Integ Final – Flashcards

MIST Therapy® is a painless, noncontact, low frequency ultrasound delivered through a saline mist to the wound bed. Unlike most wound therapies that are limited to treating the wound surface, the gentle sound waves of MIST Therapy stimulate the cells within and below the wound bed to accelerate the normal healing process. The result of these gentle sound waves pushing against the tissue include: Removal of Barriers to Healing: Reduces bacteria Disrupts biofilm Reduces sustained inflammation Reduces MMP-9 (which breaks down the extracellular matrix) Stimulates Cells to Promote Healing: Increased blood flow through vasodilation Increased angiogenesis Early release of growth factors Increased collagen deposition Kit includes: Applicator tip 2 Disinfectant wipes (for cleaning machine before and after treatment) 100ml Saline bottle Blue absorbent pad Treatment time is based on wound size Applicator should be positioned 0.5-1.5cm from wound bed Clinical relevance: MIST therapy is very cost effective in treating patients and helping them heal quicker if wounds are not very complex. Study limitations Not true experiment- was a noncomparative clinical outcomes trial. All patients were treated with SOC only for 2 weeks before study.

Over electronic implants or prosthesis (pacemakers) Over the lower back or uterus during pregnancy Over malignancy

Ancient Egyptians (3000 BC) Used honey in a variety of remedies such as in surgical dressings to facilitate wound healing. Hippocrates (460-370 BC) - Greek physician Favored the use of honey-based concoctions for fever, pain, and wound management.

Low pH, between 3.2 and 4.5 Osmotic effect - inhibits or prevents the growth of most species of bacteria. Hydrogen peroxide is present in honey in low amounts, adding to its antibacterial properties. Removes contaminants, cleanses & deodorizes Stimulates macrophage vascular endothelial growth factor that is released during the initial inflammatory stages of wound healing. This may restart wound healing process in chronic wounds.

Indications: Acute & Chronic wounds Partial Thickness Burns

Contraindications: Allergies to bees/bee venom

Precautions: Patients with diabetes Unprocessed & commercial honey

Used for medicinal purposes for several thousand years Herodotus (1000 BC) - Greek Philosopher Insights into the use of silver as a healing agent Antibacterial qualities of silver were discovered by several physicians in 17th century. Silver nitrate was successfully used in the treatment of skin ulcers, compound fractures, and separating wounds. Incorporation of silver into wound dressings is a contemporary development5

Inert metal which does not react with human skin in a non-ionized form3 In aqueous solution reactive silver ions (Ag+) are formed6 Toxic to many components of bacterial cell wall Ultimately inhibits the replication of bacteria

Indications: Critically colonized wounds, infected wounds, delayed healing, burn wounds

Contraindications: clean wounds at low risk for infections, pregnancy, silver allergy, contraindicated by manufacturer (i.e. MRIs or radiation therapy)

Precautions: use in children, metal toxicity

"Consists of a generic application of low frequency, pulsed electrical currents transmitted by electrodes through the skin surface to stimulate the peripheral nerves to produce various physiological effects." Developed by Melzack and Wall in 1965 TENS is used worldwide to decrease chronic and acute pain as well as increase skin temperature and promote blood flow. Originally became popular after a publication was printed that introduced the gate control theory of pain TENS causes pain relief through the increase of blood flow caused by electrical impulses. Stimulation of blood circulation helps to accelerate the wound healing process Increases transportation of oxygen and nutrients to the tissue The increase in skin temperature that occurs through the use of TENS "has been associated with analgesia." - Analgesia can occur due to "reduced sympathetic activity, which induces vasodilation and relieves pain." Release of endogenous opioids in the CNS Opioid receptors activated to produce analgesia with high or low frequency TENS. Low frequencies, usually below 10 Hz, activate µ-opioid receptors High frequencies, above 50 Hz, activate δ-opioid receptors Types of wounds: Arterial insufficiency Venous insufficiency Neuropathic Pressure ulcers Trauma *Must have good periwound tissue -Non-invasive -Inexpensive -Easily applied -Good alternative to pain medications when used appropriately

Electrodes are placed around the edges of the wound Short duration, higher frequency pulses Amplitude sufficient to produce a comfortable sensation without muscle contraction to decrease pain TENS units can be worn whenever pain is experienced Can be applied for 24 hours a day

Demand pacemaker or unstable arrhythmia Over the carotid sinus Venous or arterial thrombosis or thrombophlebitis Over pelvis, abdomen, trunk, or low back during pregnancy

Cardiac disease including previous myocardial infarction Impaired sensation or mentation Over malignant tumor Directly over open wounds or irritated skin

E-stim for wound healing involves the application of low-level electrical current to the wound bed or peri-wound.1 Types of E-stim Direct Current Alternating Current High Voltage Pulsed Current (HVPC) Transcutaneous Electrical Nerve Stimulation (TENS) Indications: Pressure Ulcers Stage I through IV, Neuropathic ulcers Venous Ulcers, Traumatic Wounds, Surgical Wounds, Ischemic Ulcers, Donor Sites, Wound Flaps, Burn wounds E-stim can be an effective treatment to facilitate wound healing in a wide variety of wounds Parameter selection is based on desired effect of e-stim and present stage of wound healing

Malignancy, Cancer Active Osteomyelitis Metal ions (topical) Electrical implants (i.e. pacemaker) Natural Reflex Center Children

Skin irritation Patients with severe PVD Children Patients with cognitive deficits Pregnancy

See PowerPoint

Physical agent that has both thermal and nonthermal effects Definition: "mechanical vibration transmitted at a frequency above the range of human hearing which can be used both diagnostically to monitor the rate of healing and therapeutically to stimulate the rate of wound healing" Sound with a frequency greater than 20,000 cycles/second (Hertz) No consensus exists concerning its clinical effectiveness Multiple studies report no significant differences found or no evidence of ultrasound being beneficial Physical therapy ultrasound appears to have a low risk of harm in the hands of skilled physical therapists, but the expectation of a therapeutic benefit is also low Risk of harm, such as burns, appears to be low when applied properly; however, possibly dangerous when not used appropriately According to our research: Pulsed and Continuous Ultrasound seem to have positive benefits on wound healing for pressure and venous ulcers Reduces wound surface area Increases healing rate Effective for pressure ulcers in patients with SCI Ultrasound may be beneficial for treating post-burn patients, during remodeling phase of healing when scars are forming, to ensure proper alignment of scar, functional ROM continues, and patients daily living activities are not reduced Overall, US for physical therapy has a modest level of efficacy and patient benefit, but also low level of risk

Frequency 1 MHz- depth up to 5 cm 3 MHz- depth 1 to 2 cm Intensity-varies depending on patient 1 MHz- 1.0 to 2.0 W/cm2 3 MHz- 0.5 W/cm2 or lower Duration- varies with size of wound Normally 5 minutes Continuous ultrasound (100% duty cycle) Increase circulation Increase metabolic rate Increase soft tissue extensibility Decrease pain Pulsed ultrasound (20% or 50% duty cycle) Facilitate tissue healing Promote transdermal drug penetration

Malignant tumor Pregnancy Central nervous system (CNS) tissue Joint cement Plastic components Pacemaker Thrombophlebitis Eyes Reproductive organs

