Outline the side effects for : a) Pulmicort b) Ventolin c) Atrovent d) Prednisolone 4. Why is prednisolone give as a reducing dose? 5. The patient is on calcitriol, what does this indicate? 6. What investigations might have been performed on this patient? 7. What are some other respiratory drugs that may be prescribed for this group of patients? 155 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 2 : 1. See table below DRUG GROUP ACTION ROUTE OF ADMINISTRATION Pulmicort Inhaled Anti-inflammatory Calcitriol Corticosteroid Prevention of Asthma Turbuhaler Ca++ Supplement Prevent hypocalaemia (T/H) Ranitidine Due to renal failure or Orally (O) H2 receptor osteoporosis Keflex antagonist Prevention or Intravenous(IV) Coloxyl & Senna maintenance of ulcers, Orally (O) Ventolin Cephalosporin anti-ulcerative Orally (O) Atrovent Bowel softener Antibiotic Nebuliser Laxative Prevent constipation Prednisolone Beta 2 agonist Nebuliser (Neb) Short acting bronchod Anticholinergic ilator Intravenous (IV) Weak bronchodilator, Corticosteroid potentiates the effect of ventolin ↓ inflammation 2. The primary condition affecting the patient is a respiratory one. 3. Side effects of : • Ventolin - Tremor, tachycardia, palpitations, hypotension, headaches, nausea, Hypokalaemia • Atrovent - Headaches, nausea, dry mouth, cough, rash • Pulmicort - Hoarseness,throat and mouth irritations, cough and oral candidiasis • Prednisolone - Skin fragility, delayed wound healing, osteoporosis if >3 mths use, fluid retention (Cushingoid features) muscle weakness immunosuppressed 4. Prednisolone is given as a reducing dose medication to enable stimulation of the adrenal cortex to reactivate to produce the body’s own natural cortisone. 5. The patient is on calcitriol for the prevention or management of osteoporosis or to counter the long term steroid use. 156 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

6. Investigations that might have been performed on this patient CXR Spirometry PFM (Peak flow meter) Sputum m/c/s→ appropriate antibiotics 7. Other respiratory medications Inhaled corticosteroids : Becotide, becloforte, Flixotide Xanthine derivatives : Theophylline, theodur, neulinand aminophylline Beta 2 agonists : Bricanyl, respolin Mast cell stabilisers : Intal Long acting bronchodilators : Serevent QUESTIONS relating to Patient 3 : 1) Discuss the use of these medications. 2) Outline the patient’s conditions based on his medication. 3) When used in an acute situation what side effect do you need to be aware of with hydralazine? 4) Discuss the precautions that you would take with this patient? 5) Has the patient had any chest pain? 6) Has the patient experienced any nausea? 7) If the patient was a NIDDM, what drugs might be prescribed? 8) If the patient’s BSL’s were unstable what might you expect to see in their medication sheet? 9) Can you suggest another occasion on which this scale might be used? 157 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 3 : 2 pages of medications Date PRESCRIPTION Time 3/2 4/2 5/2 6/2 Drug Route Morphine IM Dose Freq Start JG 1200 2.5 - - prn 3/2/99 5 mg Route Drug Maxaloon IM/IV Metochlopram Start ide Dose Freq 10mg Prn 3/2/99 Drug Route Panadeine O ES Forte Start 0800 Dose Freq 3/2/99 II prn Route Drug Ranitidine O 0800 (Zantac) Start 3/2/99 2000 Dose Freq Route 150m Bd g Drug Heparin S/C 0800 ES JG JG LH Dose Freq Start 5000u Bd 3/2/99 2000 AC LH LH JG Drug Route Nolvadex O 0800 ES JG JG LH (Tamoxifen) Start Dose Freq 158 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

20mg Mane 3/2/99 PRESCRIPTION Date 3/2 4/2 5/2 6/2 Time ES JG JG LH AC LH LH JG Drug Route ES JG JG LH AC LH LH JG Alphapress O 0800 AC LH LH JG (Hydralazine) Start 2000 LH JG Dose Freq LH JG 50mg Bd 3/2/99 Drug Route Isoptin 1000 (Verapamil) Start 1800 3/2/99 2200 Dose Freq Route 360m tds g Drug Anginine S/L Start Dose Freq 3/2/99 600m prn Route g S/C Drug Monotard (Insulin) Dose Freq Start 2100 nocte 12u 5/2/99 Drug Route Actrapid S/C 1200 (Insulin) Start Dose Freq 4u midda 5/2/99 y 159 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 3 : USE 1. Narcotic analgesia MEDICATION Anti-emetic Mixed analgesia Morphine H2 receptor antagonist – Prevention and Maxalon / Metochlopramide maintenance of ulcers, anti-ulcerative Panadeine Forte Prophylactic anti-coagulant Ranitidine / Zantac Anti-oestrogen, Rx of breast cancer Beta stimulant, powerful systemic vasodilator Heparin Rx of severe HT Nolvadex / Tamoxifen Ca++channel blocker, Rx of HT, angina Alphapress / Hydralazine ,tachycardia Short acting Coronary Artery Vasodilator Isoptin / Verapamil Subcutaneous insulin for IDDM Anginine Monotard Actrapid 2. Patient’s conditions : IDDM - monotard, actrapid • Angina - Anginine • Severe HT - Hydralazine, Isopten • Breast cancer - Tamoxifen • 3. In the acute situation a potential side effect of hydralazine is rebound hypotension. If the patient has been on the medication for a longer period they are less prone to these effects. 3. Precautions taken with this patient ™ Care with demnad ™ NO isometrics or inspiratory holds - monitor on a daily basis ™ Care with positioning ™ Cheeck BSL’s prior to Rx - no mobilising if < 5mmol - check for signs and symptoms - no heavy exercise for 45 mins post insulin ™ Potential for vascular involvement in view of IDDM 5. The patient has had no chest pain as no anginine has been given. 6. If the patient has experienced nausea it has not been sufficient to require maxalon. 7. NIDDM medications - ORAL HYPOGLYCAEMICS Diabenase Metformin / Diabese Diaformin Glibenclamide Minidiab / Glipizole 160 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

