Midterm Exam

Rete Pegs

Provide strength to our skin so its harder to have wounds form

Between the epidermis and the dermis

Where are rete pegs found?

They flatten out as we age causing less skin integrity

How does aging effect the rete pegs?

Causes of Pressure Injuries

-Shear (friction with pressure)

-Moisture alters resiliency of skin

-Decreased blood flow

-Decreased blood pressure

-Psychiatric status (Can’t change positions on their own)

-Smoking (Constricts blood vessels)

-Decreased O2 perfusion

Effects of Aging that Promote Pressure Injuries

-Flattening of rete pegs

-Decreased dermal thickness

-Decreased epidermal turnover

-Decreased surface barrier function

-Decreased subcutaneous fat

Pressure Injury Stage 1

-Intact skin with non-blanchable redness of a localized area. (Usually over a bony prominence

->Dark pigmented skin individuals might not demonstrate blanching

Non-blanchable

Skin doesn’t go white when pressure is applied

Pressure Injury Stage 2

-Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed without slough

-May also present as an intact or open/ruptured serum-filled or serosanguinous filled blister

-Presents as a shiny or dry shallow ulcer without slough or bruising

-Does not have necrotic tissue at this stage

Pressure Injury Stage 3

-Full thickness tissue loss

-Subcutaneous fat may be visible but bone, tendon, or muscle are not

-Bone/tendon are not directly palpable

-Can have undermining or tunneling

-Can have necrotic tissue

Pressure Injury Stage 4

-Full thickness tissue loss with exposed bone, tendon, or muscle

-Exposed bone/muscle is visible OR directly palpable

-Can have undermining or tunneling

-Can have necrotic tissue

Common Locations for Pressure Injuries

-Scapula

-Iliac crest

-Greater trochanter

-Sacrum

-Ischium

-Lateral malleolus

-Heel

-Lateral edge of foot

Deep Tissue Pressure Injury

-Deep or prolonged pressure or shear injuring muscle and deep tissues

-Non-blanching deep red, maroon, or purple discoloration

-Can demonstrate blood filled blister

Kennedy Terminal Ulcer

-Sudden onset

-Coccygeal area or gluteal fold

-Mirror image, either pear or butterfly shape

-Red, yellow, or black skin progresses quickly to eschar

-It is a precursor to multi-organ failure and death within 2-3 weeks

Diabetic/Neuropathic Wounds

-Tend to be located on the plantar foot or places of abnormal shoe wear/weight bearing surface

-Etiology can arise from foreign objects

Venous Wounds

-Large amount of edema and exudate

-Often minimal pain (Pain is reduced with elevation)

-Poorly defined wound border

-Pulses are present

-Insidious onset

-Need compression to heal

-Hemosiderin staining present

Lower leg proximal to the medial malleolus (Gaiter Area)

Where are venous wounds usually found?

Hemosiderin Staining

Red blood cells leak into the interstitial space and release iron

Arterial Wounds

-Tend to be distal/anterior/lateral toes/feet but can be more proximal starting by a mild injury

-Painful (Pain worse with elevation)

-Often a well defined border/Punched out look

-Pale

-Minimal drainage

-Faint or absent pulses

-Surrounding skin rubor

Superficial Thickness Wound

Only the epidermis is damaged

Partial Thickness Wound

Goes into the dermis but not all the way through

Full Thickness Wound

Goes through the dermis and into the subcutaneous tissue

Inflammatory Stage Clinical Presentation

-Erythema

-Edema

-Heat

-Pain

-Necrotic tissue

-Exudate

• Puss looking

• Thick with extra materials

• Not necessarily a foul/infection odor

Proliferative Stage Clinical Presentation

-Granulation tissue (Beefy red colored angiogenesis)

-Wound contraction

-Epithelialization (Keratinocyte migration)

-Minimal transudate (Serous/serosanguinous fluid)

Complete epithelialization of the wound

When does the proliferative stage end?

Maturation Stage Clinical Presentation

-Scar size decreases

-Red color fades

When red color is all gone

When does the maturation stage end?

Sensory Neuropathy

Decreased or absent pain/sensation

Motor Neuropathy

Weakened intrinsic foot muscles, imbalance between toe flexors and extensors

Autonomic Neuropathy

-Reduced sweating causing dryness of feet

-Reduced control over vasoconstriction causing increased rate of blood flow which overwhelms the circulatory system resulting in extra connections between large arterial and venous vessels

Matrix Metalloproteases

-Break down surrounding tissue

-Cleans debris out of wounds

During inflammatory phase

When are matrix metalloproteases beneficial?