Acute inflammation Epiphyseal plates Fractures Breast implants

Inflammatory Phase: Important time for repair US helps to initiate the release of growth factors from platelets and macrophages US improves degranulation of mast cells that later form collagen-containing vascular granulation tissue Early intervention with US Accelerates inflammatory phase Leads to quick entrance into proliferative phase Should introduce during acute inflammatory phase Proliferative Phase US stimulates fibroblast migration and proliferation Fibroblasts exposed to therapeutic levels of US are stimulated to synthesize more collagen that gives soft connective tissue its tensile strength Endothelial cells affected by US Responsible for vascularization of the granulation tissue Produce vascular endothelial growth factor and angiogenesis Applied during the inflammatory and early proliferative phases May speed up wound contraction By causing cells to develop earlier and increase efficiency Some research states that if US is applied within 72 hours of the injury, it can help to promote wound contraction and decrease the size of the resulting scar Epithelialization Phase US stimulates release of growth factors important for the regeneration of epithelial cells US enhances epithelialization especially when applied to the periwound area Remodeling/Maturation Phase Affected by low-intensity US only if treatment is initiated during inflammatory phase Effects cause: Quick entrance into remodeling phase Increased wound tensile strength Increased capacity to absorb energy without mechanical damage Increased elasticity Deposition of collagen fibers in a pattern similar to intact tissue Applying thermal US during the remodeling phase has shown to enhance collagen organization and extensibility, tensile strength, and enzyme activity within the affected tissue

Impaired sensation Impaired circulation Infection

Remove wound dressings and clean the wound with saline solution on gauze to remove loose foreign debris and exudate Next, place sterile hydrogel filler from a tube onto a long cotton swab to place the gel into the wound bed so that it fills the wound to the top and even with the edges A hydrogel sheet is then removed from the package, the protective covering for the sticky side of the sheet is removed, and it is placed directly over the wound bed and margins Make sure to smooth out the sheet to remove any air bubbles underneath Medical tape may be used to keep the edges of the sheet down but be aware if it is on the patient's skin Now apply ultrasound gel over the top of the hydrogel sheet Select the appropriate sized ultrasound applicator The size of the wound should be no larger than 2 times the size of the applicator If a larger wound is being treated, it will need to be divided into sections Next, set the ultrasound machine to a 20% duty cycle at a frequency of 3 or 1 MHz The ultrasound head is then placed in contact with the ultrasound gel and moved in a slow linear technique over the wound in the pattern you want the fibroblasts and collagen to form Alternate days/treatments by going in a perpendicular or parallel pattern Set the intensity to 0.5 W/cm2 or lower if frequency is 3 MHz Reduce the intensity if the patient experiences pain or heat Treatment duration is normally around 5 minutes or 1 to 2 minutes per zone Acute wounds are treated 1 to 2 times per day until acute symptoms (inflammation) subside Treatments can then decrease to 2 to 3 times per week

Medical Maggots are available in the United States as a prescription only medical device. The use of this particular debridement technique has been approved by the FDA. The FDA acknowledges that the use of Medical Maggots is indicated for debriding chronic wounds that we have discussed in class. Some of these include pressure ulcers, venous stasis ulcers, neuropathic foot ulcers and post-surgical wounds.

The use of maggots for the cleansing of wounds dates back several centuries, and most likely gained popularity through military use. Research shows that physicians at Johns Hopkins University in Baltimore used to treat children with osteomyelitis and soft tissue injuries during the 1920s. They experienced mostly successful results and later published what was likely the first medical literature supporting their usage. Throughout the 1930s, the use of biological debridement was very popular among physicians, and ultimately the success rates were fairly high. The use of biological dropped significantly during the World War 2 era. New antibiotics and surgical debridement techniques had become more common and proved to be easier and more efficient than biological debridement. However, maggot therapy had not completely become extinct, and it was often used a last resort if antibiotics, surgery, and other modern wound care techniques failed to keep the wound from advancing. It was often used in patients with advanced wounds in an attempt to salvage a specific limb. In 1989, the first modern clinical studies were published by a group at the Veteran Affairs Medical Center in Long Beach, CA. Their usage was compared to standard modern day wound care. These studies showed that biological debridement was indeed a safe and effective method for treating common wounds. It was also determined that there was no reason to consider the use of medical maggots as a "last resort". However, many physicians are still reluctant to use them as a high priority treatment due to the nature of the treatment.

Maggot debridement therapy (MDT): Is the application of uninfected maggots to a wound to remove nonviable tissue. What are maggots? Fly larvae There are only certain species of fly larvae that are appropriate for the usage of wound debridement: Lucilia sericata Phanenicia sericata The selection of theses specific species of maggots is due to the fact that they feed solely on dead or necrotic tissue, and have been proven to not cause any additional harm to the existing wound. There are a limited number of doctors in the United States use Medical Maggots on a regular basis. It remains approved by the FDA, and any licensed physician is able to prescribe them if they deem it appropriate. Worldwide there was approximately 50,000 treatments of chronic wounds with biological debridement in 2011. Maggot therapy should be considered for... ambulatory patients home-bound patients Patients in long-term care facilities Patients in rural and medically underserved communities Patients who cannot afford the costs of hospitalization and surgical debridement Outpatient maggot debridement therapy is fiscally beneficial by providing safe and effective debridement by facilitating continuous wound debridement without the need for an attending surgeon or hospitalization. Application of MDT may be done by various healthcare professionals and does not need to be applied by MD. Number of US and Canadian clinicians using MDT has increased to more than 100, with 1000 clinicians using MTD worldwide Outpatient treatment is becoming increasingly more common in the US due to MDT being considered an accepted and efficient treatment option for outpatients with chronic and/or non-healing wounds

Maggot debridement therapy provides two methods of debridement: Mechanical debridement: Occurs because the rough bodies and mouth hooks of the maggots scratch the necrotic tissue. Mechanical debridement process occurs with the use of free-range maggot MDT. Biochemical debridement: Occurs when maggots secrete proteolytic enzymes that breakdown necrotic tissue and then ingest the liquefied tissue. Biochemical debridement process occurs with the use of free-range and biobag maggot MDT. Also known as biosurgical debridement

Acute or chronic wounds requiring debridement Diabetic foot ulcers Arterial Ischemic leg ulcers Venous leg ulcers Limited effect Burn wounds Post-operative treatment of necrotizing fasciitis or for the prevention of further amputation Osteomyelitis (patient/wound dependent)

Contraindications: Open wounds extending into abdominal cavity Pyoderma gangrenosum in patients with immunosuppressive therapy or septic arthritis. Osteomyelitis (if sever or not properly managed by MD)

Precaution: Wounds near large arteries and veins. Wounds heavily contaminated with pseudomonas aeruginosa. Limited effectiveness (must use in combination with systemic antibiotics) Very dry wounds Relative contraindication because maggots require a moist environment

Selective debridement Only non-viable tissue is liquefied and digested. Antimicrobial Maggots disinfect (kill bacteria) by ingesting it and produce antimicrobial properties that are helpful in preventing bacterial growth and proliferation. An example of an antimicrobial property is the production of ammonia. Ammonia increases pH, which inhibits the growth of bacteria. Effective on antibiotic resistant bacteria, such as staphylococcus aureus. Growth- stimulating effects: Improve granulation, by promoting the growth of human fibroblasts. Improved local tissue oxygenation occurs because of the secretion of cytokines and tissue growth factors. Cost effective

Availability Slow rate of debridement The difficulty of removing (free-range maggots > biobag) and the disposal of the larvae. The acceptance or preference of MDT. Patients may be uncomfortable with the treatment. Pain experienced in a small number of patients with diabetic foot ulcers and ischemic leg ulcers. Increased risk of intense/uncontrolled pain when pain was a significant factor to application (pain study)

Two methods of application: Free-range maggots Applied directly to the wound and covered with a nylon net. Apply 10 maggots, per square centimeter of wound surface. Remove maggots from wound by washing wound with saline. Biobag maggots Maggots are enclosed in a biobag. Biobags are permeable which allows the secreted enzymes to reach the wound. Enclose 5-10 maggots, per square centimeter of wound surface. Apply a secondary gauze for both methods. Helps contain and allows oxygen consumption for the maggots. Rinse wound and change gauze daily Must be cautious because excessive flushing can drown the maggots. Apply to wound for 1 to 4 days before applying a new application.

