PT Notes
PT Notes
PT Notes
PROCEDURES
AGE
● Skin or mechanical debridement
● Structural et physiological changes occur with
● High-pressure irrigation (whirlpool)
aging
● Improper handling during removal of dressing,
compression wraps or stockings.
CURRENT MEDICAL CONDITIONS
Color ➔ Palpation
SCAR TISSUE
Deep Tissue Injury ➔ Observation
Toenails ➔ Observation
Blisters ➔ Observation
➔ Palpation SCAR TISSUES
B = BORDER
➔ thickened but extend
Mole’s edges look ragged
beyond the boundaries
or blurred
of the original wound
C = COLOR
Uneven coloring with
shades of black, brown or
other colors
● TEST: Observation, Palpation, Girth measurement
5. HYPERKERATOTIC
(LGM), and Volumetric measurement
SCAR
➔ hypertrophy of the
horny layer of the
epidermis
➔ commonly seen in
diabetic patients
CALLUS
● Protection from shearing forces
● MC: on plantar surface of foot COLOR
○ Medial side of great toe ● Circulation
○ Over the MT heads ● Transient erythema (reactive erythema) vs.
○ Around heel margin Persistent erythema (a. k.a. nonblanchable
● (+) hemorrhage of callus - trauma and ulceration erythema)
beneath. ○ Persistent erythema - (+) erythrostasis in
the capillaries and venules, followed by
● TEST: Observation and palpation of callus hemorrhage
■ Ex. sunburn et pressure ulcer
● Special consideration for darkly pigmented skin: color
changes that differ from the patient's usual skin color.
● Hemosiderin staining: sign of wound chronicity or
repeated injury
○ Found in CVI (Chronic Venous
Insufficiency)
MACERATION OF SKIN
● TEST: Palpation (Gentle pressure on the reddened
● "softening of the tissue by soaking’ 🧴
skin)
● TEST: Observe the presence of macerated skin and
palpate it very gently. Then, determine the source of
moisture
● Thermal sensation
○ To check if the patient is high risks of burns
or cold
SKIN TEMPERATURE
● Inflammation- increase of 4 degrees of Fahrenheit
compare to the contralateral side
SENSATION
● Pain
● Surgical wound
○ Severe pain or tenderness
○ First 3 postoperative days - temperature of
■ (+) infection, deep tissue
the wound and adjacent tissues are the
destruction, or ischemia
same.
○ Day 4- temperature of the wound and
GRADING TENDERNESS WHEN PALPATING surrounding tissues decreasing gradually
○ Zone of warmth around the wound
GRADE I Patient complains of PAIN become narrower, with significantly greater
warmth over the incision
GRADE II Patient complains of PAIN & WINCES
● Infection
GRADE III Patient WINCES & WITHDRAWS the joint
○ Increase periwound skin temperature
GRADE IV Patient will NOT allow palpation of the
joint ● Increased blood flow
○ Increase temperature
D. SANGUINEOUS
● Ischemia
○ Coolness ➔ Bright red
➔ Indicates active bleeding
● TEST: Palpation, Infrared Thermometer Thermistor,
Liquid Crystal Skin Thermography
3. BATES-JENSEN
B. PURULENT ➔ Pressure ulcers and other
WOUND
chronic wounds
ASSESSMENT TOOL
➔ Thick
➔ Yellow, green, tan or 4. SPINAL CORD
brown INJURY PRESSURE ➔ Pressure ulcers persons
ULCER MONITORING with SCI
TOOL
C. SEROSANGUINEOUS
ASSESSMENT OF SCAR
1. Color
➔ Pale, red, watery 2. Pliability
➔ Mixture of serous and 3. Height
sanguineous
4. Texture
ASSESSMENT OF SCAR CLASSIFICATION combination of ischemia
SYSTEM and infection
➔ It reflects both vascularity and
pigmentation 5. MARION
1. COLOR ➔ Immature - hypervascular (bright LABORATORIES ➔ Simple and easy to use
pink) RED, YELLOW, ◆ RED = normal
➔ Mature - nearly same color BLACK ◆ YELLOW = infection
CLASSIFICATION ◆ BLACK = necrosis
➔ Mature scars are more pliable than SYSTEM
2. PLIABILITY
immature scars
ASSESSMENT OF SCAR
2. NATIONAL
➔ One of the most widely
PRESSURE ULCER
known wound classification
ADVISOR PANEL
systems.
PRESSURE (NPUAP)
➔ For pressure ulcers
STAGING SYSTEM
SELECTIVE DEBRIDEMENT
● Removes ONLY necrotic tissue and leaves the
healthy adjacent tissue
○ NECROTIC TISSUE ONLY
MECHANICAL MODALITIES
THERAPEUTIC ULTRASOUND
● Shown to have bactericidal effects (LFUS)
● US is not anti-inflammatory
● Early intervention accelerates inflammatory phase
● Apply US to periwound (around) areas; NOT in the
wound!
