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

a.Ankle 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

a.COMPRESSION 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.