INTEGUMENTARY PHYSICAL THERAPY MEDICATIONS

INT1 FINALS 1. MEDICATION

➔ affects the
IMMUNOSUPPRESSIVE
PT EXAMINATION FOR INTEGUMENTARY INTEGRITY inflammation phase
THERAPY
Sir Adriane Tuminez, PTRP
2. ANTICOAGULATION
WHY DO WE NEED TO ASSESS? AND ➔ interfere in platelet
1. Examine the severity of lesion ANTI-INFLAMMATORY activation
2. Determine the status of wound healing AGENTS
3. Establish a baseline for the wound
4. Prepare a plan of care (PoC) ➔ inhibit angiogenesis
5. Report observed changed in the wound over time 3. NONASPIRIN NSAIDS (formation of new blood
vessels)
COMPONENTS OF PT EXAMINATION (SHT)
★ History-taking ➔ delay ALL phases of
4. STEROIDS
★ Systems review wound healing
★ Test & Measures
➔ Injuries to the cells of
5. RADIOTHERAPY
HISTORY TAKING & SYSTEMS REVIEW skin repair
1. Age
2. Current medical conditions
NUTRITION
3. Medications
● Undernutrition and Dehydration
4. Nutrition
● Use nutritional screening assessment
5. Procedures

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

TEST & MEASURES

1. CARDIOPULMONARY ➔ affects the delivery of 1. Assessment of adjacent and periwound tissues
MORBIDITIES oxygen 2. Assessment of wound
3. Assessment of scar (if wound is healed)
➔ increased risk of
2. DIABETES MELLITUS
infections ASSESSMENT OF ADJACENT AND PERIWOUND TISSUES
1. Skin texture
3. IMMUNE 2. Callus
➔ affects the
SUPPRESSION (HIV, 3. Maceration of skin and Moisture Balance
inflammation phase
AIDS, CANCER) 4. Edema
5. Color
4. PERIPHERAL 6. Deep tissue injury
➔ impaired sensation
NEUROPATHY/SCI 7. Hair distribution
8. Toenails
➔ problem in following 9. Blisters
5. DEMENTIA instructions 10. Sensation
➔ Needs assistance 11. Skin temperature

6. DEPRESSION AND ➔ associated with impaired

STRESS wound healing ASSESSMENT TEST

➔ interfere the wound Skin Texture ➔ Skin turgor

7. LACK OF SLEEP ➔ Signs of early melanoma
healing
Callus ➔ Observation
➔ Palpation
 Maceration of Skin ➔ Observe the presence of D = DIAMETER
macerated skin Larger than .25 inches or
➔ Palpate very gently
(4mm)
➔ Determine the source of
moisture
E = EVOLVING
Edema ➔ Observation Changing size, shape or
➔ Palpation
color
➔ LGM
➔ Volumetric measurement

Color ➔ Palpation
SCAR TISSUE
Deep Tissue Injury ➔ Observation

Hair Distribution ➔ Observation

Toenails ➔ Observation

Blisters ➔ Observation
➔ Palpation SCAR TISSUES

Sensation ➔ Pain intensity ➔ Thinner and more

➔ Tenderness scale flexible
➔ Sensory modalities 1. NEW SCAR TISSUE ➔ Less resilient to stress
(temperature, vibration, ➔ Bright pink, increased risk
monofilament) of infections

Skin Temperature ➔ Palpation

➔ Flat scar with greater
➔ Infrared Thermometer
density and toughness
Thermistor 2. MATURE SCAR and is less resilient than
➔ Liquid Crystal Skin
surrounding skin
Thermography
➔ Nearly the same color as
periwound skin
➔ Hypopigmentation
(dark skin) or
SKIN TEXTURE hyperpigmentation
● (+) turgor- smooth, flexible skin (burn and physical
● Loss of turgor - dehydration, aging (slow return) trauma)

● TEST: Check for skin turgor; check for signs of 3. HYPERTROPHIC

early melanoma SCAR
➔ Raised scar that remains
ABCDEs OF MELANOMA MOLE MELANOMA within the area of the
original wound
A = ASYMMETRY
½ of the mole does not
match the other half
4. KELOID SCAR

