Role of Physical Therapy + Wound Care

wound care certified (WCC)

offered through the National Alliance of Wound Care + Ostomy (NAWCO)

- licensed healthcare professionals including: PT, PTA, OT, MD, DO, RN, LPN, NP

- active in wound care pulse taking wound care courses

- must pass a 2 hour exam of 110 questions

- certification lasts for 5 yrs

certified wound specialist (CWS)

offered through the American Board of Wound Management

- any licensed healthcare professional with a Bachelors, Masters or Doctoral degree with 3/more years of clinical wound care experience

- must pass 4 hour exam (65% initial pass rate)

- certification lasts for 10 years + CWS must take 6 qualifying CEUs/year

what is the requirement in order to becomes a Fellow of American College of Certified Wound Specialists (FACCWS)

individual must already by a CWS/other recognized wound care expert

what are 7 types of WOUNDS that are REFERRED to PT

1. necrotic wounds

2. wounds with purulent exudate

3. chronic wounds

4, pasty/salmon pink wounds (chronic proliferation stage)

5. wounds without good epithelial margin

6. extremity wounds with edema

7. non-healing oncology wounds (per PT/MD)

what are 4 types of WOUNDS that are NOT REFERRED to PT

1. acute stage one/stage two pressure ulcers

2. wounds that are 100% granulating w/ a good epithelial margin

3. wounds responding well to conservative nursing treatment

4. cancer lesions

what are 4 wound care treatment strategies

1. know when to change approaches

2. selecting correct dressing(s) + modalities (if any) is key

3. avoid making things worse (maceration)

4. TIME (wound bed prep care cycle)

what does TIME stand for

T: TISSUE (viable/non-viable)

I: INFECTION/INFLAMMATION

M: MOISTURE + BALANCE

E: EDGE of WOUND

what are 7 modalities used by PTs for wound treatment

1. whirlpool

2. pulsed lavage

3. compression

4. electric stimulation

5. sharp debridement

6. dressings

7. vacuum assisted closure (VAC)

what are 4 ADVANTAGES of WHIRLPOOL

1. cleansing necrotic + odorous wounds

2. softening of eschar/necrotic tissue

3. debriding by mechanical action of turbulence

4. increases blood flow + circulation

what are 5 CONTRAINDICATIONS of WHIRLPOOL

1. moderate to severe edema

2. incontinence

3. acute phlebitis/cellulitis

4. DVT

5. dry gangrene

what are 4 PURPOSES of PULSE LAVAGE

1. irrigates + cleanses wounds via pulsatile lavage jets

2. reduces bacteria + infection

3. promotes granulation + epithelialization

4. only gets local vasodilation

what is the IRRIGATION PRESSURE RANGE for pulse lavage

4-15 PSI

what is the MOST EFFECT IRRIGATION PRESSURE for pulse lavage

8 PSI

what is used as the irrigant for PULSE LAVAGE

normal saline IV bag

what is the overall purpose of PULSE LAVAGE

debrides + cleans through pressure to necrotic tissue

what does the NEGATIVE PRESSURE provide in pulse lavage

concurrent suction (60-100 mmHg)

what does NEGATIVE PRESSURE remove in pulse lavage (3)

1. debris

2. bacteria

3. irrigant

what does NEGATIVE PRESSURE dilate in pulse lavage

arterioles to increase blood flow

what are 6 ADVANTAGES of PULSE LAVAGE

1. cost efficiency

2. faster outcomes

3. decrease length of stay

4. better control of suction + pressure

5. decrease need for OR

6. limb salvage

what are 6 PRECAUTIONS regarding PULSE LAVAGE

1. acute bleeding

2. exposed arteries, nerves, tendons + bones

3. grafts/flaps

4. cavity lining (open fascia)

5. patients on anticoagulants

6. aerosolization

what is requirement associated with AEROSOLIZATION

treatment only 1 pt/room or in separate air-lock treatment rooms

- must terminally clean room in between patients

where is PULSE LAVAGE often performed

private treatment rooms

what are the 3 pieces of PROTECTIVE EQUIPMENT that PTs should wear for pulse lavage