NERDS (Superficial Critical Colonization)

-Non-healing

-Exudate increases

-Red and bleeding

-Debris

-Smell

STONEES (Deep Critical Colonization)

-Size is bigger

-Temperature increases

-Os (Probe to bone or exposed bone)

-New breakdown

-Exudate increases

-Erythema, Edema

-Smell

S/S of Infection

-Induration

-Fever/heat

-Erythema

-Edema

Pseudomonas

-Blue-green exudate and appearance to wound

-”Sweet” smell

-Commonly treated with topical antimicrobial, Sulfamylon

Maceration

-Softening or dissolution of tissue after lengthy exposure to fluid

-Pruney, wrinkly appearence

-Caused by wound being too wet

Compression for venous wounds

-Reduces risk of DVTs

-ACE wrap not a good candidate for venous wounds since it is a “long stretch” wrap

-Short stretch bandages are inelastic for 30-40 mmHg pressure and are great for venous wounds

-Multilayer wraps

Ankle Brachial Index (ABI)

-Systolic BP at ankle/Systolic BP at brachial artery

-Need a venous doppler

-Value >1 is normal or venous disease

-0.8-1 some arterial involvement

-<0.8 = arterial involvement, do not compress

-<0.5 = urgent referral to vascular surgeon

Charcot Joint

-9% of diabetics

-Remodeling

-Rocker-Bottom foot

Inflammation

-Erythema

-Edema

-Pain

Deformity

-Subluxation of midfoot bones

UVC Indications

Infected or highly colonized wounds where traditional interventions are not working

UVC Contraindications

-Light sensitive disease such as SLE

-Current or PMH of melanoma or squamous cell carcinomas

-HIV

-Fever

-Radiation or deep XR therapy

UVC Application

-Skin sensitivity test to uninvolved skin for 15 secs. and observed for 24 hrs.

-Drape/protect periwound skin

-Therapist must wear protective eye wear and have patient cover eyes

-Protocols vary from 30 secs. to 2.5 minutes

-Flush wound to wash

Effectiveness of UVC

-Combating a developing surface infection,

-Infected wounds where poor circulation reduces the effectiveness of systemic antibiotics

-Replacing topical antibiotics

-Treating antibiotic resistant species such as MRSA

-5 daily treatments should begin to show infection improvement

Extended Spectrum Beta-Lactamase

-Causes hydrolysis of many antibiotics

-Can produce carbapenemase

Levine Technique

-Cleanse the wound first

-Hold the culturette tube in one hand and remove the cap and applicator with other hand

-Apply gentle pressure and swab wound gently to obtain a sample of drainage on applicatory

-Do not culture purulent or necrotic debris or drainage over hard eschar

-Roll the tip of the applicator completely over in a one centimeter square area for 5 seconds

-Return applicator to culture tube without contaminating the applicator or outside of container

-Apply cap

-Break the liquid capsule at the bottom of the culture tube if present

-Make sure the culture medium surrounds the swab

Ultrasound Treatment Settings

-20% duty cycle

-3 MHz frequency

-<0.5 watts per square cm for intensity

-Treatment time is 1-2 minutes 2-3 times per day 3 times a week

Gauze Dressings

-Thick with significant absorption ability

-Tends to dry out wound (No moisture retention)

-Used for maximal exudate where frequent dressing changes are required and maceration is not a problem

Transparent Films

-No ability to add or absorb moisture

-Use as a primary dressing over negligible or non-draining wounds to hold in moisture

-Impermeable to liquids and bacteria but permeable to gases

-Can help maintain moisture in superficial wounds or as a secondary dressing on deeper wounds

Hydrocolloid

-Maintain tissue moisture but have a moderate absorption ability

-Slow rate of moisture absorption

-Use with minimal to moderate draining wounds changing towards minimal drainage

-Often used as a secondary dressing

-Allow 2-3 days between dressing changes depending on exudate levels

Foam

-Moderate to max moisture absorption but must be over a relatively shallow wound

-Cannot be easily packed in undermining or tunneling due to the “memory” of it that does not conform to the shape of the new wound space

-Some are designed to conform to undermining and tunneling, however, some spread moisture out to the edges of the foam and macerate surrounding tissues if not cut to the specific wound dimensions