● Reduces the size of scar, promote closing of wound
● Setting: High Frequency, Low Intensity, Pulsed
TOPICAL AGENTS
○ Pulsed - do NOT produce heat
○ Effect is very close to surface, vicinity of
TOPICAL ANTIMICROBIALS (HSCSvIo)
wound
1. Hypochlorites
○ Healing impaired in high intensity and dermal
2. Superoxide
burns may occur, avoid continuous
3. Chlorhexidine
■ 3 MHz - Ideal Frequency used
4. Silver
5. lodine
● EFFECTS
○ Pain relief, increased pain threshold
TOPICAL ANTIMICROBIALS ○ Transdermal drug delivery -
PHONOPHORESIS
➔ Bleach
➔ Major concerns with cell
1. HYPOCHLORITES
toxicity ELECTRICAL STIMULATION
➔ Can cause renal failure ● Galvanotaxis - the attraction of cells to electric
charge
➔ Microcyn ● Chemotaxis - attraction of cells to wound site
2. SUPEROXIDE ➔ Management of infected
diabetic wounds
POSITIVE POLE (+) NEGATIVE POLE (-)
3. CHLORHEXIDINE ➔ Bactericide
Neutrophils (wound NOT Neutrophils (wound infected)
4. SILVER ➔ In medication or dressings infected)
SENSORY SENSATION
LOCATION
RECEPTOR MEDIATED
FREE NERVE
Epidermis Pain, itch
ENDING
FREE NERVE
Dermis Pain
ENDING
Stratum
MERKEL’S DISKS
spinosum EPIDERMAL BURN
Touch
MEISSNER’S COLOR ➔ Erythematous, pink or red
CORPUSCLE VASCULARITY ➔ Irritated dermis
➔ Broken blisters
SURFACE ➔ Wet surface;
APPEARANCE/PAIN ➔ Sensitive to pressure, but not
to light touch or soft pinprick
20
SUBDERMAL BURN
● Prolonged heat exposure or electrical injury
○ Electric Current = Makes muscle super soft
like a baby’s bum2
SUBDERMAL BURN
COLOR
➔ Charred
VASCULARITY
2 TOOLS USED:
★ Rule of nines
★ Modified Lund and Browder
1. RULE OF NINES
● Uses multiples of 9 to determine the amount
of body surface area burned
● Total body surface area (TBSA)
● Quick way of evaluating the amount of skin
damaged
● Used in emergency cases/immediate 2. MODIFIED LUND AND BROWDER
assessment ● More accurate assessment tool when
● Tx in genitalia - depends on depth on injury therapist/clinicians have ENOUGH time
● Quick assessment – not that accurate ● Has different classifications per age group=
more accurate
● Rules of 9s in ADULTS ● Total = 100%
○ Ant head - 4.5% ● Identify if injury is partial or full thickness
○ Back of head - 4.5% (PT/FT)
○ Ant arm - 4.5% ● Memorize adult et 1-4 y/o
○ Post arm - 4.5%
○ Ant torso - 18%
○ Post torso - 18%
○ Genitalia - 1%
○ Ant thigh - 9%
○ Post thigh - 9%
INFECTION
● MC infectious organism
○ Pseudomonas Aeruginosa (green bacteria) ● Either general (systemic) or localized - one specific
○ Stap Aureus (MC in scald injuries) area that is affected
● Most Fatal = Septic Shock ● Localized neuropathy - brought by improper
positioning (compressed due to changes in the body)
○ Compression bandaging - improper
PULMONARY bandaging will lead to peripheral nerve
● Signs of inhalation injury damage
○ Facial burns ● Brachial plexus, ulnar nerve, common peroneal
○ Singed nasal hairs nerve (CUB) = MC nerves affected by neuropathy
○ Harsh cough in burns
○ Hoarseness
○ Abnormal breath sounds BURN WOUND HEALING
○ Respiratory distress ● Dependent on what layer is affected
○ Carbonaceous sputum
○ Hypoxemia EPIDERMAL HEALING
● Epithelial cells will start to detach and migrate to
● Primary complications gaps in wounds and once they come into contact,
○ CO poisoning migrating stops (Contact inhibition - close the
○ Tracheal damage wound) and start to specialize in other cells
○ Upper airway obstruction
○ Pulmonary embolism (PE) DERMAL HEALING
○ Pneumonia - DEADLIEST 💀 ● Aka scar formation
● Divided into 3 phases
METABOLIC ○ Inflammatory
● Burn changes the fluid dynamic of our body ■ 3-5 days after injury
● Rapid decrease in body weight (BW) ■ 5 cardinal signs of inflammation
● Negative nitrogen balance ■ Platelets are present by depositing
● Effects on muscle mass (mm atrophy d/t metabolic fibrin to create clot
changes) ■ Blood vessels will constrict for
● Decrease in energy stores - body will use up protein 5-10 mins and start to dilate to
stores increase blood flow and promote
● 1-2°C increase in core temperature - brought by healing
changes in hypothalamus (thermoregulating ■ Ruled by platelets - help close
mechanism) platelets
● Impaired thermoregulation - easily get cold; keep in ■ Leukocytes (WBCs) will fight out
a room with 30°C temp the infection
● Muscle atrophy ■ Macrophages attracts fibroblast
● Fibroblast creates collagen
CARDIOVASCULAR
● Significant edema ○ Proliferation
● Decrease in CO (as low as 15% of normal within 1st ■ Fibroblast start to randomly
hour post injury) deposit collagen fibers (active
● Hematological changes - levels of platelets will be fibroblast activity)
affected; impaired fluid replacement = death ■ Start to apply stress/pressure to
● Decompensation - from an endurance determine the direction of the
standpoint/conditioning perspective growing scar
■ Tissue granulation is created -
HETEROTOPIC OSSIFICATION (HO) composed of blood vessels, nerve
● Abnormal formation of bone in soft tissue fibers and some myofibers
● MC site = ELBOW ■ Wound contraction - edges of
● Idiopathic cause wound will contract towards the
● Can affect ROM center to close the wound
○ 1st sign of presence = decrease in ROM ● No new tissue is created
et swelling, joint specific pain but they make the most
● Increases, burn injury is 30% TBSA burn out of tissue available to
contract towards the
NEUROPATHY center (existing tissues try
to close the gap)
● When met at the middle or
COMMON TOPICAL MEDICATIONS USED IN TREATMENT OF
if force to the skin is too BURNS
strong, contraction stops
Medication Description Method of
○ Remodeling / Maturation Application
■ Wound is closed
■ Decreased fibroblast activity Silver Most commonly used White cream applied
■ Scar is taking up its parallel sulfadiazine topical antibacterial with sterile glove 2-4
effective agent against mm thick directly to
orientation
Pseudomonas wound or impregnated
■ More organized and structured infections into fine mesh gauze.