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

DEEP TISSUE INJURY

● (+) Ecchymosis
○ purple discoloration
EDEMA
● "the presence of abnormally large amounts of fluid ● TEST: Observation
in the intercellular tissue spaces of the body"
○ Localized (obstruction in
venous/lymphatic, increased vascular
permeability) or
○ Systemic (heart failure or renal disease)

● Types: Pitting edema vs Non Pitting edema

○ Non Pitting - caused by thyroid or
lymphedema
○ Pitting edema - caused by blockage in
lymphatics or venous problem HAIR DISTRIBUTION
● Loss of hair
○ impaired circulation
 ● Prognosis of wound healing: GOOD ● Protective sensation
○ Epithelialization - stratum basale produces ○ Minimal protective sensation threshold-
epithelial cells to protect the neuropathic foot from
ulceration
● TEST: Observation ○ Semmes-Weinstein monofilaments - 5.07
monofilament

● Thermal sensation
○ To check if the patient is high risks of burns
or cold

● Vibratory perception threshold

○ Predict the risk for ulceration
○ Recommended:
TOENAILS ■ patients without neuropathy
● Color, thickness, and shape and note any (annually)
irregularities. ■ patients with neuropathy but do
not have deformity or vascular
● TEST: Observation disease (every 6 months)
■ patients who have neuropathy
BLISTERS with deformity or vascular
● Trauma to epidermis disease (every 3 months)
○ clear blister ■ history of ulceration (13 months)
● Trauma that is deeper than the epidermis ○ Use of 128 Hz tuning fork
○ bloody or brown
● TEST: Pain intensity, tenderness scale, sensory
● BLOODY blisters need to be UNROOFED. modalities (temperature, vibration, monofilament)

● TEST: Observation and palpation (tissue resilience)

○ Good resilience - deep tissues may be
mildly congested
○ Soft, spongy or boggy high probability of
tissue congestion and probable necrosis

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 METHODS FOR WOUND ASSESSMENT

1. Linear methods
2. Wound tracing (or acetate method)
3. Wound photography

METHODS FOR WOUND ASSESSMENT

➔ Measurement tool and

1. LINEAR METHODS
recording form
ASSESSMENT OF WOUND
➢ Wound location ➔ Use of tracing kit or
➢ Wound size 2. WOUND TRACING (or digital recording, Graph
ACETATE METHOD)
○ Length-by-width open area paper of grid
○ Length-by-width area of erythema
○ Depth 3. WOUND ➔ Camera and digital
○ Undermining/Tunneling PHOTOGRAPHY recording card or film
○ Overall wound size
➢ Wound drainage
TOOLS FOR WOUND ASSESSMENT
○ Fluid that leaks out from wound
1. Sussman Wound Healing Tool
➢ Wound bed tissue
2. Pressure Ulcer Scale
➢ Wound edges
3. Bates-Jensen Wound Assessment Tool
4. Spinal Cord Injury Pressure Ulcer Monitoring Tool
TYPE OF EXUDATE APPEARANCE

A. SEROUS TOOLS FOR WOUND ASSESSMENT

1. SUSSMAN WOUND ➔ Acute wound healing and

➔ Clear HEALING TOOL chronic wounds
➔ Watery plasma
2. PRESSURE ULCER
➔ Pressure ulcers
SCALE

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

3. HEIGHT ➔ Determine hypertrophy PT WOUND SEVERITY DIAGNOSIS

● Use diagnoses that relate to depth of wound
➔ May also indicate hypertrophy penetration.
4. TEXTURE ○ Superficial skin or partial-thickness
(rough, uneven or bumpy)
involvement and scar formation
○ Full-thickness skin involvement and scar
SCAR RATING SCALES formation
1. Vancouver Scar Scale ○ Involvement extending into fascia, muscle, or
2. The Patient and Observer Scar Scale (POSAS) bone
● Ex: impaired integumentary integrity secondary to
WOUND CLASSIFICATION partial-thickness involvement and scar formation
1. Classification by Depth Injury
2. National Pressure Ulcer Advisor Panel Pressure No Scar Formation on Superficial
Staging System - NO Collagen at Epidermis
3. Wagner Ulcer Grade Classification - Only at Dermis
4. The University of Texas Treatment-Based Diabetic
Foot Classification System NAIL PATHOLOGY
5. Marion Laboratories Red, Yellow, Black Classification
System

ASSESSMENT OF SCAR

➔ It is commonly used for

wounds that are not
1. CLASSIFICATION BY categorized as pressure
DEPTH INJURY ulcers, vascular ulcers,
surgical wounds, and
burns.