8. Unstable BSL’s ⇒ Sliding scale of insulin 9. Sliding scale of insulin utilised when IDDM patient is undergoing surgery. QUESTIONS relating to Patient 4 : 1) Discuss the use of these medications. 2) Outline the pain relief the patient is receiving and the route of administration initially post op 3) Discuss any problems the patient has had with their pain relief. 4) What are some of the possible side effects of narcotics? 5) Has the patient experienced any of these side effects? 6) Discuss other medications that may be utilised to address these problems. 7) Why was oxycodone commenced on the 11/2/99. 8) What other conditions coexist for this patient? 9) What is the purpose of heparin for this patient? 161 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 4 - 3 pages of medications PRESCRIPTION Date 6/2 7 / 2 8 / 2 9 / 2 10 / 2 11 / 2 Time Drug Route Na Heparin S / C 0800 HS PM VI PM PM VI VI Dose Freq Start 2000 VI PM HS HS PM EC 5000u Bd 6/2/99 HS VI Drug Route EC N/G 0600 EC EC EC BT BT 1200 Paracetamol PM VI PM PM VI Start 1800 Dose Freq VI PM HS HS PM 1g Q6hr 6/2/99 2400 EC EC EC BT BT Drug Route Metocloprami IV PM de Start 0800 (Maxalon) Dose Freq 10mg Q6hr 6/2/99 PM Cease Prn 1400 d Drug Route 0600 EC EC EC EC BT BT 1400 HS Ranitidine IV 2200 VI PM VI PM PM VI (Zantac) Start EC VI PM HS HS PM Dose Freq HS VI 50mg Q8hr 6/2/99 EC Drug Route 0600 EC EC EC BT BT Dilosyn O 1400 PM VI PM PM VI 2200 (Methdilazine) Dose Freq Start VI PM HS HS PM 4mg Tds 6/2/99 Drug Route Frusemide O (Lasix) Dose Freq Start 0600 EC EC EC BT BT 162 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

120m Mane 8/2/99 g PRESCRIPTION Date 6 / 2 7 / 2 8 / 2 9 / 2 10 / 2 11 / 2 Time VI PM PM VI Drug Route EC EC BT BT Frusemide O VI PM PM VI VI Dose Freq Start 1200 0800 PM 80mg midda 8/2/99 1600 y Drug VI PM PM VI Route BT Span K O 0600 VI Start VI Dose Freq PM I bd 8/2/99 1200 Drug Route Ondansetron IV (Zofran) Start Dose Freq 8/2/99 4g Q8hr Route prn Drug Allopurinol O 1000 (Zyloprim) Start Dose Freq 100m mane 8/2/99 g Route Drug Oxycodone O 0600 Dose Freq Start 1000 1400 5- Q 4hr 11/2/9 1800 10mg 9 163 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ACUTE PAIN SERVICE : If the service is provided in the facility check out the forms utilised. Below is a sample section of the prescription and program as recorded at the RBH. Warrd : 7FE Bed : 12 Date of surgery : 6/2/99 Allergies : NIL Surgeon : O’Loughlin Anaesthetist : Howard Operation : ( R ) Hemicolectomy Relevant Medical History : Recent TKR, PUD, HT Peptic Ulcer Disease: Y / N Renal Failure: Y / N Asthma : Y / N Opioid tolerant: Y/N PROGRAM Route Modality Initial Infusion Bolus Loading Lockout Sign Rate Range Dose (mins) Date Time IV PCA/Inf 1.5mg Smit IV PCA .5mg/hr 0-1 2.5mg - 8 mins h 6/2/99 1745 Smit .5mg/hr - - 8 mins h 7/2/99 0920 PRESCRIPTION Drug 2 Diluent Total Volume Sign Total dose/bag Date Drug 1 N / Saline 100mls Smith Total dose/bag Conc. 1mg/ml 6/2/99 Morphine 100mg APS Notes : DAY 1 : Poor analgesia currently Add regular paracetamol Cease background DAY 2 : Very drowsy after haloperidol, rouseable to touch and voice ↓ morphine bolus No pain currently Confused /agitated overnight but hadn’t used PCA for 3 hours prior to this ? hypoxia → on 50 % O2 . DAY 3 : Afebrile ? bleed yesterday ↓ Hb Comfortable 164 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 4 : USE 1. Anti-coagulant MEDICATION Simple analgesia Anti-emetic Na Heparin H2 receptor antagonist Paracetamol Prevention/maintenance of ulcers, Metoclopramide / Maxalon antiulcerative Ranitidine / Zantac Antihistamine for the itch associated with narcotics Dilosyn / Methdilazine Non K+ sparing loop diuretic K+ supplement Frusemide / Lasix For post-op nausea and vomiting usually Span K used after chemotherapy Ondansetron / Zofran For gouty arthtritis, skin tophi, renal crystal deposition, stone formation Allopurinol / Zyloprim Oral narcotic - moderate to severe pain Narcotic analgesia Oxycodone / Endone Morphine 2. Pain relief and administration : • Morphine with normal saline via PCA 6/2/99 - Initially the patient was receiving a continuous background infusion of 0-1 mg and able to push the button to receive an additional amount of a bolus of 0.5 to 1.5 mg. The patient administered dose was available every 8 minutes. 7/2/99 - As the analgesia was poor, changes were made to the prescription. The background was ceased. The dose the patient was administering to himself was ↑ by the background amount i.e. from 0.5 to 2.5 mg with the same lockout time. • Paracetamol as a regular medication was introduced to enhance the pain relief. 3. Problems with pain relief ™ Initially poor pain analgesia ⇒ bolus dose can be ↑ to 2.5 mg ™ Day 2 very drowsy ⇒ morphine dose ↓ ™ Patient agitated but assessed to be related to hypoxia not analgesia 165 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