After 48 to 72 hours, maggot removal is done conveniently at bedside. Maggots are removed by peeling off the dressing with one hand while wiping up the larvae with a wet gauze pad held in the other hand. Flushing the wound with saline will be enough to effectively remove all the maggots within the wound bed. These are doubled bagged and disposed as bio- hazard waste within the hospital environment.

Components: Sponge Adhesive Dressing Vacuum Tube Drainage Receptacle Pump Pressure: Variable pressure Do not exceed 125 mmHg Constant or Intermittent 5 on /2 off best results

Increase Local Blood Flow Increase Production Granulation Tissue Constant vs. Intermittent Management of Bioburden Exudate Bacteria

Research on Effectiveness: Intermittent: 103.4 + 35.3 % increase in granulation tissue1 Constant: 63 + 26.1 % increase in granulation tissue1

Strengths: Replacement of Surgical Procedures Home Based Treatment Portability-- Snap Model Weaknesses: Need for Adhesive Dressing Need for adequate Blood Flow to Area Overall Cost Opportunities: Outpatient Rental Further Development Research is relatively new More cost efficient means

Prevent donor site morbidity Simplify the process by eliminating surgical removal Eliminate possibility of contracture at donor site Large-scale involvement

Bi-layered bioengineered skin substitute for venous leg ulcers and diabetic foot ulcers 1st engineered skin that is FDA approved to promote healing of ulcers that failed standard wound care Approved for treatment Venous ulcers - 1998 Diabetic foot ulcers - 2000 Prescription product Must be ordered and applied by a medical doctor Not available in pharmacies nor can be purchased online When used in combination with good wound care, Apligraf has been proven to heal up to 50% more sores in 1/3 less time or 33% faster than with standard therapies.

A living, bi-layered skin substitute Consists of a simulated dermal layer and epidermal layer Epidermal layer Keratinocytes derived from neonatal foreskin Dermal layer Bovine collagen seeded with neonatal fibroblasts

Indications: Venous ulcers of at least 1 month in duration that have not responded to conventional therapy Full-thickness neuropathic diabetic foot ulcers of greater than three weeks duration which extend through the dermis but without tendon, muscle, capsule or bone exposure Contraindications: Clinically infected wounds Patients with known allergies to bovine collagen or the agarose shipping media

When Apligraf is received, physician needs to check: pH of agarose gel (must be in the pH range indicated) Expiration date Once Apligraf is removed from sealed bag must be applied within 15 min. Placed with dermal side down onto wound bed Can be cut to the size of the wound Overlap wound margin by 2 -3 mm See PowerPoint

Dermagraft is a dermal substitute derived from fibroblasts that are preserved at very low temperatures. Its composition also includes extracellular matrix and a bioabsorbable scaffold. The fibroblasts that comprise Dermagraft were derived from neonatal foreskin, much like Apligraf. The scaffold is seeded with fibroblasts that will proliferate to fill the scaffold, secreting collagen, proteins and other components that classify Dermagraft as metabolically active.

The treatment in chronic full-thickness diabetic foot ulcers greater than six weeks durations, which extends through the dermis, but without tendon, muscle, joint capsule or bone exposure.

Ulcers with signs of infection Ulcers in sinus tracts Patients who are hypersensitive to bovine products similar to Apligraf.

First remove dead or unhealthy tissue in and around the area Followed by cleaning the wound with sterile saline solution. The dermagraft in thawed, rinsed and cut to the size of the patients wound. Lastly, the dressing is placed on the wound and covered by a secondary dressing to ensure the placement of Dermagraft does not become dislodged. Dermagraft itself does not cause pain or irritation. However, debridement or other standardized wound care procedures can cause irritation to the area. Dermagraft is placed on the wound weekly for a total of up to eight applications over a 12-week time period or less if the health care provider deems it unnecessary. Some important things to keep in mind while using Dermagraft is to keep the wound and dressing dry, be aware of signs of infection, and to keep weight off the treatment area as best as possible so the patient does not cause more damage to the area.

Temporary biosynthetic dressing created by Bertek Pharmaceuticals Inc. Composed of a silicone membrane bonded to a nylon mesh that contains peptides from a porcine dermal collagen source. Used for: Superficial and partial-thickness wounds Donor sites Primarily used for burns

Wound is fully cleaned and debrided Biobrane film is pulled taught and placed over site Biobrane film is anchored by staples, steri-stips, or glue Commonly done in operating room under general anesthesia3

1891 - Nikola Telsa identified heat which resulted from irradiation of tissue exposed to high frequency alternating current. 1950s-60s - Engineers design second generation diathermy to deliver non- thermal electromagnetic energy, coined diathermy nonthermal Past 50 years - Improvements allowed applicators to be programmable, miniature, concentrated energy, battery operated, and less costly

Explain and position patient appropriately Remove metal, electronic devices Place patient on nonmetal surface Avoid contact with synthetic material Remove wound dressing, absorb all exudate Cleanse wound, blot dry Cover wound and surrounding skin with ½ inch towel Set protocol and treatment duration Physical Therapist maintain 1m distance from applicator and 0.5m from cables Energy absorbed in tissues with high electrical impedance (skin, fat) Best used for superficial treatment Inductive Applicator Energy absorbed in tissues with low electrical impedance (muscle, blood, synovial fluid) Best used for deeper tissue Deep tissue heating, superior to that of US Maintains heat 2-3x longer than US Safety: can the patient dissipate heat? Patient should report vigorous heating to achieve therapeutic effect Used largely for treatment of adaptive shortening "Pulsed", low duty cycle, low intensity Promotes circulatory effects without heat Used in the treatment of chronic wounds

Increases: Perfusion Local tissue tcPO2 Tissue metabolism Antibiotic delivery to tissue O2 antimicrobial effect Cellular processes Fibroblastic activity Collagen deposition

PSWD (thermal) effects hemodynamics - suppresses vasoconstriction and promotes nitric oxide production Improves autolytic debridement Reduces rate of infection Raises resting body temp from 37°C to 45°C Mild inflammatory response

Exposes the body to increased pressure and oxygen concentrations to increase healing 2-3 atmospheres of pressure 100% oxygen concentration Patient's often require 20-30 treatment sessions for most conditions, each lasting 90-120 minutes Inconclusive findings Some studies show beneficial effects Seems to be cost effective Stringent reimbursement by Medicare Future research Not within the PT scope of practice Physician referral If in a large-scale, inpatient facility that treated a surplus of diabetic ulcers, the cost-effectiveness of HBOT could make it a beneficial asset.