2. NATIONAL
➔ One of the most widely
PRESSURE ULCER
known wound classification
ADVISOR PANEL
systems.
PRESSURE (NPUAP)
➔ For pressure ulcers
STAGING SYSTEM

➔ Establish the presence of

depth and infection in a
3. WAGNER ULCER
wound.
GRADE
➔ Also, for the diagnosis and
CLASSIFICATION
treatment of the
dysvascular foot

4. THE UNIVERSITY OF ➔ Used for situations in which

TEXAS neuropathy is present and
TREATMENT-BASED information is needed about
DIABETIC FOOT infection, circulation and the
INTERVENTION FOR INTEGUMENTARY DISORDERS FOR ○ Contraindications: Poor Blood Supply;
PT Poor Perfusion
Sir Joseph Charl Pamplona, PTRP ● Clean up the wound yourself; protect with a bandage
and maintain a moist environment
TOPIC OUTLINE
1. Debridement WOUND CLEANSING
2. Wound Cleansing ➢ Wound Cleansing - the use of fluids to remove
3. Topical Agents surface contaminants, bacteria and other debris
4. Mechanical Modalities through fluids by mechanical force
5. Dressings
6. Scar Management Cleansing Solutions
➢ Normal Saline - for healthy, clean wounds, for
DEBRIDEMENT (isotonic)
● The removal of non-viable, necrotic tissue ➢ Povidone-iodine - bactericide
● Key to wound bed preparation ➢ Dakin's Solution - dilute solution of Sodium
● Convert chronic, non-healing wounds → acute Hypochlorite (bleach) bleach:water - 0.5%
● “Restart” healing process; going back to acute ○ Water is hypotonic (Shrinks RBC)
○ Bactericide and Dakin’s solution should
THREE (3) TYPES: NOT BE USED in Healthy tissue; kills
1. Non-selective healthy tissue
2. Selective
3. Autolytic TYPES:
1. Soaking hydrotherapy
NON- SELECTIVE DEBRIDEMENT 2. Whirlpool hydrotherapy
● Removes necrotic tissue but may also remove 3. Pulsatile lavage with suction
healthy adjacent tissue
○ NECROTIC + HEALTHY TISSUE SOAKING HYDROTHERAPY
● Bucket or Hubbard Tank (soaking)
➔ Wet to Dry Dressings - saline gauze placed on ● Softens tissue, helps with separation of necrotic
wound and allowed to dry, dead tissue comes out debris
when gauze is removed ● Only appropriate for wounds with LARGE
➔ Surgical - for large wounds AMOUNTS of necrotic debris
➔ Whirlpool
➔ Pulsatile Lavage

SELECTIVE DEBRIDEMENT
● Removes ONLY necrotic tissue and leaves the
healthy adjacent tissue
○ NECROTIC TISSUE ONLY

➔ Sharp - use of tools such as a scalpel WHIRLPOOL HYDROTHERAPY

➔ Chemical - soften dead tissue; indicated for ● Wound decontamination, antiseptics for necrotic
non-affected wounds wounds
➔ Enzymatic - digest dead tissue ● Debriding through the use of turbulence
➔ Biosurgery - maggots release enzymes and ● Also increases perfusion to the area through heating
prevent bacteria from growth ○ Increase blood supply/flow
○ Collagenase - enzyme to breakdown ● Dependent positioning can increase venous
collagen congestion
○ People with venous insufficiency = not really
AUTOLYTIC DEBRIDEMENT for them
● Uses body's intrinsic debriding mechanisms to ● Potential for maceration and skin breakdown
remove non-viable tissue
● APPROPRIATE for patients in long term who
cannot tolerate more aggressive options
● Comfortable and usually effective, but it can take
longer to accomplish than other methods of
debridement
 ➔ Beneficial following extensive
PULSATILE LAVAGE WITH SUCTION
procedures
● Provides cleansing and debridement with pulsed
irrigation combined with suction
➔ Work on the CNS to alter the
● Used for OPEN WOUNDS
2. OPIOIDS patient's perception to pain
● Less water, less time, can be performed bedside
➔ Possibility of addiction
● Risk of overuse and trauma, may be painful
● Gun-shaped
● PPE should be used; necrotic tissue may go ‼
everywhere 🤢 Hubbard - Soaking
● Uses normal saline Whirlpool - Turbulence