4. Possible side effects of narcotics : ♦ Drowsiness ♦ Respiratory suppression ♦ Nausea and vomiting ♦ Itch ♦ Hypotension 5. Side effects experienced by the patient: ƒ Day 2 - drowsiness - nausea - maxalon not effective ⇒ Ondansetron commenced - itch - dilosyn commenced 6. Other medications : ƒ Naloxone - to counter the effects of drowsiness ƒ Stemetil - for nausea and vomiting ƒ Tropisetron / Navoban - strong anti-emetic ƒ Phenergan - for the itch, can cause drowsiness. 7. Oxycodone was introduced on 11/2/99 as the oral narcotic for pain relief once the PCA was ceased. 8. Co-existing conditions : ™ Peptic Ulcer Disease - Ranitidine ™ HT / Fluid overload - Frusemide ™ Gout - allopurinol 9. Heparin is being used as a prophylactic anti-coagulant post-operatively. 3 features that designate that it is prophylactic are (i) The units - 5000units (ii) The route of administration - subcutaneous. If it were to treat a thrombus it would be given IV. (iii) The frequency - bd - to treat a thrombus it would be delivered as a continuous infusion. 166 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 5 - 3 pages of medications PRESCRIPTION Date 8/2 9 / 2 10 / 2 Time Drug Route Vit B Freq O PJ PJ DF Daily Dose Start 1200 I 8/2/99 Drug Route Becl,methason MA 0800 PJ PJ DF e Start LT DF PJ (Becotide) Dose Freq II bd 8/2/99 1800 Drug Route Lithium O 0800 PJ PJ DF Dose Freq Start 250m MWF 8/2/99 g Route Drug Fe Fol O 0800 PJ PJ DF Dose Freq Start I bd 8/2/99 1800 Drug Route Paracetamol O LT 1730 Dose Freq Start II qid 8/2/99 /prn Drug Route Ranitidine O 0800 PJ PJ DF (Zantac) Start 1800 LT DF PJ Dose Freq 167 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

150m bd 8/2/99 g PRESCRIPTION Date 8 / 2 9 / 2 10 / 2 Time PJ PJ DF Drug Route PJ PJ DF Amlodipine O 0800 JJ JJ JJ (Norvasc) Start 8/2/99 JJ JJ JJ Dose Freq PJ PJ DF Route LT DF PJ 100m Daily LT DF PJ g Drug Perindopril O 0800 (Coversly) Start Dose Freq 8/2/99 8mg Daily Route Drug NaHCO3 O 0700 Start Dose Freq Daily 8/2/99 I Route Drug Nephrex 0700 (CaAcetate) Dose Freq Start 1200 III tds 8/2/99 1700 Drug Route Quinine O Dose Freq Start 2000 nocte 8/2/99 300m g Route Drug 168 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Imdur 0800 PJ PJ DF Isosorbide O Mononitrate Dose Freq Start 8/2/99 60mg mane PRESCRIPTION Date 8 / 2 9 / 2 10 / 2 Time Drug Route Teazepam O LT DF PJ (Normison) Dose Freq Start 2000 8/2/99 20mg nocte Route Drug EPO S / C 0800 PJ PJ DF (Eprex) Start Dose Freq 8/2/99 300u X2 /wk SINGLE DOSE MEDICATIONS Administration DOCTOR’S Administere SIGNATURE d DATE DRUG ROUT DOSE 20mg Lewis Initi Tim TIME E al e 9/2/99 0345 Nifedipine O JJ 0355 QUESTIONS relating to Patient 5 : 169 1) Discuss the use of these medications. 2) What primary conditions does this patient demonstrate? 3) Outline the relationship between these conditions. 4) What other conditions coexist for this patient? © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 5 : USES 1. See the following table for the use of the medications MEDICATIONS Vit B Supplement Beclomethosone / Becotide Lithium Inhaled Corticosteroid - Rx of asthma Fe Fol Management of manic depression Paracetamol Ranitidine / Zantac Management of iron an folic acid deficiency Amlodipine / Norvasc Simple analgesia Nifedipine / Adalat Perindopri / Coversyl Prevention and maintenance of ulcers, anti- NaHCO3 ulceratives Ca++Channel blocker - Rx of HT, angina Nephrex / Calcium Acetate Ca++Channel blocker - Rx of HT, angina ACE Inhibitor - Rx of heart failure , HT Quinine / Biquinate Sodium Bicarbonate - Management of Imdur / Isosorbide Mononitrate metabolic acidosis Temazepam / Normison Rx of hyperphosphataemia in remnal EPO / Erythropoietin impairment For muscle cramps Coronary Artery Vasodilator Sedative for short term management of insomnia Base for red cell production ⇒ ↑ Hb 2. Primary Conditions : • Chronic Renal Failure - CRF Medications - EPO, Nephrex, Fe fol, NaHCO3, + quinine for the muscle cramps • HT - Amlodipine, Perindopril and the once only dose of nifedipine 3. Relationship between HT and CRF : Review in Renal Failure Section CRF HT ⇒ CRF CRF worsen HT HT LVF 4. Conditions that co-exist : • Asthma / COAD - Beclometasone • Manic depression - Lithium • Peptic Ulcer Disease - Ranitidine • Leg cramps - Quinine • Insomnia - Temazepam 170 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

