BRIGHAM & WOMENS HOSPITAL Department of Rehabilitation Services Physical Therapy

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure Case Type / Diagnosis: This standard of care applies to any patient s/p any general surgical procedure by the following surgical services: General/GI (GGI), Gastrointestinal (GIS), Oncology (OSS), Plastic (PLA), Vascular (VAS), Otolaryngology (OTO) and Dental (DEN) surgery. These procedures include but are not limited to ascending aortic aneurysm (AAA) repairs, gastric bypass surgery, exploratory laparotomies, and lower extremity revascularizations. This standard does not include the physical therapy management of patients s/p cardiothoracic, neurosurgical or orthopedic procedures nor does it include patients s/p skin grafting procedures for burn management and patients who require prolonged intensive care monitoring. Refer to the separate standards of care for the excluded procedures. Indications for Treatment: New abdominal or lower extremity surgical procedure that has affected a patients functional independence. Prevention of deconditioning and complications from bed rest associated with surgery.

Contraindications / Precautions for Treatment: 1. Contraindications A. Deep Vein Thrombosis (DVT) Signs and symptoms of DVT include: o Pain and swelling distal to the thrombus o Redness and warmth o Low-grade fever o Dull ache or tightness in the region of the DVT Homans sign: pain in the upper calf with forced ankle dorsiflexion in conjunction with the above signs and symptoms should be reported to the team. Defer physical therapy for patients with a suspected DVT until cleared by the physician. Diagnostic tests include UE/LE ultrasound and/or LE noninvasive (LENI). Avoid physical therapy until the patient is therapeutic on anticoagulation medications, usually 24 72 hours. Therapeutic INR: 2.0-3.0. Inferior vena cava (IVC) filter may be placed when patients are at high risk for a pulmonary embolism (PE). o Patients are usually on bed rest for 4-6 hours after the procedure. Physical therapy may resume once activity orders are advanced. INR does not have to be within therapeutic range. Prevention of DVT includes avoiding immobilization, LE elevation, compression stockings (TEDS), pneumatic compression boots, and anticoagulation medications. 1

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure B. Pulmonary Embolism (PE) This complication of DVT is an emergent medical situation. Notify the RN immediately. Signs and symptoms of PE include: o Rapid onset of tachypnea o Possible chest pain o Anxiety o Dysrhythmia o Lightheadedness o Hypotension o Tachycardia o Decreased SpO2 C. Blood Transfusion Defer physical therapy treatment during the blood transfusion. Exceptions may include positioning interventions. Discuss with experienced therapist prior to treatment and then check with M.D. One unit of blood takes approximately 3-4 hours to transfuse. Most blood transfusion reactions occur within the first 15 minutes of the transfusion. Vital signs are taken every 15-30 minutes by the nursing staff during the transfusion. Observe for the following signs and symptoms which may be indicative of a delayed reaction to the transfusion (may occur up to 24 hrs after transfusion): o Low grade fever o Headache o Chills o Flushed skin o Muscle pain o Anxiety o Hypotension o Tachycardia o Tachypnea o Severe cough. o Emesis o Diarrhea 2. Precautions A. Vital Signs Obtain parameters from the order entry Or use BWH Rehab Services guidelines: HR: 50-120 bpm SBP: 90-150 mmHg RR: <30 resting SpO2: > 90% Avoid 20 mmHg increase in BP Avoid 20 bpm increase in HR B. Lab Values Hematocrit (Hct): normal = 40-54 for males; 36-48 for females o Defer therapy if there is a significant decrease from the previous day or if Hct < 20. Platelet count: normal = 150,000 450,000 o < 10,000: functional activities only, stairs prior to discharge, defer exercises o 10-20,000: ambulation, functional mobility, therapeutic active exercise, stationary bike (minimal resistance OK) o 20-50,000 all of above, resistive exercises as tolerated up to 5# o 50-150,000 continue to progress with moderate resistance as tolerated. o Once platelets are in normal range, continue with activities as tolerated 2

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure INR: normal value 1.0 2.0, therapeutic range 2.0 3.0. Obtain activity orders from MD if INR > 3.0 Generally therapy will be deferred if INR > 4.0 Cardiac enzymes: Rule out MI protocol: CK, CK-MB and troponin (Tn-I) will be drawn 3 times, once every 8 hours, over a 24 hour period. Defer all physical therapy and maintain strict bed rest until rule out is complete. If the patient ruled in for MI, obtain new activity orders from M.D. prior to resuming therapy.