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)

5. IODINE ➔ Common topical antiseptic Macrophages Fibroblasts

ANALGESICS ● Study by Stromberg showed that alternating polarity

1. NSAIDs every 3 days accelerated wound contraction
2. Opioids
ELECTRICAL STIMULATION
● Wounds that respond well with ES
ANALGESICS ● Necrotic tissue and pus
● Inflammation
➔ Routinely used for common
1. NSAIDs ● Infection
pain complaints
● Wounds of any depth
 ULTRAVIOLET RADIATION
APPROPRIATE WOUND TYPES FOR ELECTRICAL
STIMULATION ● Effects of UVR
○ Skin erythema
LEVEL OF TISSUE Superficial, partial thickness, full ○ Epidermal hyperplasia - UVB stimulated
DISRUPTION (WOUND thickness, subcutaneous, and epithelialization
SEVERITY) deep tissues ○ Immunosuppression - Langerhan cell
necrosis; no long term effects
Burns. neuropathic ulcers, ○ Bactericidal
ETIOLOGIES/DIAGNO pressure ulcers, surgical
STIC GROUPS wounds, vascular ulcers (venous
and arterial) PROCEDURE
➔ Remove all dressings
Inflammatory phase: acute, ➔ Protect the periwound areas by draping
chronic, absent ➔ Cleanse the wound and remove necrotic tissue
➔ Wear UV protected goggles
Proliferative phase: acute, ➔ Treatment time - 30 to 60 seconds, no more than
chronic, absent 180 seconds
WOUND HEALING
PHASE ➔ Treatment distance - 1 inch
Epithelialization phase: acute,
chronic, absent
HYPERBARIC OXYGEN THERAPY (HOT)
Remodeling phase: acute, ● Patient is placed in a chamber with increased air
chronic, absent pressure and oxygen concentration
● Lungs can gather much more oxygen than normal to
AGE Older than 3 y/o help fight bacteria and release growth factors
○ 90-120 minutes, 20-35 sessions
CONTRAINDICATIONS ● Maximum Exposure (ATA = Atmosphere Absolute, 1
● When stimulation of cell proliferation is Cl, ATA = 14.7 PSi)
malignancy ○ 3 ATA for 90 minutes
● Osteomyelitis ○ 2 ATA for 120 minutes
● If wound penetrated to the bone ○ If above 3 ATA, seizures can occur
● ES may stimulate tissue growth covering the infection
● Contact physician INDICATIONS
● Where there are metal ions - cause undesired ★ Hypoxic wounds
iontophoresis ★ Diabetic foot ulcer
● Severe cardiac arrhythmia ★ Burns
★ Anemia
TWO (2) TECHNIQUES:
1. Monopolar RISKS
2. Bipolar ★ Temporary myopia
★ Fire
MONOPOLAR TECHNIQUE
● Can exploit the effects of polarity CONTRAINDICATIONS
● Active electrode is directly on the wound site ★ Pneumothorax - inc pressure outside = lung collapse
● Inactive electrode is 10-30 cm away ★ Chemotherapy drugs
● Protocols usually start with the negative pole as
the active NEGATIVE PRESSURE WOUND THERAPY (NPWT)
● Then change the polarity after a period of treatment ● NPWT is a method of drawing out fluid and
infection from a wound to help it heal
BIPOLAR TECHNIQUE ● A special dressing is sealed over the wound and a
● The electrodes are placed on either side of the gentle vacuum pump is attached
wound near the edge ● Results in accelerated healing
● Minimal to no disruption of wound dressing ● Mechanism somewhat unknown