PATIENT 6 - 4 pages of Medications PRESCRIPTION Date 5/2 6/2 7/2 8/2 9/2 Time Drug Route Verapamil O 0800 ML ML BN ML BN (Isoptin) Dose Freq Start 2000 BN BN ML BN ML 160m bd 5/2/99 g Route Drug D O 0700 GM GM AC AC AC Penicillamine Start Before food Dose Freq 375m bd 5/2/99 1700 BN BN ML BN ML g Drug Route Calcitriol O 0800 ML ML BN ML BN (Rocaltrol,Sitri ol) Dose Freq Start 0.25m Daily 5/2/99 g Drug Route Prednisolone O 0800 ML ML BN ML BN Dose Freq Start 8mg Daily 5/2/99 Drug Route Frusemide O 0800 ML ML BN ML BN (Lasix) Dose Freq Start 40mg Daily 5/2/99 Drug Route Heparin S/C 0800 ML ML BN ML BN 171 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Dose Freq Start 5000u bd 5/2/99 2000 BN BN ML BN ML PRESCRIPTION Date 5/2 6/2 7/2 8/2 9/2 Time GM GM AC AC AC ML ML BN ML BN Drug Route BN BN ML BN ML Cholrvescent O 0600 ML ML BN ML BN Effervescent Start 1200 BN BN ML BN ML K+ 1800 ML ML BN ML BN Dose Freq BN BN ML BN ML II QID 5/2/99 2200 ML ML BN ML BN BN BN ML BN ML Drug Route ML ML BN ML BN Agarol O 0800 Start Dose Freq 20ml bd 5/2/99 1600 Drug Route Coloxyl & O 0800 Senna Dose Freq Start II bd 5/2/99 1600 Drug Route Microlax PR 0800 Start Dose Freq bd 5/2/99 1900 I-II Route Drug Aspirin O 0800 Start Dose Freq Daily 5/2/99 150m g Route Drug Gentamicin IV 172 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Dose Freq Start 2100 BN 80mg Daily 5/2/99 Cease d PRESCRIPTION Date 5/2 6/2 7/2 8/2 9/2 Time Drug Route ML ML 0600 BN Cease Ampicillin IV 1200 1800 d Dose Freq Start GM 1g Q6h 5/2/99 2400 ML BN ML Drug Route BN ML BN ML BN ML Digoxin O BN ML BN Dose Freq Start 2100 ML BN ML nocte 7/2/99 125m AC AC g Route BN ML BN Drug ML BN ML AC AC AC Magnesium O 0800 Sulphate Dose Freq Start I bd 7/2/99 2000 Drug Route Brufen O 0800 Start Dose Freq 400m Bd 7/2/99 1800 g Route Drug IV Dicloxacillin 0600 In 250mls 1200 over 1-1 ½ hrs Dose Freq Start 1800 2g Q6h 7/2/99 2400 Drug Route 173 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Ranitidine O 0800 BN (Zantac) Start BN ML Dose Freq 8/2/99 1800 150m bd g PRESCRIPTION Date 8/2 9/2 Time Drug Route Metocloprami IV ML BN de 0800 (Maxalon) Start 8/2/99 1000 Dose Freq Route 10mg Q6h prn Drug Metronidazole IV 1000 ML BN (Flagyl) 2200 BN ML Dose Freq Start 8/2/99 500m bd g QUESTIONS relating to Patient 6 : 1) Discuss the use of these medications. 2) What conditions does this patient demonstrate? 3) Why is this patient on calcitriol 4) What is a possible rationale for the patient being prescribed heparin? 174 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