Neuropathic Ulcers Burn Wounds Carbon Monoxide Poisoning Decompression Sickness Anemia Arterial Gas Emboli Crush Injuries Gangrene Osteomyelitis Less common uses: HIV/AIDS Allergies Cancer Bell's Palsy Hepatitis Parkinson's Disease Stroke Gastrointestinal Ulcers Heart Disease

Increases the level of oxygen dissolved in the bloodstream Increases the number of reactive O2 and N species in the body which then set off many pathways Increased wound growth factor synthesis, enhanced ECM formation, mobilization of Stem/Progenitor Cells (SPC) from the bone marrow Increased post-ischemic tissue survival Decreased monocyte and chemokine synthesis, decreased inflammatory response, improved neutrophil activity Improves healing rates by decreasing lactate accumulation and increasing post-ischemic ATP production Greatly increases microvascular blood flow Anti-Bacterial Properties Increases free radicals in the blood Oxidize protein and membrane lipids, damage, DNA, and inhibit bacterial metabolic function Improves the oxygen-dependent transportation of certain antibiotics across bacterial cell walls Creates an environment not conducive for anaerobic microbial growth

"A phototherapy which involves the application of monochromatic and coherent light to injuries and lesions to stimulate healing" Monochromatic - one light color or one wavelength Coherent light- "light in which the electromagnetic waves maintain a fixed and predictable phase relationship with each other over a period of time" Overall, beneficial modality for wound healing Useful for acute, chronic, slow, non-healing, infected, or colonized wounds Promotes faster wound healing Promotes progression of phases of healing Beneficial in all phases of healing Short treatment time Comfortable treatment

Wavelength Measured in nanometers Effects the depth of penetration Frequency Number of waves per unit time = Hertz Wavelength and frequency are inversely related Power Density (Irradiance) The therapeutic parameter in treatment with laser. Measured in: W/cm² Many machines utilize Joules as the output instead of power, which means the desired output will be achieved and the treatment time will be predetermined. Energy density(J/cm−2) = [Output power(W) x time(s)]/Beam area(cm-2) Dosage Recommendations: World Association of Laser Therapy The simplest most reliable way to express the dosage is still not convention. NIH suggests that Tx should be documented in two parts: irradiance and time.

LLLT has substantial cellular benefits which will be discussed in future slides. The general idea is that when the laser penetrates the skin, it stimulates the powerhouses of the cells to eliminate unhelpful products (NO) and stimulate ATP production. The elimination of NO also frees up O2 which allows for cellular messaging for increased healing. Laser has been found to have a particularly strong effect on leukocytes Increases their motility, proliferation, and increases tissue permeability, allowing leukocytes to enter cells.

Visible light span in the spectrum of light is small! We can only see from ~400nm(blue) to ~750nm(red)

Blue-green light (405nm to 532nm) is bactericidal and can be used to destroy staph and MRSA Dosage: 10 - 15 J/cm-2

Used for: decreased inflammation, reduction of edema, pain relief The most popular wavelength is 632.8nm Dosage: 25J cm-2

Spectrum ranged from 780nm- 1200nm Most popular wavelength is: 904nm 700-770nm has been shown to be ineffective Dosage: 10 J cm-2

Combinations of light included red and blue lasers simultaneously. The results showed that combined laser was no more effective than monochromatic laser.

Populations with poor healing wounds Acute or chronic wounds Infected or colonized wounds Slow or non-healing wounds Open wounds Venous ulcers Decubitis and diabetic ulcers Lacerations Incisions Burns Grafts

Increases: Mitochondrial production of ATP Collagen synthesis, density, composition, and arrangement Cellular differentiation Activity of T and B lymphocytes Macrophage activity Number of fibroblasts Hydroxyproline Mast cell count

Pregnancy Epiphyseal plates in children Impaired sensation Impaired cognition Photophobia, or increased sensitivity to light Pretreatment with photosensitizers Beware! Laser therapy can cause burns

Direct irradiation of the eyes Malignancy Within 4-6 months after radiotherapy Hemorrhaging regions Over thyroid or other endocrine glands

The frequency of UV radiation lies between that of x-rays and visible light1 UV light is divided into three separate bands UVA, UVB, and UVC Sources of UV light include that of the sun and tanning beds UV light therapy is shown to help improve blood circulation to an infected area, decrease excess drainage and necrotic tissue, and stimulate growth of granulation tissue Due to the lack of research and experimentation in the field of UV treatment of chronic wounds it may or may not be reimbursed by insurance companies UV light therapy can be costly, averaging $1,500 per unit More research needs to be completed to support the use of UV light therapy for the treatment of chronic wounds in the physical therapy setting

UVA is the long wave, and penetrates the ozone layer producing fluorescence UVB produces skin erythema; some of the UVB radiation is absorbed by the atmosphere UVC is germicidal in nature and is absorbed by the atmosphere

MED (minimal erythemal dosage) Used to determine treatment dose UVC 200-290 nm Causes little erythema Low Carcinogenic effects Absorbed equally by all skin colors Fluorescent lamps Large and emit higher intensity in middle than at the end of the wavelength Arc lamps Preferred in the treatment of wound healing Generally smaller and emits consistent intensity throughout wavelength Can be used in treating small wound areas

Skin erythema Tanning Epidermal hyperplasia Vitamin D synthesis bactericidal

Burning Premature aging of skin Carcinogenesis Eye damage Adverse effects of psoralen with UVA

Irradiation of the eyes Skin cancer Pulmonary tuberculosis Cardiac, kidney, or liver disease Systemic lupus erythematosus Fever

Photosensitizing medications Photosensitizing dietary supplements Recent x-ray therapy UV radiation should not be applied until the effects of previous dose have disappeared

Is the use of telecommunication and information technologies in order to provide clinical health care at a distance. It helps eliminate distance barriers Can improve access to medical services that would often not be consistently available in distant rural communities. Types: Store-and-forward or pre recorded Real-time or video conference Hybrid Mobile/Cellular Integration Model Classes: Tele-assistance Tele-consultation Tele-expertise Equiptment: Computers Smart phones, tablets Video Conferencing equipment Specialized Equipment Minimum 2 megapixel camera Preferred 4G internet access

Need to acquire up-to-date electronics for clinic and members of multidisciplinary team Would need to educate patients and all members of team about: Wound care terms Wound care treatments Equipment usage Program usage What to do in case of emergency Can educate PT's in physician wound care knowledge Wound care knowledge that is not always acquired in school

>24 million in US with diabetes Approx. 15% w/ DM have had a foot ulcer 80-85% of amputations follow a foot ulcer ½ of patient w/amputation will experience an ulcer on the contralateral foot within 18 months Mortality rate after amputation= 50% in 3-5 yrs Rate of contralateral amputation=50% in 5 yrs WHO expects number w/DM to be >366 million by 2030 Also known as diabetic ulcers Numbers are bleak but 1988-1990- 44% of diabetic ulcers healed By 2009 - 65% of those with good glycemic control attained wound closure **importance of preventative care and appropriate interventions

Diabetes is a disorder of carbohydrate, protein, and fat metabolism related in inability to produce or use insulin 3 hypotheses of mechanism of tissue damage Damage due to hemodynamic changes and microvascular pressures Hyperglycemia changes RBC, platelets, capillaries resulting in altered blood flow and increased microvascular pressure Hyperglycemia causes glucose to bind w/proteins which causes tissue damage Cannot bind to usual protein receptors and may cause free radicals Accumulation of sorbitol results in tissue destruction Increased sorbitol or by-products cause tissue damage Several types and subtypes of DM (1A juvenile diabetes, or IDDM: from immune-mediated destruction of beta cells in pancreas. Require insulin) (type 2 DM: typically middle-aged and obese, may be genetic predisposition or insulin resistance or impaired insulin secretion)

Contribute to development of ulcers and delayed wound healing: Hyperglycemia Vascular disease Neuropathy Mechanical stress Abnormal foot function Impaired immune response Poor vision Inadequate education Risk factors when considered independently are not much of a threat, but combined have significant impact Patients may have little control over some factors: vascular disease, ulcer characteristics, length of time with DM or inadequate professional care Other risk factors are modifiable so it is imperative to minimize the number and magnitude of risk factors

DM is leading risk factor for CAD, CVA, and PVD Accelerated rate of atherosclerosis Causes thickening of basement membrane resulting in decreased delivery of oxygen and nutrients Less likely to have revascularization if circulation problems occur Patients with DM more likely to cause amputation Smoking may accelerate complications and delay wound healing Current research does not support that these ulcers are caused by decreased circulation Neuropathy thought to be major contributing factor