● Good for superficial or partial-thickness wounds
● NOT as effective for deep ulcers
○ Deep wounds; US Electricity won’t pass DRESSING
through the skin
MOIST WOUND HEALING
● The practice of keeping a wound in an optimally
moist environment in order to promote faster healing
 ➔ If wound exudates; do not
● Traditional Healing
use this dressing
○ Wound should be kept clean and dry
○ Exposed to air
Indications (SM)
○ Cover with dry dressing
➔ Minor burns
➔ Simple injuries
● Problems
○ Scab formation becomes a barrier to
➔ Absorb exudate
healing
➔ Provides thermal
○ Exposure to air reduces temperature 3. FOAM
DRESSINGS insulation
➔ Protection and
● Wounds managed in a moist environment covered
cushioning
by an occlusive dressing:
○ Do not form a scab
Indications (SUE)
○ Epidermal cells are able to move rapidly
➔ Exuding wounds
○ Prevent secondary damage from
➔ Ulcers
dehydration
➔ Sutured wounds
○ Promotes autolytic debridement
○ Facilitates wound cleaning
➔ Hydrophilic homopolymers
○ Heal 50% faster 4. HYDROGEL ➔ Provide and absorb
moisture to/from wounds
DRESSINGS
● Properties of an ideal dressing.
Indications (DR)
○ Removes excess fluid but not dry out the
➔ Dry and sloughy wounds
wound
➔ Rehydrate eschar
○ Allow gaseous exchange of oxygen and
carbon dioxide ➔ Liquid absorbed will turn
○ Thermally insulating into a gel
5. HYDROCOLLOID ➔ Only adheres to adjacent
TYPES OF DRESSINGS: intact skin
1. Gauze/Fiber
2. Film dressings Indications (PUB)
3. Foam dressings ➔ Ulcers
4. Hydrogel ➔ Burns
5. Hydrocolloid ➔ Pressure wounds
6. Alginates
7. Hydroactive ➔ Made from seaweed
TYPES OF DRESSINGS 6. ALGINATES ➔ Provides calcium to the
wound, clotting factor
1. GAUZE/FIBER ➔ Sheds quickly, adheres to
the wound Indications (BIP)
➔ Can cause contamination ➔ Post surgical donor sites
➔ Highly absorbent, tend to ➔ Bleeding wounds
dry the surface of wound ➔ Infected wounds
➔ Permeable to bacteria
7. HYDROACTIVE
➔ Highly absorbent to liquid,
2. FILM ➔ Permeable to moisture swell
DRESSINGS vapor and oxygen
➔ Impermeable to Indications
microorganisms and ➔ Exuding wounds
moisture, cannot absorb
exudate
➔ Flexible, elastic, extensible SCAR MANAGEMENT
➔ Transparent - easy ● Surgical Interventions
assessment ○ In severe cases where conservative
➔ Moisture vapor; more wet treatment fails
● Factors
 BURNS AND BURN REHABILITATION
➔ Head
Miss Michaela Angelica Tajanlangit, PTRP
➔ Face
LOCATION (C/I)
➔ Neck
BURN 🔥
➔ Axilla
● Type of injury caused by excessive ranges of
temperature
TIMING ➔ After the scar has matured
● Thermal type of injury
● Damage to skin d/t exposure to excessive ranges of
➔ The bigger the scar, the more
SIZE temperature
extensive the surgery
○ Cause: fire, ice
● Depends on length of exposure and number of agent
CONSERVATIVE INTERVENTIONS exposed to you
1. Pressure therapy
2. Massage EPIDEMIOLOGY
3. Exercise
4. Positioning CHILDREN 1-5 Y.O 👦
5. Splints ● Scald injuries from HOT liquids
6. Heat ● Increase child mortality