ANSWERS - Patient 6 : USES Ca ++ Channel blocker HT, angina or 1. tachycardia MEDICATIONS SAARDS - Slow acting anti rheumatoid drugs Ca++ Supplement Prevent hypocalaemia Verapamil / Isoptin Oral corticosteroid - ↓ inflammation D Penicillamine Non K+ sparing loop diuretic Calcitriol Anti-coagulant Prednisolone Replace potassium lost with use of diuretic Frusemide / Lasix Laxative Heparin Bowel softener Chlorvescent / Effervescent Potassium Enema for constipation Agarol Coloxyl & Senna ↓ platelet aggregation Microlax Aminoglycoside antibiotic Aspirin Penicillin antibiotics Gentamicin Inotropic Agent for AF, CHF Ampicillin Rx of hypomagnesaemia Digoxin / Lanoxin NSAID Rxof arthritis and inflammatory Magnesium Sulphate disorders Brufen / Ibuprofen Penicillin antibiotic H2 receptor antagonist Prevention and Dicloxacillin maintenance of ulcers, anti-ulceratives Ranitidine / Zantac Anti-emetic for nausea and vomiting Antibiotic for Rx of anaerobic organisms Metoclopramide / Maxalon Metronidazole / Flagyl 2. Conditions demonstrated: • Atrial Fibrillation - AF - digoxin • Sepsis - 4 different antibiotics - Gentamicin, Ampicillin, Dicloxacillin, Metronidazole • Rheumatoid Arthritis - RA - D Penicillamine, Brufen, ? Aspirin or prednisolone • Peptic Ulcer Disease - related to NSAID Rx with Ranitidine • HT - Verapamil, Frusemide • Constipation - Agarol, Coloxyl and Senna and Microlax • Low magnesium 3. The patient is on calcitriol due to osteporosis , a complication of long term steroid use ( prednisolone) 4 Possible rationale for the use of heparin: Due to the sepsis the patient’s mobility would have been limited ⇒ ↑ risk of DVT. Once again it is being used prophylactical 175 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

SEMI/UNCONSCIOUS PATIENT Review - Lecture Notes and prac sessions relating to Acute Head Injury and Neurosurgery Then complete the following Case Scenarios Patient 1 A 28 year old male with an intraventricular haemorrhage whoa had an evacuation of the haematoma ~ 4/52 ago. He was weaned from the ventilator 2/52 ago but still has a tracheostomy insitu. He remains unconscious with fluctuating tone in his lower limbs. He has been transferred from another hospital to your ward. This patient is referred for physiotherapy, outline the information you would need to obtain prior to treating 1. from the medical file 2. from the bed chart Explain the purpose of the equipment you might see at the bedside. How would your respiratory assessment be altered for this patient? Your treatment decisions will be based upon your assessment findings. Outline the range of respiratory techniques you could use with this patient. Having treated this patient’s chest to mobilise secretions how will these secretions be removed? Outline the steps in this procedure. What precautions would have to be considered. Identify the broad goals of early rehabilitation for this patient Outline the role of passive movements with this patient Discuss any precautions in their use for unconscious patients. PAC is essential for these patients. Comment on the physiotherapist’s role. Discuss when you would sit this patient out of bed. What precautions need to be considered. 176 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

