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References

Principles of Evaluation, Diagnosis, and Prognosis

Principles of Procedural Intervention

Patient Education

Prevention

Scar Management:

Wound Management:

  • Depends on depth of wound
  • Conservative management
  • Venous Ulcers
  • Pressure Ulcers
  • Burns
  • Prevention
  • Wound Management
  • Scar Management
  • Patient Education
  • Major Functional Problem
  • Loss of Function/Cosmetic Defects
  • Surgical Options
  • Nonsurgical Options
  • Positioning
  • Splint/Serial Splinting
  • Dynamic Splints
  • Passive Stretching/Active Exercise
  • Pressure Garments

  • Pt. who are risk of ulcers:
  • need to be position, supported or cushioned.
  • inspect the skin frequently
  • use water repellent lotions and absorbent products (baby oil and bed pads)
  • appropriate dressing (if pt has an ulcer already), and being careful w xfers to avoid shear and friction to prevent skin breakdown
  • Pt who have small cuts/ small lesion
  • if is a small lesion let formation of scab built
  • let scab fall on its own, if removed may cause to further injury and delay collagen build up
  • Most Important Rehab Team Member: Patient
  • Second, Those assisting with Care/Caregiver
  • Things to be taught:
  • Skin Care and Protocols
  • Positioning Techniques
  • Exercise Program
  • Pressure Garments
  • Preform under observation
  • Reason Why?

  • Bottom Line: Compliance with Care
  • Minimum entry-level integumentary knowledge and skill deemed necessary by the profession
  • Johnstone, C., Farley, A., & Hendry, C. (2005). The physiological basics of wound healing. Nursing Standard, 19(43), 59-68 9p.
  • Pagliarulo, M. (2012). Physical Therapy for Integumentary Conditions. Introduction to Physical Therapy (4th ed., pp. 268-286). St. Louis, Missouri: Linda Duncan.
  • Roebuck H., Morgan K., MacDonald D., Shumer S. and McCune R. (2015). Assessing Skin cancer prevention and detection educational needs: an andragogical approach. Journal for Nurse Practitioners, 11, 409-416. 8p. doi:10.1016/j.nurpra.2015.01.036
  • Gibbs, Karen A, Furney, Steven R. (2013). The importance of integumentary knowledge and skill in physical therapist entry-level education: Are they prepared for practice? Journal of Allied Health, 
  • 42(1), 40-5d. Retrieved from http://search.proquest.com/docview/1443468975?accountid=44514
  • A Nurse's Guide to the Prevention of Neuropathic Ulcers in Patients with Diabetes. (2015). MEDSURG Nursing, 24(5), 299-308 6p
  • de Permentier, P. (2013). An anatomical evaluation of skin scar tissue. Journal Of The Australian Traditional-Medicine Society, 19(4), 236-238 3p.

Evaluation: condition of scar, identification of impairment cause by wound/scar (if any), level of lost of function cause by wound/scar (if any) , pt health condition, and factors affecting care.

Diagnosis: sign and symptoms

Prognosis: is related to the diagnosis and PT and PTA ensures that the wound is stable, clean, and healing or healed. Scaring should also be on the prognosis because it gives the PT/PTA a clue how wound is progressing during treatment

Types of scars:

Scar Tissue

Hyperatrophic scar Keloid Scar Atrophic Scar

  • Scar tissue is form when a wound begins to heals

Contracture Scar Stretchmarks Scar

Pressure Ulcers

  • Bony prominences
  • Examiner should document:
  • Depth
  • Size
  • "Staging System" by National Pressure Ulcer Advisory Panel
  • 4 stages (Table 11.2, page 280)
  • Based on characteristics, but mostly depth

Skin Disease

  • Physician carries out diagnosis/treatment
  • PT/PTA's must be able to recognize
  • Signs and symptoms:
  • New skin growth
  • Sore that does not heal within 3 months
  • Bump getting larger
  • Size, color or shape
  • Elevation
  • Surface appearance
  • Sensation