ADOLESCENTS & ADULTS

CONSERVATIVE INTERVENTIONS
● Accidents with HOT liquids
➔ Pressure garments placed
1. PRESSURE over the scar for at least 23 M👨>W👩
THERAPY ● d/t occupational hazards, accidents, violence
hours per day
● Ages 16-40
➔ Useful in mobilizing
superficial tissue but does TYPES OF BURNS
2. MASSAGE
not appear to decrease 1. Flame Injury - MC; 40% 🔥🔥
scarring 2. Scald - exposure to hot liquids
3. Contact - touching hot objects
➔ Encourage the patient to 4. Electrical - 7% ⚡exposed to open wirings
stretch the scar to prevent 5. Chemical burns - muriatic acid, etc.
contracture
◆ Active exercises are Burns typically occur at HOME
3. EXERCISE ● 73%
preferred — px can
control how far to ● Open fire, scald, contact
stretch, promote px ● Most of the deaths associated with home or
independence; structure fires are due to inhalation injury.

➔ To avoid deformation or to Other occurrences

4. POSITIONING maintain a stretch, counter ● Occupational hazards
scar contraction ○ Firemen
○ Chef
5. SPLINTS ➔ Maintain position ● Motor vehicles
● Recreational activities
➔ Warming the tissue will
6. HEAT make stretching more ER concerns = Jollibee
effective PEACH MANGO PIE - ex of scald injury

★ A major reason for the improved prognosis and

survival of patients with severe burn injury is the
availability of specialized burn centers
ANATOMY

EPIDERMIS -Superficial layer

5 stratums: Come Let’s Get Some Bitches
● Corneum - waterproof characteristic, infection BURN WOUND CLASSIFICATION
protection ● Most medical lit do NOT use terms “1st, 2nd, 3rd
● Lucidum degrees”
● Granulosum - water retention
● Spinosum - adds a layer of protection 1. Epidermal burn
● Basale - enables the dermis to regenerate 2. Superficial partial-thickness (SPT) burn
melanocytes 3. Deep partial-thickness (DPT) burn
4. Full thickness burn
DERMIS - true dermis due to the vessels, collagen fibers, and 5. Subdermal burn
other epidermal appendages
● Papillary dermis - loose basketweave of collagen EPIDERMAL BURN
fiber ● Damaged limited to the EPIDERMIS; dermis is red
● Reticular dermis - densely woven collagen fibers but intact
● MC cause is Sunburn - irritated dermis; redness
SUBCUTANEOUS TISSUE / HYPODERMIS ● Dry surface ; no blisters; pain manifests
● Fat myofascia ● Desquamation - 3-4 days peels off

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

RUFFINI’S ➔ (-) blisters

Papillary dermis Warmth
CORPUSCLE SURFACE ➔ Dry surface;
APPEARANCE/PAIN ➔ Delayed pain (1-2 days)
KRAUSE’S END ➔ Tender
Cold
BULB
➔ Minimal edema;
SWELLING/HEALING
PACINIAN Pressure, ➔ Spontaneous healing;
Reticular dermis /SCARRING
CORPUSCLE vibration ➔ (-) scars
 Frostbite - extremely cold; distal extremities; internal injury
DEEP PARTIAL-THICKNESS (DPT) BURN
SUPERFICIAL PARTIAL-THICKNESS (SPT) BURN
➔ Mixed red
● At the level of papillary dermis; whole epidermis is
➔ Waxy white
damaged and certain parts of papillary dermis is
COLOR ➔ the whiter the wound, the
damaged
VASCULARITY more ischemic the wound
● Layers involved: Epidermis and Papillary dermis
➔ Blanching with slow capillary
refill

➔ Broken blisters
SURFACE ➔ Wet surface;
APPEARANCE/PAIN ➔ Sensitive to pressure, but not
to light touch or soft pinprick

➔ Marked edema (Hallmark)

➔ Slow healing (3-5 weeks if
infection does not develop)
SUPERFICIAL PARTIAL-THICKNESS (SPT) BURN
➔ Becomes full thickness burn
➔ Bright pink or red, mottled red when infection is not treated
COLOR ➔ Inflamed dermis ➔ Excessive scarring
VASCULARITY ➔ Erythematous with blanching ◆ Deeper injury, more likely
➔ Brisk capillary refìll scars will form