Degeneration of peripheral nerves-segmental demyelination Not well understood Varied manifestations Often involves sensory, motor and autonomic nerves Onset any typical progression (gradual or sudden) Gradual onset- painless w/numbness, tingling, burning, pins/needles Sudden onset- usually painful Conditions associated DM, spina bifida, Lupus, HIV/AIDS, chemotherapy, Vit B deficient, MS, Vascular disease, Charcot-Marie Tooth muscle disease

Sensory neuropathy 50% of patients unaware of protective sensation loss Also may have paresthesia's (burning pain, tingling, numbness) Unable to perceive 5.07 monofilament—risk for ulceration Motor neuropathy Paralysis of foot intrinsic musculature Atrophy predisposes to plantar pressure and shear forces Cause foot to be less stable in gait Autonomic neuropathy Disturbances in sweating, callus formation, blood flow Leads to dry, less elastic, cracked skin Increased risk of osteopenia and foot fracture Inability to perceive trauma—most significant risk factor in development of ulcers (often don't know its there until they see their sock is bloody/drainage or foot is big and swollen) Paresthesia's may be very painful and debilitating also may cause patient to erroneously believe that because they feel this, they have accurate protective sensation Need early detection to alert patients to trauma or irritation glass/sharp objects, blisters, improper shoe fit Muscle imbalances cause hallux valgus, claw toe deformities, claw toe-hyper extension of MTP and flexion of IP makes MT heads more prominent on plantar aspect of foot. Creating increased pressure

Impaired range of motion Combined with sensory neuropathy-decreased 1st toes extension, DF and subtalar motion decrease ability to accommodate to vertical pressures Foot deformities PF contractures, forefoot varus or valgus create increased plantar pressures at MT heads Charcot foot-neuropathic fracture and dislocation-rocker bottom foot Inadequate footwear Inappropriate size of rigid orthoses may cause ulcerations Impaired motion, foot deformities, previous ulcers or amputations predispose the patient with DM to plantar ulceration

Wagner 1-2 or small size= better prognosis Short duration (less than 2 mo.)= better prognosis Average healing= 12-14 weeks In one month should see 20-50% decrease in size- if not reassess patient, modify plan of care, make appropriate referrals Small size/short duration: need to find quickly -- prevention important Reason why wound may be larger: Cannot feel the wound and may not be able to see the wound or reach the wound (decreased rom) to see it

Assessment of circulation: Capillary refill-- 2 sec for normal adult, up to 5 sec for elderly ABI Doppler studies Assessment of sensory integrity: Semmes-Weinstein monofilaments - gold standard 4.17 monofilament=normal sensation 5.07 monofilament=protective sensation 6.10 monofilament=loss of all light touch sensation-continue to assess proximal Standard locations: dorsal midfoot, plantar aspect at 1st, 3rd and 5th digit and MT heads, medial and lateral mid foot, calcaneous Sensory neuropathy is leading cause of neuropathic ulcers Sensory testing over thick callous may be inaccurate, so attempt to access non callous skin if possible

See PowerPoint

Heel ulcers are most often pressure but you need to look at pt hx and what lead to the wound because often pressure ulcers and neuropathic ulcers may be named wrong and staged wrong; ex: if pt has neuropathy in feet but rigid shoe causing pressure and develop wound, probably consider it a neuropathic wound brcaus they have neuropathy See PowerPoint

Pain - absent or significantly reduced Position- plantar aspect of foot Wound Presentation- round, punched-out lesion, callus rim, little or no drainage Peri-wound area- dry, cracked, callus, structural deformities Pulses- normal Temperature- normal or increased Typical characteristics of neuropathic ulcers: Described using 5 PT method Pain- may report paresthesias Position- plantar aspect of MT heads. mid foot of rocker bottom deformity w/ claw toe may have pressure on dorsal surfaces without extra depth footwear tips of toes or later 5th mtp and medial 1st mtp with improper fit shoes also under or obscured by calluses Presentation: eschar or necrotic material in base is uncommon

Precautions: Many patients do not demonstrate cardinal signs of infection when infected May need wound culture for ulcers that fail conservative interventions High risk for sensory loss, so always educate in foot care And associated appropriate footwear Monitor for signs of hyperglycemia Schedule therapy after meals Blood sugar may increase with infection-- If they have infection -- make sure they check their sugars and do what they need to to maintain their sugar levels; Consideration with therapy -- do they have enough insulin and/or food Cardinal signs limited because of decreased inflammatory response and common vascular disease

Inspect feet daily Always wear socks Socks w/seams: turn inside out Inspect soles and inside of shoes Shoes should fit properly Do not walk barefoot Do not soak feet If you smoke, quit Wash feet daily and dry well Test water temperature Trim nails straight across Regular foot exams Physician to remove corns/calluses Report wounds or foot changes immediately Maintain good diabetes control Intervention needs to be holistic: Include physician, endocrinologist, podiatrist, medical nutritionist (Diabetic and weight control: loss of 5-10% of body weight can improve insulin sensitivity, glycemic control, blood pressure and serum lipid levels) Use mirror Magnifying glass Between toes Be sure patient understands quality and quantity Check socks when removed, check for odor

Pare callus flush with epithelial surface Daily application of moisturizer to minimize dry, cracked skin No lotions between toes-- Use on foot and on dry, cracked skin but not on toes because increased chance of maceration Care consistent with wound appearance Adjunct modalities: Ultrasound Negative pressure wound therapy Electrical stim Growth factors

Good for grade 1 and 2 neuropathic ulcers Modified short leg casts with smaller amounts of padding to promote 'total contact' fit Toes enclosed to protect from external trauma Assists with healing: Allows wt bearing forces to be distributed over larger area Rigid cast helps with edema and improving local circulation Immobilized foot and reduces shearing forces Protects foot from trauma and microorganisims Increases patient adherence to care because it allow activity Contraindicated in presence of gangrene, osteomyelitis, fluctuating edema, active infection, inability to care for cast, ABI <0.45 If cast not appropriate, bivalve cast and make walking splint may benefit Casts require skill to apply correctly Cast similar to if there was a fx but more contact with the foot -- spread out pressure to decrease their issue with the wound

Gait and Mobility Training 90% of ulcers are caused by abnormal pressures Instruct in NWB safety and sequence Off load area: PWB, use of assistive devices, wheel chair use, step-to gait pattern or slow steps to decrease heel strike and push-off Range of Motion Exercises Great toe extension, DF, subtalar joint motion Aerobic Exercise To lower hyperglycemia, weight loss Minimum of 150 minutes of moderate intensity aerobic activity/week Low impact: Walk do not jog, Cycling, Swimming NWB usually difficult and sometimes impossible due to poor strength, endurance or balance Ensure understanding for acceptance and compliance. Patients do not willfully neglect self care, but often not aware of dangers. Also can provide foam or lamb's wool to relieve pressure: separate toes to allow air flow and prevent maceration/separate toes/ Not only can we address the wound but also the limitations that come with it

Glycemic control Management of paresthesia's/neuropathic pain Anticonvulsants, tricyclic antidepressants, opioids, topical capsaicin Surgical interventions Debridement Antimicrobial bead implantation MTP arthroplasty, tendon lengthening, stabilization of Charcot deformities Amputations - for gangrenous wounds See PowerPoint for shoes and boots

External fixation through all areas that areas that are out of line from Charcot (bones, muscles) Non WB for months Usually elective procedure Once realignment is obtained and healed, boot is used to maintain alignment Charcot joint: painless, progressive and degenerative arthropathy. Usually present painless, swollen, and red with fractures caused by extensive bong demineralization. Often treated with TCC. Changed often to accommodate volume changes See PowerPoint for picture