When would you progress this patient to standing on the tilt table? Outline the benefits of this procedure. What precautions need to be taken when standing this patient? The patient’s fluctuating tone alters to increased flexor tone. How would you manage this change? Discuss the difference in prognosis between a head injured patient who has been unconscious for four (4) days and a CVA patient who has been unconscious for four (4) days. Answers • Information prior to treating • Medical file • Confirm cause of LOC ( HI, CVA, Metabolic dysfunction ) • Length and depth of coma • Investigations - CT Scan, Angiography • PMHx • Systems Review • Medical Management • Complications • Social History - assist in determining goals and long term treatment • Bed chart VITAL SIGNS • Temperature - febrile may indicate infection - abnormality - infer alteration to thermoregulatory centre • BP - check stability • PR Fluid balance - effect cerebral oedema (complication of HI with hypophyseal damage SIADH, Diabetes insipidis) 177 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Information prior to treating (Continued) GCS - Glasgow Coma Scale ( - / 15 ) • best motor , ocular and verbal response • indication of brainstem function watch the trend of scores • lowest score 3 / 15 Turning regimes - co-ordinate Rx of chest with turns to minimise handling of the patient Medications - variety of drugs involved in management • Sedatives - only if the patient is agitated as it limits assessment of brain function On the ventilator morphine may be used + pavulon for paralysis Examples: • Hemineurin • Nitrazepam • Normison / Temazepam • Diazepam • Pentobarbitone • Promethazine • Anti-convulsants - always with HI (P) as predisposed to epilepsy On medication long term ==> watch for fitting Examples: • Dilantin / Phenytoin • Epilum / Sodium Valproate • Phenobarbitone • Tegretol • Clonazepam / Rivotril • Diuretics - strict fluid balance Mannitol to decrease cerebral oedema - control ICP • Anti-ulceratives - in the early stages when NBM to decrease possibility of ulceration Examples: • Zantac / Ranitidine • Tagamet / Cimetidine • Pain relief - if needed e.g. for rib # • Antibiotics - if infection present e.g. UTI from IDC or septic from CVL • Nimodipine Calcium Channel Blocker - for SAH as there is a lot of vasospasm at 7 - 10 days post op which causes a deterioration therefore it is used as a prophylactic medication 178 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Purpose of the equipment at the bedside • N/G tube - for feeding or drainage • IV Drip - for drugs if needed • Humidifier - to provide warm ,moist oxygen to trachy - to prevent the drying effects of oxygen as the nose has been bypassed • Suction Equipment - to enable removal of secretions from the airway • IDC - for drainage of the bladder, aim for removal as it is a potential source of infection • Ripple mattress - for PAC • Splints - to maintain joint range • Serial plasters - to control tone If unable to tolerate N/G feeds ⇒ TPN required via a CVL. As the patient has the potential for fitting bed rails should be up for safety at all times • Respiratory Assessment Observation • Position of patient - ensure coma position • RR - depth of breathing • Breathing Pattern e.g. laboured breathing ==> brainstem or Cheyne Stokes • Chest movement • Colour • Sweating • Tonal abnormalities • Cough - Spontaneous ? effective Palpation • Quick stretch • Use of perioral stimulation to increase size of breath during auscultation • Respiratory Techniques 179 Air Entry Techniques • Positioning • Passive limb movements or active assisted • Stretch Facilitation - slow sustained stretch © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Perinasal Stimulation • Manual Hyperinflation • Sitting out of bed / Tilt Table Secretion Removal Techniques • Percussion and vibration • Use of normal saline or ventolin • Cough - spontaneous ? effective - stimulate with tracheal rub - assisted with sternal overpressure • Suction when indicated • Secretion Removal ⇒ SUCTION Steps in suction procedure Look at 3rd Year notes Precautions with Suction • Minimise the decrease in PaO2 by hyperoxygenation before and after suction • Correct size of catheter < 1/2 diameter of tube • Intermittent suction to minimise desaturation, and decreased mucosal trauma • Suction pressure < 200mmHg - decreases potential trauma and potential arrhythmia, minimises hypoxia • Sterile technique decreases the potential for infection • Broad goals of early rehabilitation 180 • Depend on age, social history, prognosis • Prevent complication of contractures maintain muscle length, joint range of movement • Stimulate arousal to increase the conscious level • Facilitate purposeful movements • Normalise tone • Counter spatial, sensory or visual neglect • Facilitate head and trunk control for basic posture • Assess anticipated recovery and likely benefit of transfer to rehab • Passive Movements ROLE • Maintain passive joint range of movement • Maintain muscle length • Increase the depth of breathing • To increase arousal © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Stimulate circulation • Assist with pressure area care • Assist with managing tone - positioning after treatment is important PRECAUTIONS • Watch end of range movements if flaccid • Care not to push, no forceful movements may ⇒ heterotrophic ossification • Sitting out of bed WHEN • Patient’s vital signs need to be stable • The patient does not need to be conscious • Appropriate seating is available to control tone PRECAUTIONS • Monitor the patient - PR, BP, colour, RR • Sitting in wheelchair may require side wedges to maintain positioning • Position - trunk and head control - hips and knees at 900 - ankles plantargrade • If flexor tone in the upper limbs aim for extension 181 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

• Standing on the tilt table PROGRESS • Once the patient is coping with sitting out of bed O2 saturation stable not sweaty not tachycardic BENEFITS • Stimulate deeper breaths • Weight bearing • Facilitate postural tone • Stretch of lower limbs • Stimulate verticality • Facilitate normal vasomotor responses to the upright PRECAUTIONS • Monitor vital signs - PR BP O2 saturations colour • Initially the bed is raised slowly - may take several attempts to get towards vertical • Time in standing - gradually increased 10 - 15 minutes up to 30 minutes • Manage increased flexor tone • Serial plasters for lower limbs - stretch muscle length • Careful to continue circulatory observations • Difference in prognosis HI patient has a better prognosis as they may remain unconscious for prolonged periods due to cerebral oedema. The oedema causes downward pressure on the reticular activating system. When the oedema resolves it is important for there to be no joint contractures and for the muscle length to be maintained. A CVA patient who is unconscious after 4 days indicates a poorer prognosis. The unconscious state may be due to extensive ischaemia. Consult with the medical staff regarding the continuation of treatment. 182 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

CASE MANAGEMENT To be discussed with your supervisor. The following ward lists are used as an example of a new graduates potential workload in the Acute 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 183 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

SURGICAL WARD Bed Age Name Condition 1 48 Mr News (R) inguinal hernia repair (IHR) 3/7 2 55 Mr Ord (L) IHR 3/7 3 82 Mrs Bond Ant. Resection 3/7 4 78 Mr Que Abdominal Pain 5 73 Mr Issacs Abdominal Pain 6 32 Mr Crenny Wiring Mandible 6/7 7 45 Mr Board Pancreatitis 8 81 Mr Louder Bowel Obstruction - old laryngectomy 9 90 Mrs Long (R) Mastectomy 2/7 10 96 Mrs Sanders Inoperable Ca Stomach 11 18 Mr. Roberts (L) IHR 1/7 ago. 12 81 Mr Nelson R/o Wire Mandible 13 22 Mr Brady Spontaneous Pneumothorax 14 81 Mr Owens Vagotomy and Pylorplasty 1/7 15 44 Mr Boswell (R) IHR 1/7 16 40 Mrs Roberts Stripping V. Veins 2/7 Bronchiectatic 17 60 Mrs Hoge Pre-op. Laparotomy diverticular abcess 18 28 Mr Phillips Head Injury FI (for investigation) 19 56 Mr Rowan Metatastic Melanoma (L) neck 20 71 Mr Frier Abdo pain FI 21 56 Mr Emeon Haemarrhoidectomy 1/7 22 81 Mr Crowe Laparotomy with colostomy 1/7 23 76 Mr Jones Diverticular Abscess 24 60 Mrs Lang Large Bowel Obstruction 25 54 Mrs Ivan Biliary Colic 26 60 Mrs Jacobs Exploration choly wound pre-op 27 60 Mrs Kleene Closure of Colosotomy 3/7 28 70 Mrs Gow High Ant. Resection 2/7 29 64 Mr Muir BK amp. and COAD 7/7 184 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