C. Multiple lines, tubes and drains may be encountered during physical therapy session with the post-operative patient. Prior to initiating treatment, take note of each line and tube, avoid dislodgement during therapy, and ask for the appropriate assistance when necessary. Discuss with the RN about any lines and tubes that can be disconnected prior to treatment. Refer to the attached handout Lines, tubes and equipment in Acute Care (Appendix I) for specific precautions and contraindications. D. Epidural catheter Usually in place for 1-2 days after lower extremity, abdominal or thoracic surgery Always assess circulation, sensation, and motor (CSM) prior to initiating out of bed activity. If CSM is impaired, do not progress to weight bearing activities. Thoracic level epidural is used for abdominal and thoracic surgery. Ambulation is allowed if lower extremity CSM is intact. Lumbar plexus epidural is used for lower extremity surgery. Depending on the Bupivacaine dosage (0.5%) defer out of bed mobility until 4-6 hrs after epidural pump is turned off. Sometimes with lower doses of Bupivacaine (<0.25%) ambulation may be allowed earlier than indicated above IF CSM IS INTACT. Clarify with M.D. E. Vacuum (VAC) Sponge Dressing Do not disconnect VAC sponge without specific order from MD. In some circumstances the VAC may be clamped for ambulation The VAC sponge power source can be switched over to battery for a limited time for ambulation. Ask RN or experienced therapist for instructions if needed. 3. Considerations A. Activity guidelines Abdominal incision, e.g. AAA repair o Bed chair once pulmonary artery (PA) line is d/cd o Ambulate as tolerated POD #2 3

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure o Avoid lifting more than 15-20 pounds for 6 weeks o Avoid strong abdominal work, e.g. sit-ups, resisted hip flexion o Strict log rolling for getting in and out of bed o Avoid activities that encourage Valsalva maneuver Groin incision due to vascular surgery o Avoid prolonged sitting in upright for POD #1-5, sitting in a recliner is allowed o May begin ambulation with assist on POD #1 if there is no epidural Gracilis protocol s/p graciloplasty to repair pelvic floor or other adjacent structures o Bed rest for 3 days, then ambulation with assist, WBAT o No hip abduction > 30; No hip flexion > 70 o No sitting except briefly on the toilet with minimal hip flexion o Instruct patient to ascend stairs leading with non-operative extremity and descend with the operative extremity. Lower extremity incision due to vascular surgery o Bed to chair on POD #1 o Ambulation with assist on POD #2, if there is no epidural. There may be additional precautions if there is a foot wound, check with M.D. o Avoid prolonged sitting, break up activity by ambulating or resting in bed o Elevate lower extremities when lying in bed o Avoid maximal flexion or aggressive stretching at any joint where the incision is located for POD #1-5 Heel wound o Bed to chair and ambulation with assist on POD#1 o For posterior heel wounds: PWB, consider post-op shoe for ambulation and Rolyan foot drop splint for positioning in bed. o For plantar heel wounds: NWB within room ambulation on POD#1, then progress distance as tolerated, consider Multi-podus splint for positioning (request model with ambulation attachment for future use). Floor can call outside vendor for splint. Plastic and Oncology Surgical Procedures o Review the operative note to determine which structures (nerve, muscle and/or bone), if any, were compromised or sacrificed during the procedure and assess their functional implications prior to evaluating the patient. If the operative note is not available, discuss the procedure with the surgical team.

B. Pain Management Initiate physical therapy when the patient has effective pain management. Instruct patient in splinting abdominal incisions during deep breathing and coughing exercises. 4

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure Examination:
This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

1. Chart Review A. HPI & PMH Onset and duration of symptoms and cause of surgery B. HC Type and date of procedure and any post-operative complications Pertinent laboratory and diagnostic tests C. Medications Type of medications, side effects and rehab implications 2. Social History Prior functional level, use of assistive devices Home environment and current/potential barriers to returning home Family/caregiver support system available Family, professional, social and community roles Patients goals and expectations of returning to previous life roles 3. Physical Examination Vital signs (HR, BP, RR, SpO2, as indicated) Skin integrity: wound condition, potential areas for skin breakdown Pain Sensation Range of motion (ROM) Strength Balance Mobility level Endurance/ability to monitor fatigue 4. Cognitive-Perceptual and psychological considerations Mental status o Level of alertness, orientation, and ability to follow commands o Safety awareness Psychological considerations o Assess patients coping mechanisms to altered functional status Teaching/learning considerations o Patients goals, motivators and learning style

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure Evaluation / Assessment: The primary goal for inpatient physical therapy for a patient s/p a general surgical procedure is to maximize functional independence while minimizing impairments as a result of the surgery. Potential impairments include but are not limited to: decreased strength, ROM, skin integrity, balance, and endurance as well as impaired gait and impaired knowledge of exercise program and precautions regarding activity progression. The predicted optimal level of improvement for these patients is to return to their previous life roles and lifestyle using assistive device and/or adaptive equipment, as appropriate, by 1-3 months following surgery. This prognosis may need to be modified due to any of the following factors: presence of co-morbidities, complications or secondary impairments, decreased cognitive status, barriers to returning to previous living environment and any other factors that may influence the patients ability to achieve functional independence. Age specific considerations in this population include all the normal physiological changes that occur with aging. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for more details. The physical therapist will consider all of the patients impairments whether they are disease or age based and will determine a comprehensive assessment, prognosis and rehabilitation plan for each patient. Suggested goals: (1-6 weeks) 1. Return to independent functional mobility 2. AROM bilateral UE/LE WFL, as appropriate 3. Strength grossly > 3/5 throughout bilateral UE/LE, as appropriate 4. Good balance in sitting and standing, with or without assistive device 5. Demonstrate independent exercise program 6. Demonstrate good understanding of all precautions regarding activity progression 7. Good safety awareness with all functional mobility Treatment Planning / Interventions Established Pathway _X_ Yes, see attached. AAA pathway ___ Yes, see attached. ___ No

