| REVISED STEPS AFTER ROUND 1 | n | RATING ROUND 2 MEDIAN (SIQR) | RATING ROUND 3 MEDIAN (SIQR) |
---|---|---|---|---|
COUGHING AND PROCEDURE ADOPTED TO FACILITATE COUGHING | Â | Â | Â | |
Teach pt to huff/cough with wound support | 1. Teach patient to huff/cough with wound support. Use following strategies to facilitate procedure: deep breathing, PEP, high-pressure PEP and CPAP in combination with FET (or adjusted autogenic drainage). | 5 | 2.0 (0.5) | 1.0 (0.0) |
If unsuccessful: suction patient through mouth piece | 2. If all else fails include suctioning as a possible management strategy for removing secretions | 5 | 2.0 (0.5) | 2.0 (0.0) |
 | 3. Use nebulization as a management option for the removal of secretions | 5 | 3.0 (0.5) | 3.0 (0.0) |
Position pt in high sitting over the side of the bed | 4. Position the patient in a stable, supported upright sitting position with a goal of positioning the patient out of bed to facilitate removal of secretions | 5 | 1.0 (0.0) | 1.0 (0.0) |
CRITERIA FOR MOBILIZATION | Â | Â | Â | |
At rest pt is presenting stable blood pressure and heart rate with less than 8/10 rating on pain scale | 5. Perform a clinical evaluation of pain level | 5 | 3.0 (0.0) | 3.0 (0.0) |
At rest pt is presenting with no dyspnoea | 6. At rest dyspnoea does not exceed 1 on MBS. | 5 | 3.0 (0.5) | 3.0 (0.0) |
 | 7. Ensure sufficient pulmonary reserve (Oxygenation level PaO2:FiO2 > 40 kPa/300 mmHg) before initiating mobilization. | 5 | 2.0 (1.5) | 2.0 (0.0) |
 | 8. Motor block assessment in patients receiving epidural analgesia | 5 | 2.0 (0.5) | 2.0 (0.0) |
BREATHING TECHNIQUES | Â | Â | Â | |
Position pt in high sitting over the side of the bed/Long sitting in bed | Incorporated into steps 4 and 16 | Â | Â | Â |
 | 9. Prescribe frequent breathing exercises-the goal is at least five maximum breaths every waking hour. | 4 | 1.0 (0.25) | 1.0 (0.0) |
Use any of the following techniques based on pt performance: PEP mask; IPPB; PEEP Bottle; IS | 10. Present breathing technique choice in the following hierarchy: DBE's followed by PEP mask or bottle; then IS and IPPB as the least likely choice. | 4 | 2.0 (1.0) | 2.0 (0.13) |
 | 11. Deep breathing exercises (pursed lips breathing; inspiratory hold) are the first choice of breathing exercises with PaO2:FiO2 > 300 mmHg. | 4 | 2.0 (0.88) | 2.0 (0.0) |
 | 12. In the presence of persistent post operative hypoxaemia (PaO2:FiO2 < 300 mmHg) initiate CPAP. | 4 | 2.0 (0.63) | 2.0 (0.0) |
MOBILIZATION | Â | Â | Â | |
Pt must reach at least one of these goals with each treatment session: Sit out of bed; Walk 5 m; 15 m; 30 m with assistance; Walk 30 m without assistance. | 13. Perform activities at dyspnoea intensity of 6 on the MBS. | 5 | 1.0 (1.0) | 1.0 (0.0) |
Progression based on walking intensity of 6/10 on Borg Scale | Incorporated into step 13 | Â | Â | Â |
Active dorsiflexion while in bed at least 20 times every waking hour | 14. Active dorsiflexion while in bed at least 20 times every waking hour | 5 | 4.0 (0.5) | 4.0 (0.0) |
Frequency: Days one and two (three times/day) | 15. An intensive mobilization protocol that includes walking and stair climbing should be performed at least once daily with the goal of three times per day. | 5 | 1.0 (0.5) | 1.0 (0.0) |
 | 16. Have patient sitting out of bed for a minimum of one hour twice daily AND walking at least 5 m as the goal on the first post operative day | 5 | 1.0 (0.5) | 1.0(0.0) |