➔ INTACT blisters (delay healing; SWELLING/HEALING ➔ Hair follicle, sebaceous gland

should be popped = lead to /SCARRING may remain INTACT (Pacinian
glistening surface) - Hallmark corpuscle is still intact = patient
➔ Fluid of the blister = STERILE can still feel deep pressure)
SURFACE ➔ Hair can still regenerate;
➔ Moist weeping or glistening
APPEARANCE/PAIN remanence is still there
surface
➔ Very painful - d/t nerve fibers ➔ (Have a chance to
➔ Sensitive - changes in temp et re-epithelialize than full
light touch thickness burn)
➔ If not treated may develop to full
➔ Moderate edema; thickness burn
➔ Spontaneous healing
SWELLING/HEALING ◆ Heal on their own (7-21 FULL THICKNESS BURN
/SCARRING days) ● Affects epidermis to reticular dermis (WHOLE
➔ Minimal scarring reticular layer)
➔ Discoloration ★ Wait for 5-7 days until the tissues are dead in order to
determine the depth of injury
DEEP PARTIAL-THICKNESS (DPT) BURN
● Affects the epidermis. WHOLE papillary dermis and
MOST parts of reticular dermis (not completely)
● Texture: WAXY — capillary refill is sluggish because
the vessels are affected

20

FULL THICKNESS BURN

➔ White, charred, tan, fawn,

mahogany, black, red
COLOR wound color
VASCULARITY ◆ White - less blood
supply
➔ No blanching
 Why do we develop electrical burns?
➔ Thrombosed vessels
● Body has water component, can’t withstand higher
➔ Poor distal circulation
voltage
◆ Presence of eschar
● Certain parts of body
○ Least resistant - part of body that are
➔ Parchment-ike
nonconductive
➔ Leathery
○ Nerves → blood vessel→ fat/muscles →
➔ Rigid,
bones
➔ Dry
■ Least resistant - nerves
➔ Anesthetic - damaged
SURFACE ■ Most resistant - bones
receptors, ONLY the
APPEARANCE/PAIN ● Tissues resist current = damage
surrounding areas will have
the sensation (surrounding
ENTRY Wounds - yellow, ischemic, depressed, small; where
areas still have nerve
current enters
endings)
➔ Body hairs pull out easily
EXIT Wounds - current goes out; usually in feet; looks like an
explosion happened (contact site where it is grounded)
➔ Area depressed
➔ Heals with skin grafting
SWELLING/HEALING
➔ Scarring (deeper the wound
/SCARRING
more scars)
◆ Zone of Coagulation

SUBDERMAL BURN
● Prolonged heat exposure or electrical injury
○ Electric Current = Makes muscle super soft
like a baby’s bum2

BURN WOUND ZONES (CSH or HSC)

1. Zone of Coagulation
2. Zone of Stasis
3. Zone of Hyperemia

SUBDERMAL BURN

COLOR
➔ Charred
VASCULARITY

➔ SubQ tissue evident

SURFACE ➔ Anesthetic BURN WOUND ZONES
APPEARANCE/PAIN ➔ Muscle damage
➔ Neurological involvement ➔ Dead nonviable tissue
➔ Irreversible
➔ Heals with skin graft or flap 1. ZONE OF ➔ Found in full thickness burns
SWELLING/HEALING
(IMPORTANT!) COAGULATION ➔ Requires extensive skin graft
/SCARRING
➔ Scarring ➔ Color: dark/brown
➔ Composed of necrotic tissues
ELECTRICAL BURN⚡🔥 - special type
➔ Area with potentially salvageable
● Exposure to electrical currents
2. ZONE OF tissue - composed of damaged
● Depends on type of current, intensity of current, area
STASIS cells but can remain viable
of the body the electric current passess through
24-48 hours with diligent tx
● Does not lead directly to death but increases the
morbidity (VTACH - deadliest complication)
 ● Rules of 9s in CHILDREN (head is bigger)
➔ Death may occur and expansion
○ Ant head - 8.5%
of zone of coagulation if no
○ Back of hed - 8.5%
treatment occurs
○ Ant arm - 4.5%
○ Post arm - 4.5%
➔ Area of minimal cell damage
○ Ant torso - 18%
3. ZONE OF ➔ No lasting effect on cells in the
○ Post torso - 18%
HYPEREMIA zone
○ Genitalia - 1%
➔ Red → recover
○ Ant thigh - 6.5%
○ Post thigh - 6.5%
EXTENT OF BURN INJURY
● we can determine the extent of injury by using 2 tools:
● depth = classification