450,000 injuries per year receiving medical treatment 3400 Fire/burn/smoke inhalation deaths/year 75% of burn injuries and deaths are preventable Child abuse is responsible for 10-30% of pediatric burns Those who do not survive are hospitalized on average 3 weeks---high cost human suffering, mortality, financially Burns cause destruction to the integumentary system as well as physiologic changes that affect every system. There are not many burn centers and there are even less pediatric burn centers Generally patients with burns were pretty healthy before burn, however, elderly patients can also have burns Damage to skin and underlying tissues by: Heat Friction Chemicals Electricity Radiation American Burn Assoc (2013): 96.6% survival rate 69% males 17% children under 5 (primarily scalding) Hosp stay: 1 day per percent of total body surface area burned + rehabilitation and out-patient care

Direct or indirect contact with flame, hot liquid or steam Severity is proportional to contact time, temperature and type of insult (steam or flame, etc.) Less time needed for full thickness burns to infant, toddler or elder at same temperatures Most common type of burn injury Hot water heaters should be set at 110 degrees.- anything over 120 degrees can burn within a few seconds

Direct contact with either acidic or basic caustic agents Severity noted by duration of contact, strength/concentration and nature of agent Burning process continues until chemical is sufficiently diluted Burns from alkaline chemicals tend to be more severe than those caused by acids Chemical agents are more likely to cause full thickness injuries Chemical burns account for 2-7% of burn unit admissions- think of these a lot in industrial accidents, etc. More likely to cause full thickness burns

Complex injuries from electrical current passing through the body Damage caused by tissue resistance or direct electrical damage to tissue Creates entrance wound (site of contact) & exit wound ( 1 or more exit sites) Often appears as healthy appearing skin covering deep necrosis Severity depends on current, duration of contact, and voltage 4-7% of burn unit admissions (20% are children) Dry tissues have high resistance, wet tissues have less resistance: blood vessels, nerves have low resistance and are good conductors of electricity. Electric current may also cause flame burns if sparks ignite clothing Entrance wound: focal injury often dry, charred, depressed and smaller than exit wound, local wound Exit wound: larger and explosive-appearing, more damage Travels the path of least resistance from entrance wound to exit wound Cause deep tissue damage

Historically described in terms of degrees More accurately categorized by level of tissue involvement Superficial burns: (first degree)- epidermis only pink, red, dry surface--no blisters resting inflammatory pain and tender to touch Superficial burns- ex: sunburn without blistering. May cause dehydration and pain. May peel days after exposure- still considered a 1st degree burn commonly heal in 2-5 days without scarring If there is blistering, then it has gone into the epidermis and is deeper than superficial Superficial partial-thickness: (second degree)- epidermis and papillary dermis blisters, moist, bright red surface very painful, sensitive touch Superficial partial thickness burns- usually sensitive to pressure and air. Drainage if blister is broken commonly heal in 7-14 days with minimal to no scarring Burn injuries are classified by level of tissue involvement (depth) and amount of surface area affected. Size and depth determine severity of injury and prognosis Superficial and superficial partial-thickness injuries will both blanch under pressure with good capillary refill Deep partial-thickness: (second degree)- destroys epidermis, papillary layer and reticular layer of dermis red, pale, white, moist, blanches with delayed capillary refill painful and sensitive to touch/pressure DPT-may have ruptured blisters, may convert into full-thickness burns if become infected or if adequate tissue perfusion if not restored healing time depends on wound size 21-35 day to heal (but it depends on where the burn is, how deep it is, etc so there is a huge range in terms of healing). May need skin grafting for extensive areas scarring and pigment changes occur. Full-thickness: (third degree)- epidermis, dermis & subcutaneous tissue dry, firm, leathery, white to red/black- need to debride this no blanching/refill insensate to touch, pain associated with viable tissue FT- damage subcutaneous fat but not fascia. several weeks to heal- preferred intervention to achieve wound closure is skin grafting. Scarring is expected Main cause of death with burns is infection May need to debride wound to get to healthy tissue and then use a graft on top to help wound to heal With burns, the center of the wound may be full thickness and as you work your way out to the edges of the wound, it may be less deep and therefore, they may lack sensation in center of wound but may be painful at edges Subdermal burns: (fourth degree)- destruction beyond dermis into fat, muscle, tendon or bone damaged tissue insensate, inflammatory pain of associated tissue Sub dermal- typically caused by electrical injuries, prolonged thermal contact, or exposure to strong chemicals typically require surgical intervention (fasciotomy, escharotomy, and grafting) healing takes several weeks Can recover from this They will graft it with skin- maybe from his other side, both thighs, or may get it from skin banks Most of the area will not fill in, and his shape will be different then before burn Probably will be in wound center for months and put in a medically induced coma for wound care

Rule of Nines: divides body into 11 areas equal to 9% each, with 1% for genitalia quick estimate often in triage Estimates percent of total body surface area that is injured Areas of superficial burns are not used in these calculations Rule of 9—often inaccurate- used mostly in triage because this is an estimate of how much burn is there, not accurate in kids because they have different proportions than adults Lund & Browder: Chart to measure allowing for age and development Preferred for pediatric units Chart for pediatrics and adults so more accurate Has 2 charts- one for child and one for adult Child- has more head involvement Picture on this slide is in our book

Pain: from tissue damage, damaged nerves, stimulation of nociceptors from inflammation. anxiety increases pain perception Cardiovascular: fluid shift from vascular system to interstitium, may cause significant edema, decreased perfusion to core organs & organ failure, decreased cardiac output and increased heart rate Burn shock: if perfusion is unable to meet demand of body tissues, they can go into shock. Deprive tissues of oxygen and nutrients and waste products accumulate. Increased metabolism: response to injury and bacterial load that it is trying to fight. BMR may double or triple risk for malnutrition and for sustained hyperglycemia- often put on insulin Immune system: sepsis and infection common loss of skin barrier function decreased tissue perfusion reduces immune cells to area neutrophils that reach area often ineffective and they don't know why eschar, blister fluid breed bacteria immune response stressed by severe burn injury Pulmonary- smoke inhalation pulmonary edema as a result of fluid shift hypoxia, dyspnea, pneumonia, ARDS Psychological - disrupted sleep, confusion/delirium, depression, posttraumatic disorder Other organ systems- kidney failure, ulcers, ileus Burns involve all systems Emergent period until all full-thickness wounds are covered by grafts Care objectives: 1. Remove eschar ASAP and cover wounds with grafts. 2. Prevent complications. Remember patients are ACUTELY ILL for a long time - >80% complication rate decreases Complications: infection, sepsis, psychological, mental status, pain All systems are affected by a burn injury Cardiac output may decrease by 50% for 2-4 days post injury. Burn shock- causes tissue necrosis, organ dysfunction or death. Large amounts of IV fluids needed to counteract burn shock. Patients with >15% TBSA burn at high risk for burn shock Significant amount of pain- on IV pain meds for significant amount of time and often put in medically induced comas because of pain, metabolically effects the patient Often pumping patient with fluids Watching for respiratory failure, liver failure, etc. Nutrition: need for supplements of protein, carbs and essential fatty acids Infection: estimate of 75% of burn deaths are due to infection prophylactic use of topical antimicrobials should be standard. and often on systemic meds Patients with burns are often followed by a bunch of specialists Most of these patients had trauma of some kind that caused the burn so therefore they may be effected psychologically Risk of delirium, esp. with older patient Goal for wound patient: Remove eschar, cover wound, prevent complications

Escharotomy- medial & lateral incisions through eschar to allow expansion of subdermal space and decompression of tissues Excision-removal of burn eschar to prepare wound bed for skin grafting Skin graft- transferring surgically removed skin from one area of body to cover damaged or missing skin Treatment aimed at managing infection and wound closure Escharotomy- may have fluid under eschar that won't expand and then causes pressure on the wound If patient has a skin graft taken from themselves, they will have a donor site- they try to take the skin graft from the patient if there is an appropriate area

