Introduction
Medicine Basic concepts in Rehabilitation Wound Care Rehabilitation in Wound Management
to Rehabilitation
Sg Buloh Hospital Serdang Hospital Hospital Rehab Cheras
Penang GH
Ipoh Hospital HKL S Seremban Hospital Sultanah Aminah Hospital
Tuanku Ismail Hospital
Hospital RPZ 2 HSNZ
W Persekutuan N Sembilan
Hospital TAA Hospital Queen Elizebeth Sarawak general Hospital
Is the process of helping a person to reach the fullest physical, psychological, social, vocational, avocational and educational potential consistent with his or her physiologic or anatomic impairment, environmental limitations and desires and life plans.
(WHO)
To provide quality rehabilitation services to the disabled people so they can regain their independence and make a successful return to the society.
Reviewed 2007
To manage Referred Cases from other disciplines requiring rehabilitation
Orthopedic Neuromedical Neurosurgical medical Surgical Pediatric
includes rehabilitation physicians, nurses, Penolong Pegawai Perubatan, physiotherapists, occupational therapists, speech and language pathologists and medical social workers (interdisciplinary)
May involves other professionals medical discipline (multidisciplinary)
Rehabilitation Physician Physiotherapist Occupational Therapist Nurses/Penolong Pegawai Perubatan Speech Therapist Medical Social Worker Counselor / Clinical psychologist Prosthetist/Orthotist
Rehabilitation Physician Occ Therapist Physioterapist
Through interdiciplinary collaboration and synergistic practice model Goal-oriented therapy which include patient and family.
patient Speech therapist Psychiatrist
Social worker
nurse PPP
ACTIVITIES
SCHOOL VISIT
CONFIDENTIAL
16
Increased independence Shortened length of stay Efficient use of health-care system Improve quality of life
Joel A. DeLisa, Rehab Med Principle and Practice 1998
Wounds have a
major personal, social, economic impact, Wounds not only impact on the individual and their quality of life, our health service and our society
Wounds
occur when the skin is broken or damaged because of injury.
skin can be damaged in a variety of ways depending upon the mechanism of injury.
The
Being bedridden or in a wheelchair Fragile skin/Older age Having a chronic condition, such as diabetes or vascular disease, that prevents areas of the body from receiving proper blood flow Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis) Malnourishment Mental disability from conditions such as Alzheimer's disease -- the patient may not be able to properly prevent or treat pressure ulcers Urinary incontinence or bowel incontinence
Altered foot sensation Foot deformities Previous foot ulcer Previous amputation of other foot
Pressure Ulcer Significant trauma injury to the skin Surgery (cuts made during operations) may become infected and slow to heal burns Underlying medical conditions such as diabetes or some types of vascular disease (diabetic foot Ulcer , limb Ischemia) Specific types of infection such as the Bairnsdale or Buruli ulcers (Mycobacterium ulcerans) Trophic ulcers, where a lack of sensation allows everyday trauma to lead to an ulcer such as in diabetic neuropathy and leprosy.