1. impervious gowns

2. mask with face shield

3. hair caps + booties

what should PTs identify with PULSE LAVAGE

any drug resistant organisms in wound

if swelling is visible what percent increase is there in the diffusion distance

100%

what are *4

INDICATIONS of COMPRESSION THERAPY*

1. LE edema due to impaired venous return/lymphedema

2. manage edema until fitted for custom stockings

3. decrease frequency of dressing changes for venous ulcers

4. clean venous ulcers with minimal drainage

what are 7 CONTRAINDICATIONS regarding COMPRESSION THERAPY

1. ABI < 0.8

2. poor personal hygiene

3. infected necrotic ulcers

4. mixed arterial/venous disease

5. DVT

6. non-Doppler pulses

7. osteomyelitis (non-treated)

what are 3 INDICATIONS of UNNA BOOT COMPRESSION

1. venous stasis ulcers + edema

2. light to moderate drainage

3. more active patients

how much COMPRESSION does an UNNA BOOT provide

20-30 mmHg

what is involved in the application of an UNNA BOOT

1. gauze impregnated w/ thick creamy mixture of zinc oxide, glycerin + calamine

2. ace wrap over gauze to secure it

how much COMPRESSION is achieved from a FOUR-LAYER COMPRESSION

30-40 mmHg

what is a FOUR-LAYER BANDAGE placed over

a primary dressing (wound contact layer)

what is LAYER 1 of a four-layer bandage

absorbent padding

what is LAYER 2 of a four-layer bandage

crepe bandage

(holds layer 1 in place)

what is LAYER 3 of a four-layer bandage

class 3a elastic compression bandage

what is LAYER 4 of a four-layer bandage

class 3b cohesive bandage

what is a common type of ELECTRICAL STIMULATION used for wound treatment

high voltage pulsed current (HVPC)

what does HIGH VOLTAGE PULSED CURRENT (HVPC) use to increase wound healing

bioelectric current to attract cells to increase wound healing

what is primarily used during the application of HIGH VOLTAGE PULSED CURRENT (HVPC)

positive + negative polarity current in wound bed w/ electrodes/aluminum foil with use of dispersive pads

what are 3 BENEFITS of HIGH VOLTAGE PULSED CURRENT (HVPC)

1. increases blood flow

2. increases collagen synthesis

3. decreases edema

who is qualified to *perform SHARP DEBRIDEMENT8

ONLY PTs should perform sharp wound debridement

what are BOTH PTs + PTAs qualified to do regarding wound treatment

apply topical agents + dressings to wounds

what is the GENERAL TIME LIMIT for SHARP DEBRIDEMENT

15-20 minutes

what area of a wound should be focused on FIRST with SHARP DEBRIDEMENT

cleaner area first then necrotic

what are 11 RULES of SHARP DEBRIDEMENT

1. known your anatomy

2. avoid unknown structures

3. attempt to remove only devitalized tissue

4. pre-medication

5. set a general time limit of 15-20 minutes/patient's tolerance

6. recommend performing ABI first if indicated

7. may require several sessions

8. minimize overall bleeding (know patient's coagulation status)

9. work on cleaner areas first then necrotic

10. OK to remove necrotic tissue until a little bleeding occurs

11. for reimbursement: MUST be performed with a sharp instrument (scalpel/scissors) involving CUTTING away tissue + not merely scraping tissue away

what MUST SHARP DEBRIDEMENT be performed with for REIMBURSEMENT purposes

sharp instrument (scalpel/scissors) involving cutting away tissue + not merely scraping tissue away

what are 5 ELEMENTS of PROPER DOCUMENTATION regarding SHARP DEBRIDEMENT

1. description of procedure as excisional

2. instruments used

3. tissue removed

4. appearance + size of wound

5. depth of debridement