Donor site: harvested from healthy skin Meshed graft- skin graft expanded by meshing harvested skin Sheet graft-non meshed Split thickness skin graft- superficial partial thickness depth Full thickness Site where they remove the skin is treated like a superficial partial thickness burn- sometimes kept moist with dressings until it heals or use Vaseline impregnated gauze- these areas often do scar, not a severely as wound but often do scar

Superficial thickness: encourage reepethelialization-moisturizer use Superficial thickness-- Often not hospitalized, treated locally, often not see in the outpatient setting Partial-thickness: prepare for primary healing cleanse antibacterial agent (silver sufadiazine),debate, re: blister debridement petroleum impregnated gauze covered with plain gauze, secured with netting once healed use moisturizer- takes years for scars to mature and never as strong as skin that was originally there Debate whether or not you should break a blister or not- depends on physician, patient, risk of infection, etc. Full thickness: prepare wound for surgical management by controlling infection cleanse, treat with anti microbial topical agent directly to wound or to gauze then placed on wound Sub dermal burn: treat to maintain moist wound environment until surgical coverage completed Sub dermal burn- usually very deep Apply dressings in a manner to allow movement and allow function

Goal: protect graft from shearing or displacement, minimize hematoma formation, decrease possible infection- so that it can heal Soaked gauze to keep moist Splint to protect site Compression wrap to prevent hematoma Once graft adhered: ointment dressing gauze Often splint skin graft to protect the site Splinting and protecting the area is very important with skin grafts Compression helps with managing scars (esp. hypertrophic scars) Want to keep it moist

Goal: to maintain moist tissue bed to encourage healing, decrease pain and control infection Common dressings: petroleum gauze transparent gauze hydrocolloid dressing alginate for high exudate- Kris has never seen one Once healed: moisturizers

Positioning- enhance healing, reduce edema, prevent or reduce contracture, prevent pressure ulcers, improve pulmonary hygiene ROM exercises- BID every joint, active vs. passive Mobility training- increase functional independence as soon as medically stable Breathing exercises- deep breathing and incentive spirometry Aerobic exercise- start slow (initially 20 bpm above resting HR - progress to 50-70% maximum HR) Restore full active motion asap, Rom during dressing changes if able, dressings may limit motion We as PTs do a lot for these patients and early on Scars with partial thickness and full thickness is going to happen- if over joint, it will impair motion Want burn patient to do as much motion as they can to prevent contractures- may need to premedicate patient because of pain; however, once there is a skin graft, you need to protect the graft Usually vented initially so once off ventilator, work on breathing exercises Start slow with all of these because these patients are ill 20 beats per min above normal to start for interventions

Burn location Predicted contracture Prevention position Ant neck cervical flexion supine w/o pillow Axilla Add/restricted elevation abd to 90 w/ER Cubital fossa elbow flexion elbow extension Ant thigh hip flexion supine/hip ext, knee ext, ankle in normal DF Post knee knee flexion knee extension Ankle PF neutral/slight DF Anterior neck- position in supine and maybe with pillow under neck to stretch front of neck Axilla- hard to prevent, will use slings, etc. to prevent tightness

Scarring is related to: age, ethnic origin, severity/depth & location of burn injury Scar formation begins with proliferation and stimulation of fibroblasts during inflammation. Collagen deposits strengthens wound site and collagen degradation remodels the wound Predictors of scars: Deep wound, high pigmentation, skin tension, younger pts A lot of this will apply with any wound because they all have scarring toward the end stage of healing Compression on a scar is very good to help the shaping of the scar

Burn scars require 6 mo to 2 yrs to mature Formation of scar may lead to cosmetic and functional complication During remodeling phase: gentle cleansing, moisturizer, gentle massage Complications: Hypertrophic Keloid Abnormal scarring occurs in 30-70% of burn wounds.-- Also consider with other wounds including surgical wounds

Hypertrophic: Excessive overgrowth of dense collagen tissue deposits. Margins remain within the wound site develop in 1st few mo after injury, often deep red to purple color and raised, can be warm to touch, hypersensitive and itchy, more noticeable around joints where skin tension is high Keloid- scar extends beyond wound borders into surrounding tissue Many scars become very hypersensitive and itchy and are not very strong so can open scar

Vascularity - normal, pink, red, purple Pliability - normal, supple, yielding, firm, banding, contracture Pigmentation - normal, hypopigment, mixed pigment, hyper pigment Height - flat, 0.5mm scores range from 0-14 Describe quality of scar tissue after burn and monitor success of scar modeling interventions Many use this scale for scars Color reflects vascularity and pigmentation Pliability- mature scars generally more pliable, to test: pinch it. Decreased pliability will be difficult to pinch btw fingers Height: above plane of adjacent skin You do not want scars to adhere to tissue below scars so that's why we do cross friction massage- scar should be pliable

Treatment: Positioning Proper wound care AROM/PROM Patient education Stretching Scar Specific: Pressure therapy Modalities (laser, US) Conformers/inserts Massage (deep cross friction- want to move the scar on the underlying tissue, want to break up the adhesions) Splinting/casting Silicone gel sheets Avoid sun exposure to healing scars Recommendations: stretch a minimum of 5-6X/day moisturize area prior to stretching cast/splint in position of stretch AROM/functional use to use full ROM Scars burn easily. Use spf at least 15, cover if able

See Burn PowerPoint

Help remodel scar tissue quality and appearance Compression wraps/garments- used prophylactically to prevent excess scarring (self adherent wrap, short-stretch bandage, tubular bandage) Silicon sheets - help reduce or prevent scarring of healed, intact, burned skin. Secured with gauze or combo with compression Massage - loosen adhesions, combine with stretching- scarce evidence Compression mandatory in burns taking > 3 weeks to heal- not used consistently Silicon: placed over scars, reduces itching, dryness

Techniques: skin slide sustained pressure direct oscillation frictional pressure

Function: soften scar, enhance scar flexibility and extensibility, improve appearance, reduce itching, redness & inflammation Does not require pressure to be effective & early application is key to produce effective outcomes Theory of Action: Hydration, decreases oxygen tension (hypoxia stimulates angiogenesis & tissue growth), occlusive properties, increases temperature (helps breakdown collagen bundles) Silicon sheet under bandage and usually wrapped with some form of compression Studies have shown that you don't need to have a lot of compression to have the effects of silicon

Poor positioning causes inappropriate high pressure pressure over tissues overlying boney prominences 50% of tissue breakdown occurs on sacrum and ischial tuberosities 75% of sitting dependent patients develop ischial or other pressure ulcers Sacral wounds most associated with recumbent position **number of hrs spent sitting or supine is correlated with risk of breakdown

Decrease pain Increase functional activity Increase independent mobility Increase ease of care for the caregiver Decrease risk of tissue breakdown Assist in healing existing tissue breakdown

Neurologic eval: Hyperactive reflexes Abnormal muscle tone ATNR/STNR/Extensor thrust/Clonus --excessive extension (like when in supine) Musculoskeletal eval: Strength & ROM Fixed or flexible Postural control

IDEAL POSITION: 95 degrees at hip and knee; ankle neutral to 5 degrees DF LIMITATIONS: Spine: affect ability to sit upright-- Increased Kyphosis, lack of lordosis Pelvis: PPT will flex/flatten lumbar spine=slouched Obliquity-tilt to left or right in frontal plane-- Sit on one side more than the other (hip hike on one side) Hip: Less than 90 degree flexion affects ability to sit in chair Knee: Less than 90 degree flexion or more than 90 degrees will pull body forward out of position from seat-- Increased flexor tone causes them to flex/PPT and pull themselves out of the chair - sacral sitting (activate hamstrings to pull) Ankle: Limitations in DF, PF, Inv, Ev affect support on footrest-- Don't dangle feet - so they don't sacral sit Weakness of trunk/UE: contributes to postural instability and inability to wt. shift