Pressure Ulcers
GRADE 1
GRADE 2
GRADE 3
GRADE 4
Grade 5
G/physical condition
Good - 4
Mental state
Activity
Mobility
Incontinence
Alert -
Ambulatory 4
Full -
Absent -
Fair -
Apathetic 3
Confused 2 Stuporous - 1
Walks with help
- 3
Slightly
limited Very limited - 2 Immobile 1 3
Occasional 3
Usually Urinary - 2 Double 1
Poor - 2 Very bad - 1
Chairbound 2 Bedfast 1
Pressure Area
asis
pinna
maleoli
fibula
shoulder
trochanter pelvis
Pressure Area
pinna
heel
sacrum elbow
occiput scapula
Pressure Area
shoulder blade
Back of knee
FEET
sacrum ischium
deformities
contractures
Transhumeral amputation
Elbow disarticulation
Forequarter amputation
Transradial amputation
Wrist disarticulation
Transfemoral amputation
Transtibial amputation
SYME AMPUTATION
RAY AMPUTATION
Transmetarsal amputation
Observe
Measure
Documentation
Extreme Lengths
Depth
Surface Area
Wound Tracings 1 cm Grid Photography
perfusion must be assessed, because: * in the setting of poor perfusion, therapeutic compression might cause pressure necrosis; and i. Macrocirculation
[Link] brachial index b. pulse volume recording c. Angiogram
ii. Microcirculation a. Transcutaneous oxygen b. Segmental pressure
Erythema (Rubor) Edema (Tumor)
Pain (Dolor)
Heat (Calor) Loss of Function (Functio laesa)
Delayed healing Discoloration Friable granulation tissue
Elevated white blood cell count
Abnormal wound drainage Odor
Treat underlying infection Prevent/treat complications Optimize medical issues ( eg: diabetes) Nutrition (high protein diet) Off load
Assistive devices
Orthosis/prosthesis
Wound Dressings for Ulcer Stages
Stage 1 II or III Clean Type of dressing Polyurethane or hydrocolloid Wet to moist saline dressing Hydrogel dressing Polyurethane foam dressing Hydrocolloid dressin Topical antiseptic Wet-to-dry saline Wet to moist saline dressing Hydrogel dressing Hydrocolloid dressing Topical antiseptic Wet-to-dry saline
II or III Infected IV Clean
IV Infected
Surgical treatment of infection (eg: debridement, pustule, fistula repair) Soft tissue recontruction (eg; flap ) Bone repair and recontruction (eg: osteotomies, tendon recessions Revascularization (ischaemic & gangrenous wound) Amputation (eg: expanding gangrene, overwhelming infection)
2. Educations *etiology, *pathology/risk factors, *terminology, *principles of wound healing, *nutritional support, *cleaning/hygiene, *infection control, * positioning, *prevention, *complications/outcomes.
Positioning should be designed for the specific individuals needs and be closely monitored and altered as the patients medical status changes. It should not compromise mobility and function as these will greatly affect the final functional outcome
Important factor in giving the patient the opportunity of recovery Ensures optimal physical recovery is promoted 24hrs/day
( National Clinical Guidelines for Stroke 2004)
Reduces edema Respiratory complications e.g. Aspiration pneumonia, atelectesis Maintains joint alignment Maintains tissues elongated Prevents contracture formation Maintains ROM Promotes wound healing Relieves pressure Protects joints, exposed tendons and new grafts/flaps
All members of the TEAM Nurses provide 24hr care Patients often spend long periods of time in one position, when they are unable to move themselves
PUSH UP . . . & MAINTAIN FOR 15 SECS
EVERY 15 MINS
DO A PUSH UP!!
5.
Wheelchair cushion/ seating system
TYPES OF WHEELCHAIR
LIGHT WEIGHT
BASKETBALL
RECLINING
TENNIS
Tilt in space
Standing wheelchair
ripple matress
CLEAN INTERMITTENT SELF CATHETERIZATION ( CISC )
TO MAINTAIN REGULAR REMOVAL OF A FORMED STOOL AT A REGULAR TIME TO ACHIEVE SOCIAL CONTINENCE
LOT OF FIBRES DIET AND WATER
Do not walk barefoot. Inspect the inside of your shoes daily for foreign objects, nail points, torn linings, and rough areas
For dry skin, use a very thin coat of a lubricating oil or cream. Apply after bathing
12. SKIN CARE
The goal of load management is to create an environment that enhances soft tissue viability and promotes healing of the ulcer (s). Avoid positioning patients on a pressure ulcer. A patient should avoid sitting if he/she has an ulcer on a sitting surface. Move a sitting patient at least once an hour.
Total Contact Casting vs Removable Cast Walker vs Half Shoe
Armstrong et al, Diabetes Care, 2001 After 12 weeks of treatment:
Total contact casting significantly increased ulcer healing (89% healed) Removable cast walkers (65% healed) Half shoes (58% healed)
Electrical stimulation Ultrasound Hydrotherapy
[Link] GARMENT
Compression therapy has emerged over the centuries as the standard of care for venous stasis ulcers. Edema reduction typically results in pain reduction and wound healing
b. STOP SMOKING
Do NOT massage the area of the ulcer. Massage can damage tissue under the skin. Donut-shaped or ring-shaped cushions are NOT recommended. They interfere with blood flow to that area and cause complications.
Aims optimizing functional independence, optimizing quality of life and minimizing burden of care. Requires interdisciplinary team approach to acquire the best outcome.
