The physiotherapist has an important role to play in assessing which patients being prepared for surgery are at risk of developing complications that she may help to prevent. As a member of the surgical team in the surgical ward she may be alerted about any problems or potential problems by the medical or nursing staff. The medical history of any patient must be checked for any respiratory or circulatory problems that could place the patient at risk or any other factors such as smoking, obesity, inactivity because of another disease or injury or age that could predispose to post–operative complications.
Preoperative careThe physiotherapist will explain to the patient why treatment is necessary and teach the patient the exercises that he will be required to perform post–operatively. Respiratory movements will concentrate on lower costal and posterior basal movement. The patient will be taught how to cough effectively and how to support the wound site. Instruction will be given on the leg exercises that the patient will be expected to do post–operatively and any other exercises or postural correction that may be related to specific surgical procedures.
The patient should practice the exercises so that they become familiar and are performed correctly. If the preoperative treatment is taught carefully it will be much easier for the patient to respond to instructions post–operatively. It is very important that whenever possible the same physiotherapist should treat the patient both preoperatively and post–operatively.
Physiotherapy for Post–Operative Care
Prevention of chest complications
The physiotherapist must take into consideration the effects of the anesthetic on secretions in the respiratory tract. One is that pain causes reflex inhibition of the diaphragm and therefore breathing is difficult. Another is that in any operation affecting the abdominal muscles the patient tends to avoid using them because of pain or fear of pain and this again hampers respiratory movements.
Breathing exercises 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. It is important not to make the patient take too many deep breaths at one time as this may make the patient feel faint.
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. If the secretions are very sticky the patient may need an inhalation to loosen them.
If secretions cannot be removed it may be necessary to use other techniques such as postural drainage and vibrations. These may have to be modified depending on the condition of the patient and the particular surgical procedure. Chest complications are most likely to occur in the first 48 hours after surgery and so treatment should be given frequently during this time and the patient should be encouraged to do them on his own if he can. The physiotherapist can stop treatment when there appears to be no further risk and the patient has good respiratory movement and no secretions. If a complication does occur then the treatment must be frequent and intensive until the problem is solved.
Prevention of thrombosis
Adequate movement post–operatively is essential. While the patient is in bed he must be encouraged to move about and be as independent as he can. Leg exercises should be given until the patient is up and moving around the ward. The exercises may have to be modified if the patient has an intravenous drip in the leg, or if there is any from of pelvic drainage. Once the patient is up the physiotherapist should see that he is moving around as it is not sufficient for the patient just to sit in a chair. It is important that these exercises are done properly. Initially the physiotherapist should supervise them but the patient must try to set up a realistic schedule, such as before or after each meal. They must be practiced frequently if they are to be effective.
Prevention of pressure sores
These should not occur in patients who have early mobilization after surgery. However, for patients who have to remain in bed for some days or longer and particularly for the elderly there is a risk. Care must be taken in positioning the patient and he must be encouraged to move around in bed. All members of the team must watch and report any signs of pressure.
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.