Supine: head/neck centered w/cervical/lumbar curves supported & trunk aligned Hips and knees not fully extended or straight (25-30 degrees) Ankle/foot close to 90 degrees Side-lying: Not full sidelying 30 degree incline support entire trunk align upper leg with body, neutral rotation-- don't cross legs

30 degree tilt side-lying or prone Alternate Right side, Left side, and Back-- 2 hours Sleep in 30 or 40 degrees sidelying or flat in bed-- Higher than than then they tend to slide = shear on sacrum Avoid 90 degrees sidelying or semi-recumbent Limit HOB to 30 degrees for patient on bedrest If HOB higher, use semi-fowlers If sitting in bed is necessary, avoid slouched position Increases pressure and shear on sacrum and coccyx Continue to turn and reposition regardless of support surface Inspect skin every time repositioning occurs

Ensure heels are free of surface of bed Knee in slight flexion (5-10degrees) Avoid pressure under Achilles tendon-- Don't roll towel under - need to support the entire calf 'float the heels' to completely unload-- support entire calf 'floating' ankle pumps-- AP without floating = shear

Surfaces designed to either increase the body surface area in contact with surface or to sequentially alter the parts of the body bearing load High specification reactive foam-- Helps to spread out surface area Use active support surface for high risk patient-- air mattress Avoid small cell air mattress Select breathable cushion cover that fits loosely Ask for heat dissipation and moisture Provide complete training for use of devices/surfaces HSF mattresses as 'mattresses made of high density foam or visco-elastic foam which conforms to the body contours resulting in superior pressure reduction to the standard hospital foam mattress.' The review found that people lying on ordinary foam mattresses are more likely to get pressure ulcers than those lying on a higherspecification foam mattress. people who used sheepskin overlays on their mattress developed fewer pressure ulcers. While alternating-pressure mattresses may be more cost effective than alternating-pressure overlays, the evidence base regarding the merits of higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure ulcers is unclear. Rigorous research comparing different support surfaces is needed.

Overlays: on top of mattress, 1-4 in. thick, thus raise surface height-- Makes bed higher - what do we need to do to make pts safe to get in and out (avoid shear) mostly used to prevent breakdown Mattress/cushion replacements: replace standard mattress foam, foam/air, foam/gel do not increase height prevention or first-level treatment Powered mattress/cushion: air mattress low-air-loss vs. Alternating pressure used as treatment for breakdown Air-fluidized: best for equalizing pressures and reducing shearing but difficult for positioning and impossible for independent transfers

Heat increases metabolic rate, induces swelling, decreases tolerance of tissues for pressure Consider: polyurethane foam dressings for boney prominences Silk like fabrics rather than cotton/cotton-blend Fabrics designed to reduce shear, friction, moisture and temperature

Maintain stability and full range of activities Consider Adequate seat tilt to prevent sliding Feet supported directly of floor or on footrest Avoid elevating leg rests with limited hamstring ROM-- Elevated secondary to edema but if they have limited hamstrings rom then they will out pressure on their post leg Consider periods of bed rest to promote ulcer healing Limit sitting to 3Xday for 60 minutes or less Modify schedule if ulcer fails to improve Do not use ring or donut-shaped devices-- Increases pressure all around

Primary intervention in positioning patients Considerations: Pressure- Ability to decrease pressure under ischium via pressure mapping (red/yellow=high pressure and green/blue=low pressure) or palpation (1 inch btwn seat and ischium) Heat & Moisture—Choose cotton or air exchange covers heat may cause sweat, maceration, increased friction Palpating pressure: Place cushion in place and patient on cushion---insert on hand, palm up between bottom of cushion and chair under the ischium. There should be 1 inch of soft material b/t seat and ischium Anyone who sits in a wc for longer than a few min needs a cushion designed for a wc (not a pillow)

Red and yellow (warm colors) are areas of high pressure, whereas green and blue (cool colors) are areas of low pressure. Mapping is evaluated by color distribution, not by numbers. Here, the same subject (5'10" and 175 pounds) was placed on two different seat cushions. See pressure relief PowerPoint for picture

Pressure-Reduction non-contoured foam, gel, air cell bladders, plastic matrix honeycomb Generically Contoured shaped with bucketed area under pelvis for pelvic placement and channels under femurs Selective Pressure Elimination eliminate pressure on IT via a pocket while supporting entire posterior femurs for: sitting dependent, minimally ambulatory, insensate, existing/recurrent breakdown See pressure relief PowerPoint for pictures

Width: add two inches to widest part of the hip (not wide enough = shear on bottom and pressure on sides; too wide = can't reach the wheels, slide around in it, can't reach arm rests so they lean which causes pressure -- one hand on each side Depth: back of the butt to behind the knee and subtract two inches (too long causes pressure, too short causes little support through femur and decreased trunk control) -- two fingers between back of knee and chair Arm height: seat of char and sit with elbow to 90 (olecranon) and add one inch (support the shoulder) Back height: rule of thumb is to sit straight and one inch below the inferior angle of the scapula (allows for decreased pressure and increased mobility), may need to be higher for poor trunk control but need to watch pressure Foot rest: measure from foot to knee and add an inch, approx 90 at knee and 90 at hip (too long pressure or slide forward)

Reduce duration and magnitude of pressure Frequency- individual considerations Patient medical condition Level of activity Skin condition Comfort Techniques Establish schedules that specify frequency & duration of weight shifts **teach pressure relief techniques Regularly reassess skin condition and comfort Reposition to relieve and redistribute pressure Avoid position on area of non-blanchable erythema Use aides to reduce friction—lift and do not drag Remove sling from mechanical lift when in chair Avoid positioning on medical devices (tubes, drainage systems) Important for both prevention and treatment of ulcers Hoyer lift=use split leg sling Do not leave individual on bedpan

Bariatric Assess skin folds; proper size/weight of bed/chair Routinely check for 'bottoming out' Critically ill Slow gradual turns for hemodyamic status Older Adults Barrier for aged skin; continence management Pediatric Age appropriate, high specification for height, weight, age SCI Variable seating positions Tilt wheel chair before reclining

See pressure relief guidelines for pictures

GENERAL GUIDELINES: 1. Reposition bed-bound persons at least every two hours and chair-bound persons every hour consistent with overall goals of care. 2. Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning persons in chairs or wheelchairs. 3. Teach chair-bound persons, who are able, to shift weight every 15 minutes. 4. Use a written repositioning schedule 5. Place at-risk persons on pressure-redistributing mattress and chair cushion surfaces. 6. Avoid using donut-type devices and sheepskin for pressure redistribution. 7. Use pressure-redistributing devices in the operating room for individuals assessed to be at high risk for pressure ulcer development. 8. Use lifting devices (e.g., trapeze or bed linen) to move persons rather than drag them during transfers and position changes. 9. Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other. Pad skin subjected to device related pressure and inspect regularly. 10. Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use. 11. Avoid positioning directly on the trochanter when using the side-lying position; use the 30° lateral inclined position. 12. Maintain the head of the bed at or below 30° or at the lowest degree of elevation consistent with the patient's/resident's medical condition. 13. Institute a rehabilitation program to maintain or improve mobility/activity status.

Pressure required to minimize scars is controversial 24-28 mmHg is accepted average difficult to determine how much pressure is truly applied--- lose 50% of compression in first month of wear monitor closely especially in children - wounds, blisters, skeletal/dental disturbances Usually start these very early Too much compression can cause pain and discomfort Lose about 50% of compression in first month of wear so are they even effective? Try to get close up in axilla Need to watch them closely because can blister, etc. If have burns on the face, they do recommend compression- social aspect, do they go out once they are home?