Trauma

  • Types:
  • Abrasions
  • Lacerations
  • Puncture wounds
  • Avulsion injuries
  • Degloving injuries
  • Burn Injuries
  • Severity Factors:
  • TBSA affected
  • Location
  • Depth
  • Associated trauma
  • Smoke inhalation

Burn Injuries

  • Cause:
  • Flame
  • Chemicals
  • Scalding
  • Radiation
  • Electrical current

Level:

  • Superficial
  • Painful
  • Minor Swelling
  • Partial Thickness
  • Painful
  • Red
  • Pliable and blistered
  • Full Thickness
  • No pain
  • Tan, yellowish, brown skin
  • Leathery, non pliable texture

Neuropathic Ulcers

Venous Ulcers

  • Plantar surface of foot
  • Circular shaped
  • Deep
  • Painless
  • Skin around the wound:
  • Sensory deficit
  • Fairly normal
  • Irregular shaped
  • Shallow with red or pink base
  • Edema prevents healing
  • Pain level:
  • Mild
  • Decreased when leg is elevated
  • Skin around the wound:
  • Inflamed
  • Dilated veins
  • Abnormal pigmentation
  • Hardness
  • Dry and scaly

Vascular Compromise

  • Arterial Wounds
  • Found in LE
  • Irregular shaped and deep
  • Pain is severe and increases when leg is elevated
  • Skin around the wound:
  • Hair Loss
  • Cool to the touch
  • Thin and shiny

Common Conditions

Measuring a Wound

  • Size
  • Tracing diagrams
  • Total Body Surface Area (TBSA) estimates
  • Photography
  • Depth
  • Injecting saline into wound
  • Wound filler
  • Observation

Principles of Examination

Remodeling Phase

Trauma

Trauma

Proliferative Phase

Vascular Compromise

Inflammatory Phase

Variables of Patient Response

  • Puncture wounds
  • Burn injuries
  • Injuries from loss of sensory feedback
  • AKA maturation phase
  • may last several months

Factors affecting scar formation:

  • race, hx, age depth, size, and location of wound

A

B

CONCERNS:

  • Wound contraction
  • handled with care

Disease

A

C

  • Inflammatory skin diseases
  • Neoplastic skin diseases
  • Arterial wounds
  • Venous insufficiency ulcers
  • Pressure ulcers
  • Neuropathic ulcers
  • Vascular Compromise
  • Trauma
  • Disease

C

  • repair of the damaged tissue occurs
  • vasoconstrictive response
  • vasodilatation --> battles against infections
  • normally 2 weeks long
  • chronic inflammation

B

  • fibroblasts
  • elastin
  • collagen
  • ground substance
  • Vascular genesis
  • depth of wound
  • location
  • size
  • healing time
  • and cause of disruption
  • Abrasions
  • Lacerations
  • Avulsion injuries

Types of scars

  • hypertrophic
  • keloid

Concerns

  • scar contracture
  • Wound Exam
  • History and physical assessment of the cause
  • Depth
  • Size
  • Infection
  • Patient Exam
  • Test and measures
  • Assessment of:
  • Communication
  • Comprehension
  • Muscle performance
  • Ventilation
  • Circulatory
  • Sensory test

Wound Healing

3 phases

  • inflammatory phase
  • proliferative phase
  • remodeling phase

Integument

Objectives

Integument - largest organ of the body, is a protective organ that plays a role in temperature control and provides sensory information

  • 2 layers - epidermis and dermis
  • subcutaneous tissue below the dermis
  • Be familiar with the structure and functions of the integumentary system.
  • Understand the wound healing process (inflammation, proliferation, and maturation).
  • Describe common conditions (vascular compromise, trauma, and disease).
  • Understand the principles of examination that involve these common conditions.
  • Be familiar with the principles of the evaluation, diagnosis, and prognosis.
  • Describe interventions that are required for excellent patient care.

Integumentary Physical Therapy

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By: Jamie Crouse, Joseph Espinoza, Stephanie Patterson, Antonio Martinez, and Peter Kaijala

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