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%

COMPLICATIONS OF BURN INJURY

1. Infection
2. Pulmonary
3. Metabolic
4. Cardiovascular
5. Heterotrophic ossification (HO)
6. Neuropathy

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

SHEET GRAFT INTERVENTION

● Use in face, hands, neck for better cosmesis and 1. Positioning
function 2. Splinting
● Good for cosmetic purposes and promotes better 3. Active and passive exercises
function 4. Resistive and conditioning exercise
● Harvested from the donor site and apply to the wound 5. Ambulation
bed
When does PT begin?
MESH GRAFT ● ASAP
● With small incisions to cover larger area ● 1st priorities
● Minimal skin harvested (minimal donor site ○ Prevent contracture formation
available) ○ Maintain ROM integrity
● Over time, will start to re-epithelialize
● Must have enough blood supply/vascularity in the POSITIONING
wound to successfully adhere. When should it begin?
● On the 1st day
Z-PLASTY ● Important = prevents contracture
- Lengthening scar contracture (severe) ● Prevents further impairment
● GOALS - prevent contracture, minimize edema,
REHABILITATION prevent pressure ulcers

Role of PT General Principles

● To restore function ➔ Px will go to position of comfort and convenience =
● Avoid contractures FLEXION and ADD
● Px education ➔ PT will elongate the tissue; position px against the
potential deformity
EXAMINATION (multi-system) ➔ Elongated/Neutral
● Sensation
● ABCD
● 5 cardinal signs of inflammation
● ROM
● Endurance
● Fever
● Skin changes
● Functional status
● Strength
● Limb girth
● Mm mass
● Size of burns
● V/S
● Pain scale
● Cardiovascular state
● Psychological status
POSITIONING STRATEGIES FOR COMMON DEFORMITIES
GOALS AND EXPECTED OUTCOMES
➔ Minimize peripheral edema Joint Common Motions to Suggested
➔ Improve joint integrity and mobility Deformity Be Stressed Approaches
➔ Improve muscle performance
➔ Improve ROM Anterior Flexion Hyperextens Use double
neck ion mattress;
➔ Safe and independent patient handling
position neck in
➔ Improve physical function extension; with
➔ Optimize utilization of rehabilitation services healing used
➔ Acceptable access, availability, and services rigid cervical
➔ Coordination of care orthosis
 ● 3 TYPES:
Shoulder Adduction Abduction, Position with
axilla and internal flexion, and shoulder flexed ○ Static - prevent contracture
rotation external and abducted ○ Static progressive - prevent contracture +
rotation (airplane splint) increase ROM
(FABER) ○ Dynamic - prevent contracture + increase
ROM
Elbow Flexion and Extension Splint in
pronation and extension ACTIVE AND PASSIVE EXERCISE
supination
● ACTIVE - initiated in the 1st day
Hand Claw hand Wrist Wrap fingers ○ Best for px who are alert, conscious and
(also called extension; separately. cooperative
intrinsic metacarpop Elevate to ○ Best used during dressing changes
minus halangeal decrease edema.
position) flexion, Position in ● General considerations
proximal intrinsic plus ○ Make sure skin is well-lubricated to prevent
interphalang position, wrist in
shearing injuries
eal and extension,
distal metacarpophalan ○ Use of correct moisturizer - type, frequency
interphalang geal in flexion, and how to apply
eal proximal ○ Skin graft - refer to physician’s protocol
extension; interphalangeal
thumb and distal ● Pain
abduction interphalangeal ○ Incorporate rest
in extension,
○ One of struggles with burn px
thumb in
abduction with ○ Ask for medication from the physicians
large web space
RESISTIVE AND CONDITIONING EXERCISE
Hip and Flexion and All motion, Hip neutral (zero What should the therapist look out for?
groin adduction especially degrees of ● Monitor V/S
hip flexion/extension ● Watch out for overexertion (valsalva maneuver)
extension ), with slight
and abduction
abduction

Knee Flexion Extension Posterior knee Type of activities and exercises

splint ● Must add stress and strengthen cardiovascular
activity (aerobic activity)
Ankle Plantarflexio All motion Plastic ankle-foot ○ Walking
n especially orthosis with ○ Cycling
dorsiflexion cutout at Achilles
○ Treadmill
tendon and ankle
positioned in ○ Hand grips
neutral ○ Swimming

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

When should this be worn?

What should a therapist consider/anticipate?
● Worn at night /Most of the day
● Orthostatic hypotension (OH)
● Continuously for week
○ Depends on surgeon