■ Important to apply stress to scar
Mafenide Topical antibacterial White cream applied
INITIAL TREATMENT acetate agent; effective against directly to wound with
(Sulfamylon) gram-negative or thin 1–2 mm layer
AMERICAN BURN ASSOCIATION CRITERIA FOR gram-positive twice daily; may be
REFERRAL TO A BURN CENTER organisms; diffuses left undressed or
easily through eschar covered with thin layer
➢ Partial-thickness burn greater than 10% TBSA of gauze
➢ Burns that involve the face, hands, feet, genitalia,
perineum, or major joint Mafenide Topical solution with 50-gram packet of
➢ Any full-thickness burn acetate antimicrobial function white powder that is
➢ Electrical burns, including lightning injury solution against gram-positive mixed with either
➢ Chemical burn (Sulfamylon 5% and gram-negative 1000 mL sterile water
➢ Inhalation injury Solution), silver organisms. or 0.9% sodium
nitrate Maintains a moist chloride–soaked
➢ Burn injury in patients with preexisting medical
environment. gauze,
disorders that could complicate management, Antiseptic germicide
prolong recovery, or affect mortality and astringent; will Dressings or soaks
➢ Any patient with burn injury and concomitant penetrate only 1-2 mm used every 2 hours;
trauma in which the burn injury poses the greatest of eschar; useful for also available as
risk of morbidity and mortality surface bacteria; stains small sticks to
➢ Burned children in hospital without qualified black. cauterize small open
areas.
personnel or equipment for the care of children
➢ Burn injury in patients who will require special socal, Bacitracin/ Bland ointment; Thin layer of ointment
emotional, or rehabilitative intervention Polysporin effective against applied directly to
gram-positive wound and left open
GOALS: organisms.
➔ Address critical life-threatening problems and
stabilize the patient Collagenase, Enzymatic débriding Ointment applied to
Accuzyme agent selectively eschar and covered
➔ Fluid volume replacement therapy
débrides necrotic with moist occlusive
◆ improved the prognosis tissue; no antibacterial dressing with or
➔ Determine extent and depth of injury action without an
◆ Emergency go to chart = Rule of Nines antimicrobial agent.
➔ Initial wound cleansing and debridement
◆ Whirlpool is NOT recommended for it is an
SURGICAL MANAGEMENT
environment for bacterial growth (increases
Primary grafting -
the likelihood of infection)
➔ Inspect wound
SKIN GRAFTING
◆ Check smell, color, signs of infection
● AUTOGRAFT
➔ Topical medications and dressings
○ Taking skin from px own body
○ Common donor sites - buttocks, back &
★ Open technique - ointment (reapply 1-2x a day)
thighs
★ Close technique - use gauze or dressing, to protect
○ Best graft
further injury and infection
● ALLOGRAFT/HOMOGRAFT
○ Skin for the Same species / cadaver (other
human)
● XENOGRAFT/HETEROGRAFT
○ Skin from another animals/species ULTIMATE PURPOSE:
○ MC used: pork skin ★ Return to normal, preinjury function and lifestyle
AMBULATION
SPLINTING
When should it begin?
When to use?
● After skin graft is healed
● If it can improve ROM et function of px
○ Apply compression bandage (figure of 8
● Extension of positioning program
pattern) - promote venous return
● General indications
● Transfers, bed mobility, ankle pumps
○ Minimize edema
● Make sure px is stable in dependent position
○ Prevent edema
● Use of tilt tables to check for toleration
○ Promote proper positioning
● BEST to start ASAP but with consideration
○ Reduce pain
● Patients may need assistive devices on the first few
○ Protect joints/tendons
days