Established Protocol

_X_ No

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure Interventions most commonly used for this case type/diagnosis.
This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

1. Intervention Initiate physical therapy intervention, as appropriate, given the patients medical status, activity orders and weight bearing precautions as indicated by the physicians orders. A. Therapeutic exercise program Progress from supine, sitting, and standing P/AA/AROM for UE/LEs, as appropriate B. Endurance Training Increase tolerance to sitting in bedside chair Depending on medical status, the patient may not be able to transfer bed chair. Recommend stretcher chair or EZ-lift transfers to the RN staff and coordinate therapy sessions around the patients out of bed schedule to optimize the effectiveness of therapy and limit the patients fatigue. Progress time, distance and frequency of ambulation. Recommend activity schedule to other healthcare providers or family members, as appropriate. Post activity schedule in room, if necessary C. Functional Mobility Training Bed mobility and supine sit activities Transfer training (bed chair wheelchair commode), using adaptive equipment, as appropriate (e.g. slide board) D. Balance Training Sitting and standing activities, as indicated E. Gait Training Assistive device prescription, as appropriate, given weight bearing status Progress to stair training, as appropriate, prior to discharge home 2. Patient/Family Education A. Discuss realistic expectations regarding function, appropriate level of assist that patient requires from family and their anticipated rehab progression. B. Provide emotional support to the patient and family as needed. C. Instruct the patient in pacing activities and safe activity progression D. Instruct the patient and family members in the following and assess their understanding via return demonstration: Therapeutic exercise and endurance program Safe mobility techniques encouraging maximal independence. 3. Available handouts (post in room and/or distribute to patient upon discharge): A. Home exercise programs (Use Exercise Pro for individualized program) B. General activity guidelines after surgery (see Appendix II) 7

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure 4. Frequency of Treatment Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his or her impairments and functional limitations. Refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting. 5. Recommended Referrals to Other Providers Discuss the patients need for additional services with the primary team. A patient may benefit from the following services if appropriate: A. Occupational Therapy: If a patient presents with impairments that affect his or her ability to perform activities of daily living independently and/or who may have adaptive equipment needs B. Speech and Swallowing: If a patient presents with impairments that affect his or her ability to swallow without difficulty and/or a new communication impairment. C. Care Coordination: If a patient has a complicated discharge situation and the care coordination team is not involved. D. Social Work: If a patient has a complicated social history and he or she requires additional support or counseling. Re-evaluation / assessment Reassessment will occur under the following circumstances: all physical therapy goals are met, significant change in medical status occurs, patient is discharged from services or facility, and/or within 10 days from the previous assessment. Discharge Planning Discharge planning will occur on an individual basis depending on the patients medical, physical and social needs. Discharge planning is a coordinated effort that occurs with the physician, care coordination, therapist(s), the patient and his or her family. If the patient continues to have significant impairments and functional limitations and/or complicated medical needs at the time of discharge from the acute hospital, he or she may be discharged to an acute or sub-acute rehabilitation facility, skilled nursing facility (SNF), or extended care facility. The patient will continue to progress towards their physical therapy goals at the alternate inpatient facility, as appropriate. If the patient has met all inpatient physical therapy goals, he/she may be discharged home with or without services. Consider the following resources for continued therapy: Home PT (e.g. VNA) Outpatient PT for patients who have a high level of function but continue to have specific impairments

Standard of Care: General Surgery

Physical Therapy Management of the patient s/p a general surgical procedure Bibliography / Reference List APTA Guide to Physical Therapy Practice, Second Edition. Physical Therapy 81:(1); 2001. BWH Department of Rehabilitation Services Activity Guidelines for Vascular Patients BWH Department of Rehabilitation Services Guidelines for frequency of physical therapy patient care in the acute-care hospital setting Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwark, CT: Prentice Hall, 1994. Paz JC, West MP, Acute Care Handbook for Physical Therapists, Second Edition. Boston: Butterworth-Heinmann,. 2002, 887-896. Polich S, Faynor SM. Interpreting Lab Test Values. PT Magazine. 1996;76-88.

K.Weber, PT Completed 4/03 Accepted 10/03 2005, Department of Rehabilitation Services, Brigham & Womens Hospital, Boston, MA 9