Calcium Alginate

-Used with maximally exudating/maximally draining wounds

-Used as sheets for more shallow wounds or rope for wound filling/packing

-Can dry a wound out that does not have significant drainage

Hydrogel/Hydrogel Infused Dressing

-Provide moisture to a dry wound

-Can help hydrate necrotic tissue to facilitate autolytic debridement

-Can cause wound maceration if too much moisture

-Use for dry wounds or to hydrate dry necrotic tissue

Collagen Dressing

-Absorbs exudate

-Acts primarily as a matrix on which granulation tissue can grow

-Can distract excess MMPs to attack the dressing instead of the growing granulation tissue

Collagen-Oxidized Regenerated Cellulose

-Binds MMPs and renders them inactive bringing MMP levels back down to normal levels in chronic wounds to allow granulation tissue to grow and epithelialization

-It is believed this destroys the 3-dimensional shape of the MMPs so they can not bind to any other cells or chemicals

-Use in chronic wounds where high levels of MMPs are suspected of slowing or stagnating wound healing

Copper Oxide Impregnated Dressing

-Increases angiogenesis by increasing vascular endothelial growth factor

-Increased expression of integrins

• Stimulates:

  • Extracellular matrix

  • Basement membrane

  • Cell adhesions

  • Growth factors

-Increased activity of copper dependent enzymes for matrix remodeling, cell proliferation, and re-epithelialization

-Can eliminate Gram positive and Gram negative bacteria, viruses and fungi

Composite Dressing

-Contact layer of primary dressing with a secondary dressing component

• EX: Collagen with a hydrocolloid

-Some additions for odor such as activated charcoal or additions for pain such as silicone contact layers covering absorptive foams

Honey Dressing

-Promoted to decreased pH and increase osmotic flow of fluids to help autolytic debridement

-Draws water out of bacterial cells slowing their reproduction

-Transparent films

-Hydrocolloids

What dressings are used for moisture maintenance?

-Foams

-Hydrocolloids

-Alginates

What dressings are used for moisture absorption?

Hydrogels

What dressings are used for moisture addition?

-Silver containing dressings

-Copper oxide dressings

-Iodine containing dressings

What dressings are used to reduce bacterial levels?

-Collagen

-Collagen ORC dressings

What dressings are used to reduce protease levels?

Activated Charcoal

What is used to reduce odor?

Silicone Dressings

What dressings are used to reduce pain?

Barrier Cream

-Protects skin from continued exposure to feces, urine, or both

-Usually contains high level of zinc oxide

-Will not wash away after repeated exposure to urine and feces

-Contains Karaya to absorb moisture and adhere to weepy, macerated skin

-Some are fragrance free (No alcohol, for reduced irritation)

-Those with a higher petrolatum base can be clear so that you can see through the ointment

Good Goals

-Wound area will decrease from _____ cm³ to ______ cm³ in order to… (Promote wound closure OR Decrease risk of future infections)

-Wound tunneling will decrease from _____ cm to _____ cm…

-Wound undermining…

-Pt will independently instruct caregiver how to reposition pt from supine to sidelying

-Pt will demo 2+/5 general bilateral LE strength to promote more independence with bed mobility and self-repositioning

Child Abuse Signs

-Bruise on ear, likely a hit on the head

-Burn older than history given

-Parent story does not match burn

-Parent story does not match child developmental abilities

-Immersion burn gives spared areas

Total Body Surface Area (TBSA)

-Head = 9%

-Trunk = 18% for each side

-Arms = 9% each

-Legs = 18% each

-Genitalia = 1%

Cutaneous Functional Units

-The entire surface of skin recruited for full movement of a joint

-Adjacent joint positions impact the amount of skin recruited

-Normal skin has 50% extensibility

->Burn scar only 15%

->Mature burn scar only 5%

-Always stretch the joint distal to the burned skin

Proper Positioning of Burn Patients

-Use crucified position if possible

-Splints are helpful

-Microstomia devices

-Tongue depressors for stretching vertical mouth

Escharotomy

-Operation where an opening is made into an area of skin that is thickened and tightened after a severe burn

-Used to cut through dead tissue to get to the lungs to assist with breathing or to help with circulation in the extremities

Integra

-A dermis substitute made of bovine collagen and glycosaminoglycan

-Has an outer silicone layer that functions like epidermis until ready for skin graft

Integra Precautions

-Must wait 5-6 days prior to ROM

-Prior to grafting over this the physician will wait until adequate dermal growth is seen by capillary growth

Ectropion

Outward turning of the eyelids due to a facial burn

Excising and grafting the wound early

How do you prevent ectropion?