MEDICAL WARD Name Condition Bed Age Mrs Abbott Social Admission Mrs Blow Rapid A-F 1 69 Mr Crawford Malena for Invest. 2 62 Mr Dawson Acute Asthma 3 87 Mr Enright Unconscious (R) CVA 4 19 Mrs Faulkner Chest Pain COAD 5 66 Mrs Gibson Rapid AF 6 73 Mr Hill MI 7 74 Mr Ibsen Pulmonary Oedema 8 27 Mrs Jones PE 9 91 Mrs Ernest COAD 10 60 Mr Lawson Gout 11 68 Mr Mullin Inferior Infarct 12 70 Mr Nolan Acute bronchitis 13 54 Mr Osbourne Respiratory failure 14 61 Mr Powell Hypoglycaemic episode 15 61 Mr Quinn CCF 16 64 Mr Crowley (R) LL Pneumonia UTI 17 81 Mr Swann Chest pain 18 86 Mrs Turner Acute RA 19 85 Mrs Ung Asthma 20 60 Mr Vanps Inflammatory Bowel Disease 21 55 Mr West Joint Inflammation FI 22 64 Mrs Youn (L) TIA 23 35 Mrs Anderson (L) DVT 24 65 Mr Bowden Peripheral Neuropathy 25 38 Mr Rogers Vertigo and UTI 26 67 Mrs Douglas (R) ML Pneumonia 27 85 Mrs Kirkland Temporal arteritis 28 55 Mrs Freer (R) CVA 29 66 Mrs George Cerebral Tumour 30 73 31 59 185 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

BURNS Revise your lecture notes on Burns and their management and then answer the questions regarding the following scenario Patient 1 A 42 year old male who received burns to his face and upper limbs in a plastics factory fire. What would the immediate medical management involve for this patient? How would the depth of burn be assessed? How is a respiratory burn defined? What may have been the cause of such a burn for this patient? Discuss other causes of respiratory burns? What symptoms would indicate your patient may have suffered a respiratory burn? Outline the investigations that may be performed. Describe the pathophysiology of respiratory burns. Outline the techniques the may be utilised as part of the physiotherapy treatment of respiratory burns. What would the nursing care of the patient’s burn involve Discuss the role of physiotherapy in relation to the nursing management When exercising this burns patient outline the factors you would take into account. What is your primary aim for each treatment session? Discuss the type of exercise that may be utilised Revise the position in which each joint is splinted Describe the exercises to be performed for this patient’s burned hands What is the best position in which to do these exercises ? Suggest some precautions that may be needed 186 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Our patient has had grafts taken from his thigh and part of his back for his upper limbs and anterior chest When would you start treating the donor site compared to the graft site ? How vigorously would you treat the donor site? When moving the graft site what signs would indicate the graft may be at risk? If in contrast to our patient example you were treating a patient with a large percentage of burns, who began losing range, what would this indicate ? How would this modify the exercise programme? ANSWERS : Medical Management • Fluid and electrolyte balance • Airway Management • ECG • Sterile Conditions • Wound Dressing • Debridement / Escharotomy • Temperature Control Assessment of the depth of burn Revise Pre-clinical Lecture Consider ¾ The tissues involved ¾ The pain associated with different depths ¾ Precautions with regard to handling ¾ Pain management 187 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Respiratory Burns Definition • Respiratory burns are anywhere in the upper or lower respiratory tract i.e from mouth or nose to alveoli Cause of respiratory burn for our patient • Noxious Chemicals - plastics Other causes of respiratory burns • Closed space • Smoke inhalation • Carbon monoxide • Steam Symptoms indicate a respiratory burn • Burns on face and mouth • Carbonaceous / sooty sputum • Singed nasal hairs • Hoarse voice or stridor - oedema of vocal cords • Haemoptysis • Crackles and wheezes - may be like acute asthma • Pa O2 decreasing Investigations • CXR • ABG”S x2 per day • Bronchoscopy - look directly at the respiratory tract • Oximetry • RFT’s if normal likely little damage has occurred Pathophysiology • Airway obstruction due to 1. Bronchospasm from histamine release 2. Airway oedema 3. Debris • V/Q Mismatch • 20 infection from debris and immobilisation - Collapse and retained secretions • Tendency towards ARDS and Pulmonary Oedema • Tendency towards fluid overload 188 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Physiotherapy Techniques with respiratory burns • Assessment findings may include Decreased respiratory excursion Immobilisation ==> decreased AE SOB due to high metabolic rate • Techniques Dependent upon assessment findings Breathing exercises Triflo Demand ventilation within limits of musculoskeletal burns IPPB Cough or FET Suction - use Aeroflo or rubber catheter to ↓ trauma to the airway Postural drainage only if certain there is no oedema around the upper airway Full thickness burns may be percussed or vibrated as there is no pain Partial thickness burn requires 1) good pain relief prior to treatment 2) use melanin instead of towels 3) may have a lot of bronchospasm No percussion or vibration over grafts in the initial stages 189 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Nursing Care of burns Baths are utilised 1 or 2 times a day for 30 minute sessions Purpose • Dressings are soaked off • Debride slough • Soak in antimicrobial solution • SSD cream applied then melanin and crepe bandages, splints and bandage Role of Physiotherapy • Exercise patient in the bath • Advantages of bath 1) stretching is easier if skin is moist 2) time when most pain relief is given prior to bath ⇓ most effective exercise session Exercise for this patient Factors to take into account with exercise • Increased metabolic rate up to 2.5 times normal ↑ PR ↑SOB • Area of burns • Depth of burn • Presence of grafts • Pain but analgesia should ensure a through treatment Primary aim each treatment session ↑ ROM Type of exercise contract relax Active Self ranging Repeated movements PNF - hold / relax Stretches Functional Activities Splinting Depends on the area burned Aim to hold prolonged position to avoid contraction 190 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

