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550

ACUTE CARE HANOBOOK FOR PHYSICAl. THERAPISTS

With all of the above colostomies, an external, plastic pouch is

placed over the stoma in which the patient's stool collects. Patients

are instructed on proper care and emptying of their colostomy pouch.

This procedure can be performed in the ascending, transverse, and

sigmoid portions of the colon, with sigmoid colostomies being the

most commonly performed.

Clinical Tip

• Before any mobility treatment, the physical therapist

should ensure that the colostomy pouch is securely closed

and adhered to the patient. When possible, coordinare

with the nurse or the patient to empty the colostomy bag

before therapy to fully minimize accidental spills.

• Patients who are experiencing abdominal pain from

recent surgical incisions may be more comfortable in the

side-lying position (if allowed) to help relieve skin tension

on the recent incision.

•

Instructing the patient to bend his or her knees up while

the head of the bed is being lowered may also decrease

incisional discomfort.

Physical Therapy Intervet!tion

The following are general goals and guidelines for the physical therapist when working with the patient who has Gl dysfunction. These guidelines should be adapted to a patient's specific needs.

Goals

The primary physical therapy goals for this patient population are similar to those of other patients in the acute care serring: (1) to optimize functional mobility, (2) to maximize activity tolerance and endurance,

and (3) to prevent postoperative pulmonary complications.

Guidelines for Physical Therapy Intervention

General guidelines include, but are not limited to, the following:

1.

Parients with Gl dysfunction can have increased fatigue

levels as a result of poor nutritional status from malabsorption and

GASTROINTFSllNAl SYSTEM

551

anemia from inflammatory and hemorrhagic conditions of the GI

tract. Therefore, consider the patient's fatigue level with treatment

planning and setting of goals.

a)

Consultation with the nutritionist is helpful in gauging

the appropriate activity prescription, which is based on the

patient's caloric intake. It is difficult to improve the patient's

strength or endurance if his or her caloric intake is insufficient

for the energy requirements of exercise.

b)

Reviewing the patient's laboratory values to determine

hematocrit and hemoglobin levels before treatment may be

helpful in planning the patient's activity level for that session.

Refer to Hematologic Evaluation in Chapter 6 for more information on hematology

c)

Malabsorption syndromes can also lead to altered

metabolism of medications and, therefore, the responses to

medications will be less predictable and can impact the treatment planning of the therapist.7

2.

Patients with GI dysfunction may have certain positioning

precautions.

a)

Dysphagia can be exacerbated in supine positions and

may also lead to aspiration pneumonia.71

b)

Portal hypertension can be exacerbated in the supine

position because of gravitational effects on venous flow.

c)

If the patient has associated esophageal varices from

portal hypertension, then the risk of variceal rupture may be

increased in this position as well.

d)

Patients with portal hypertension and esophageal

varices should also avoid maneuvers that create a Valsalva

effect, such as coughing.

e)

The increase in intra-abdominal pressure from Val-

salva's maneuvers can further exacerbate the esophageal varices.

(Huffing, instead of coughing, may be more beneficial in these

situations.)

3.

Nonpharmacologic pain management techniques from the

physical rherapisr may benefit patients who have concurrent diagnoses of rheumatologic disorders and GI dysfunction.

552 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

a)

Because NSAlDs are a causative risk factOr for many

inflammatOry and hemorrhagic conditions of the GI system,

these medications will typically be withheld from the patient

with any exacerbation of these conditions.

b)

Therefore, patients who were reliant on NSAlDs for

pain management before admission for their rheumatologic conditions may have limitations in functional mobility as a result of altered pain management.

4.

Patients with ascites or large abdominal incisions are at

risk for pulmonary complications. Ascites and surgical incisions

create ventilatory restrictions for the patient.

a)

Additionally, these conditions can hinder cOllgh effec-

tiveness and functional mobility, both of which can further contribute to pulmonary infection.

b)

Effective pain management before physical therapy

intervention, along with diligent position changes, instruction

on incisional splinting during deep breathing and coughing, and

early mobilization with or without assistive devices, will help

prevent the development of pulmonary complications and

deconditioning.

References

1. Koopmeiners MB. Screening for Gastrointestinal System Disease. In W'G

Boissonnault (ed), Examination in Physical Therapy Practice. New

York: Churchill Livingstone, 1991;105.

2. Malarkey LM, McMorrow ME (eds). Nurse's Manual of Laborarory

Tests and Diagnostic Procedures. Philadelphia: Saunders, 2000;412-

431.

3. Malarkey LM, McMorrow ME (eds). Nurse's Manual of Laboratory

Tests and Diagnostic Procedures. Philadelphia: Saunders, 2000;469.

4. Kapelman B. Approach to the Patient with Liver Disease. In DB Sachar,

JD Waye, BS Lewis (cds), Pocket Guide to Gastroenterology. Baltimore:

Williams & Wilkins, 1991 ;90.

5. Laparoscopy and Laparoscopic Surgery. In GL Eastwood, C Avunduk

(cds), Manual of Gastroenterology (2nd ed). Boston: Little, Brown,

1994;27.

6. Corbett Jv. Laboratory Tests and Diagnostic Procedures with Nursing

Diagnoses (5th cd). Upper Saddle River, NJ: Prentice Hall Healrh,

2000;698.