Role of PT in Hospital

-Get patient to the next step in recovery process (We determine where the patient goes next)

-Communicate with other healthcare staff, families of patients, and patients themselves

-Mobilizing patient ASAP (Function, function, function)

Donning PPE

1. Put on gown

2. Put on mask

3. Put on goggles/face shield

4. Put on gloves

Doffing PPE

1. Take off gloves

2. Take off gown

3. Wash hands!!

4. Take off goggles/face shield

5. Take off mask

6. Wash hands!!!!

Standard Precautions

-Clean hands

-Clean equipment

-PPE when in contact with body fluids

-Practice cough etiquette

Contact Precautions

-Clean hands

-Gown

-Gloves

Droplet Precautions

-Includes standard precautions

-Mask

-Face shield OR goggles

Novel Respiratory Precautions

-Includes standard precautions

-Gown

-Gloves

-N95 and Face shield OR PAPR

Airborne Precautions

-Includes standard precautions

-Keep door shut

-N95 or higher level respiratory

Prehab for TKA

-Strengthening quads for quicker recovery

-Focus is strengthening, ROM, and expectations following surgery

-Same exercises as post-surgery (Heel slides, quad sets, TKEs, SLRs, knee extension, knee ROM in sitting)

-Patient education on postoperative expectations

-Discussing and instructing in use of planned postoperative ADs (Walker or crutches)

-Addressing home environmental barriers that may impede independent mobility post-discharge

Prehab for THA

-AROM exercises to involved hip as tolerated

-Strengthening exercises focusing on hip and knee extensors and hip abductors such as:

• Quads sets

• Glute sets

• Heel slides

• Hip abduction

• Ankle pumps

-Patient education on postoperative epectations

-Discussing and instructing in use of planned postoperative ADs (Walker or crutches)

-Addressing home environmental barriers that may impede independent mobility post-discharge

Mental Function Outcome Measures

-Orientation

-DeJonghe’s 5 orders

-RASS

-GCS

-CAM-ICU/pCAM-ICU

-MMSE
-MoCA

Integumentary Integrity Outcome Measures

-Edema Grading Scale

-Braden Scale

-Pressure ulcer scale for healing (PUSH)

Mobility Outcome Measures

-6 Clicks

-Acute care index of function (ACIF)

-Barthel index

-10 MWT

-FIM

-AlphaFIM

Aerobic Capacity/Endurance Outcome Measures

-6 MWT

-2 MWT

-2 MST

Muscle Performance Outcome Measures

-Hand held dynamometry

-5x STS

-MMT/MRC

-30 sec. Chair stand

Balance Outcome Measures

-Function in sitting test (FIST)

-Functional reach/Modified functional reach test

-Berg balance scale (BBS)

-Dynamic gait index (DGI)

-Timed up and go (TUG)

Interventions for TKA

-Weight bearing with an AD

-Surgeon protocol/preferences

-Minimize swelling and pain as a healthcare team

-Early mobility

• Functional training (Transfers, gait with AD, stairs)

• AROM (Initiate exercises)

• Safety with ADs

-Breathing exercises with all post surgery patients

-Patient education

Interventions for TSA

-Physician protocol

-Sling

-Immobility

-PROM exercises of shoulder (Forward flexion and ER)

-Bed mobility and transfers

-Ice

Interventions for Spinal Fusion

Supine

-Heel slides

-TKEs

-Abduction/Adduction

-Ankle pumps

-UE flexion

-UE abduction/adduction

-UE IR/ER

-Diaphragmatic breathing

Goals for Acute Care

-Improve mobility (Functional activities required for daily living)

-Address equipment needs

-Patient education

-Caregiver training

-Discharge needs

Anterior Approach Hip Precautions

-No hip hyperextension

-No hip ER past neutral

Posterior Approach Hip Precautions

-No flexion past 90 degrees

-No adduction past neutral

-No IR past neutral

Global Approach Hip Precautions

-No Hip hyperextension

-No hip ER or IR past neutral

-No hip flexion past 90 degrees

-No adduction past neutral

Trochanteric Osteotomy Hip Precautions

-No active hip abduction

-Limited WB status (TDWB-PWB)

Discharge Home Independently or with Family Parameters

-Patient has returned to PLOF

-Patient is safe with transfers and mobility

-Patient has support from family or friends, OR patient can complete IADLs and ADLs independently

-May need some coordination with case manager for meals, transportation, other needs