Exercise for burned hands • With wrist in extension - flex MCP +PIP +DIP • With wrist in flexion - ext MCP +PIP +DIP • Supination / Pronation • Thumb - pincer grip • Capping action • Thumb movements Best position for hand exercises • In elevation ⇒ ↓ oedema Precautions • No combined complex movements of multiple joints • Need to supervise the exercises as full ROM of wrist and fingers in the same direction i.e. full wrist flexion with full MCP, PIP and DIP may cause tendon rupture. Grafting Start treating • Donor site - immediately with full range of movement with adequate pain relief • Graft Site - 5 days post op or on doctor’s orders Signs graft is “ at risk “ • Gaping - edges not taking or lifting • Crinkling - a sign the graft may not be healing • Fluid • Bleeding Patient losing range Indication of hetertrophic ossification - Handout Modify exercise programme Exercise within active ROM and pain limits No passive stretches - only active 191 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

DIABETES It is essential that you have an understanding of diabetes as the condition will impact on your clinical management of these patients. Please answer the following questions. 1. What is Diabetes Mellitus? 2. What is Diabetes Insipidus? 3. List the complications of Diabetes Mellitus. 4. What implications does the diabetic’s drug therapy have for physiotherapy? 5. List the signs and symptoms of hypo and hyperglycaemia. 6. What considerations must be made when prescribing exercises to Diabetics? ANSWERS : 1. Diabetes Mellitus : - Endocrine disorder characterised by insufficient insulin secretion by the B cells of islets of Langerhans - Results in increased glucose levels (BSL – blood sugar levels), abnormal fat metabolism and deposition of lipids and increased protein in the tissues - Can be juvenile onset - hereditary - Can be late onset - due to obesity (decreased insulin for metabolism) - rapid ageing - Classified into - Type I - Insulin Dependent Diabetes Mellitus (IDDM) - Type II - Non-insulin Dependent Diabetes Mellitus (NIDDM) 2. Diabetes Insipidus : - is a disorder characterised by insufficient ADH (Anti-Diuretic Hormone) secretion - due to tumour or injury that destroys the hypothalamus or hypophysis - also occurs in hormonal disturbances and head injury - results in increased urine output (UO) ~ x 5 → thirst to compensate. If uncompensated → drug treatment - also termed Secretion of Inappropriate Anti-Diuretic Hormone (SIADH) 192 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003

3. Complications of Diabetes : - Vascular disease - eye cataracts / retinopathy - renal failure - PVD - cardiac disease eg IHD, CAD - cerebral disease eg CVA, TIA’s - Peripheral Neuropathy - Mononeuritis - Diabetic Amyotrophy (muscle wasting ) - Autonomic Neuropathy - loss of sphincter control - Poor skin condition - Slow wound healing - Susceptibility to infection. Ensure that you have considered carefully the implications of the above problems to your management and handling of Diabetic patients. 4. Implications of the Diabetic’s drug therapy for physiotherapy : - IDDM need insulin injections and BSL monitoring, therefore avoid exercise prior to injections and for 40 - 60 minutes afterwards - Ensure that the patient’s BSL is within normal range ( 5 - 15 ) prior to treatment - NIDDM can comprise two groups – 1) need oral hypoglycaemic agents that stimulate the pancreas to release insulin + diet control or 2) diet controlled alone - Diabetics should never miss meals, and snacks should be available for consumption particularly during heavy exercise. 5. Signs and Symptoms of Hyper and Hypoglycaemia : Hyperglycaemia Hypoglycaemia - polyuria - dehydration - polydypsia - thirst - dizziness - acetone breath (Ketoacidosis) - ↓ respiratory rate - Increased respiratory rate -> - hunger / thirst secondary -to Metabolic Acidosis - tremor - fatigue - sweating / pale - flushed, dry face - vomiting - LOC quickly - LOC over an extended period Treatment : Hyperglycaemia - fluid and insulin Hypoglycaemia - sugar ** If not sure - give sweet drink as hypoglycaemia will give brain damage, and is more rapid to progress. 193 © - Department of Physiotherapy, The University of Queensland - Acute Stream ILP 2003