CHAPTER 5 INTEGUMENTARY PHYSCIAL THERAPY Susan B. O'Sullivan I Integumentary System in or Integument External covering of the body, the largest organ system of the body (15% to 20% of body weight). Functions of skin. a. Protection of underlying body structures against injury or invasion. Insulation of body. c. Maintenance of homeostasis: fluid balance, regulation of body temperature. 4. Aids in elimination: small amounts of urea and salt are excreted in sweat. €. Synthesizes vitamin D. f. Receptors in dermis give rise to cutaneous sen- sations. . Consists of three layers. pidermis: outer, most superficial layer; con- tains no blood vessels. Comprised of two lay- crs of stratified epithelium. (1) Stratum corneum is outermost, horny layer, comprised of non-living cells. (2) Stratum lucidum, comprised of living cells; produces melanin responsible for skin color. . Dermis (corium): inner layer comprised prima- rily of collagen and elastin fibrous connective tissues. Mucopolysaccharide matrix and elastin fibers provide elasticity, strength to skin Contains lymphatics, blood vessels, nerves and nerve endings, sebaceous and sweat glands. €. Subcutaneous tissues: underneath dermis; con- sists of loose connective and fat tissues; pro- vides insulation, support, and cushion for skin; stores energy for skin. . Underneath subcutaneous layer: muscles and fase Appendages of the skin. a. Hair. (1) Terminal hair: coarse, thick, pigmented, eg., scalp, eyebrows (2) Vellus hair: short, fine, e.g., arms, chest b. Nails: nail plate, Iunula (whitish moon), proxi- mal nail fold/cuticle, lateral nail folds. ¢. Sebaceous glands: secrete fatty substance through hair follicles; on all skin surfaces except palms and soles, 4. Sweat glands. (1) Ecerine glands: widely distributed, open on skin, help control body temperature. (2) Apocrine glands: found in axillary and gen- ital areas, open into hair follicles; stimu- lated by emotional stress. B. Circulation Blood flows through arteries to capillaries of the skin. a. Increased blood flow with an increase in oxy-hemoglobin to skin capillaries causes redden- ing of the skin. b. Peripheral cyanosis is due to reduced blood flow to skin and loss of oxygen to tissues (changes to deoxyhemoglobin) and results in a darker and somewhat blue color. c. Central cyanosis is due to reduced oxygen level in the blood; causes include advanced lung dis- ease, congenital heart disease, abnormal hemo- globins. IL. Common Skin Disorders A. Dermatitis (eczema) 2. Sp 6. Inflammation of the skin with itching, redness, skin lesions. Causes: a. Allergic or contact dermatitis: e.g., poison ivy, harsh soaps, chemicals, adhesive tape, etc. b. Actinic: photosensitivity, reaction to sunlight, ultraviolet. ¢. Atopic: etiology unknown, associated with allergic, hereditary, or psychological disorders. Stages. a Acute: red, oozing, crusting rash; extensive erosions, exudate, pruritic vesicles. b_ Subacute: erythematous skin, scaling, scattered plaques. © Chronic: thickened skin, increased skin mark- ing secondary to scratching; fibrotic papules, and nodules; postinflammatory pigmentation changes. Course can be relapsing, Precaution or contraindication to some physical therapy modalities; avoid use of alcohol. Medical management aimed at inflammation: top- ical or systemic therapy. Daily care includes hydration and lubrication of skin, B. Bacterial Infections 1 2. Bacteria typically enter through portals in the skin, e.g., abrasions or puncture wounds. Impetigo: superficial skin infection caused by staphylococci or streptococci; associated with inflammation, small pus-filled vesicles, itching: contagious; common in children and the elderly. . Cellulitis: suppurative inflammation of cellular or connective tissue in or close to the skin. a, Tends to be poorly defined and widespread. b. Streptococcus or staphylococcus infection common; can be contagious. . Skin is hot, red and edematous. d. Management: antibiotics; elevation of the part; cool, wet dressings. e. If untreated, lymphangitis, gangrene, abscess, and sepsis can occur. f. The elderly and individuals with diabetes, wounds, malnutrition, or on steroid therapy are at increased risk. Abscess: a cavity containing pus and surrounded by inflamed tissue. a, The result of a localized infection. b, Commonly a staphylococcal infection. b, Healing typically facilitated by draining or incising the abscess. C. Viral Infections 1, Herpes I (herpes simplex): itching and soreness followed by vesicular eruption of the skin on the face or mouth; a cold sore or fever blister. Herpes Il: common cause of vesicular genital eruption. a. Spread by sexual contact, b, In newborns may cause meningoencephalitis, may be fatal. Herpes Zoster (shingles): caused by varicella- zoster virus (chickenpox); reactivation of virus lying dormant in cerebral ganglia or ganglia of posterior nerve roots. a. Pain and tingling affecting spinal or cranial nerve dermatome; progresses to red papules along distribution of infected nerve; red papules progressing to vesicles develop along a dermatome. b. Usually accompanied by fever, chills, malaise, GI disturbances. Ocular complications with C.N.IIL involve- ‘ment: eye pain, corneal damage; loss of vision with C.N.V involvement. d. Postherpetic neuralgic pain: may be intermit- tent or constant; lasts weeks; occasionally intractable pain lasting for months or years. €. Management: no curative agent, anti-viral drugs slow progression; symptomatic treat ‘ment for itching and pain, e.g., systemic corti- costeroids. f. Contagious to individuals who have not had chicken pox. g. Heat or ultrasound contraindicated: can increase severity of symptoms. |. Warts: common, benign, infection by human papilloma viruses (HPVs). a. Transmission is through direct contact;Se Fungal Infections 3. . Athlete's foot (Tinea Pedis): autoinoculation is possible. b. Common warts: on skin, especially hands and fingers cc. Plantar wart: on pressure points of feet. . Management: cryotherapy, acids, electrodesicea- tion and curettage; over-the-counter medications. Contagious, observe standard precautions. Ringworm (Tinea Corporis): fungal infection involves the hair, skin, or nails; forms ring-shaped patches with vesicles or scales; itchy; transmission is through direct contact. Treated with topical or oral antifungal drugs (e.g., Griseofulvin). fungal infection of foot, typically between the toes; causes erythema, inflammation, pruritus, itching and pain. Treated with antifungal creams. Can progress to bacterial infections, cellulitis if untreated. ‘Transmission is person-to-person or animal-to- person; observe standard precautions. E. Parasitic Infections 1 iz Caused by insect and animal contacts. Scabies (mites) burrow into skin causing inflam- mation, itching, and possibly pruritis. Treated with scabicide. Lice (pediculosis): a parasite that can affect head, body, genital area; bite marks, redness, and nits. ‘Treatment with special soap or shampoo. “Transmission is person-to-person or can be sexual- ly transmitted. Avoid direct contact; observe stan- dard precautions. F. Immune Disorders of the Skin 1 Psoriasis: chronic disease of skin with erythema- tous plaques covered with a silvery scale; common on ears, scalp, knees, elbows, and genitalia, . Common complaints: itching and pain from dry, cracked lesions. b. Variable course: exacerbations and remissions are common. c, May be associated with psoriatic arthritis, joint pain, particularly of small distal joints. ._Etiological factors: hereditary, associated immune disorders, certain drugs. ¢. Precipitating factors: trauma, infection, preg- nancy and endocrine changes; cold weather, smoking, anxiety and stress, f, Management: no cure; topical preparations (corticosteroids, occlusive ointments, coal tar); systemic drugs (methotrexate). g. Physical therapy intervention: long-wave ultra- 2. Lupus erythematosus: chronic, Integumentary Physical Therapy 189 violet light; combination UV light with oral photosensitizing drugs (Psoralen). progressive inflammatory disorder of connective tissues; char- acteristic red rash with raised, red, scaly plaques. Forms include: a. Discoid lupus erythematosus (DLE): affects only skin; flare-ups with sun exposut Ss can resolve or cause atrophy, permanent scar- ring, hypo-or hyperpigmentation. b. Systemic lupus erythematosus (SLE): chronic, systemic inflammatory disorder affecting mul- tiple organ systems including skin, joints, kid- neys, heart, nervous system, mucous mem- branes; can be fatal; commonly affects young ‘women. Symptoms can include fever, malaise, characteristic butterfly rash across bridge of nose, skin lesions, chronic fatigue, arthralgia, arthritis, skin rashes, photosensitivity, anemia, hair loss, Raynaud's phenomenon. ¢. Management: no cure; topical treatment of lesions (corticosteroid creams); salicylates or indomethacin with fever and joint pain; immunosuppressive agents (cytotoxic agents) with life-threatening disease. . Observe for side-effects of corticosteroids: edema, weight gain, acne, hypertension, bruis- ing, purplish stretch marks; long-term use of ds is associated with increased ity to infection (immunosuppressed patient); osteoporosis, myopathy, tendon rup- ture, diabetes, gastric irritation, low potassium. . Scleroderma: a chronic, diffuse disease of connec- tive tissues causing fibrosis of skin, joints, blood vessels, and internal organs (GI tract, lungs, heart, kidneys). Usually accompanied by Raynaud's phe nomenon. Progressive systemic sclerosis (PPS) is a relatively rare autoimmune form. a. Skin is taut, firm, edematous, firmly bound to subcutaneous tissues. b. Limited disease/skin thickening: symmetrical skin involvement of distal extremities and face; slow progression of skin changes; late visceral involvement. ¢. Diffuse disease/skin thickening: symmetrical, widespread skin involvement of distal and proximal extremities, face, trunk; rapid. pro- gression of skin changes with early appearance of visceral involvement. . Management: no specific therapy: supportiveG. therapy can include corticosteroids, vasodila- tors, analgesics immunosuppressive agents. . Physical therapy slows development of con- tracture and deformity. f. Precautions with sclerosed skin, sensitive to pressure; acute hypertension may occur, stress regular BP checks. 4. Polymyositis (PM): a disease of connective tissue characterized by edema, inflammation, and degen- eration of the muscles; dermatitis is associated with some forms, a. Affects primarily proximal muscles: shoulder and pelvic girdles, neck, pharynx; symmetrical ribution b. Etiology unknown; autoimmune reaction affecting muscle tissue with degeneration and regeneration, fiber atrophy; inflammatory infil- trates. . Rapid, severe onset: may require ventilatory assistance, tube feeding. 4. Cardiac involvement: may be fatal. €. Management: medication (corticosteroids and immunosuppressants) f. Precautions: additional muscle fiber damage with too much exercise; contractures and pres- sure ulcers from inactivity, prolonged bedrest. Skin Cancer 1, Benign tumors, a. Sebortheic keratosis: proliferation of basal cells leading to raised lesions, typically multi- ple lesions on trunk of older individuals; untreated unless causing irritation, pain; can be removed with cryotherapy. b. Actinic keratosis: flat, round or irregular lesions, covered by dry scale on sun-exposed skin, Precancerous: can lead to squamous cell carcinoma. c. Common mole (benign nevus): proliferation of melanocytes, round or oval shape, sharply defined borders, uniform color, < 6mm, flat or raised. Can change into melanoma: signs include new swelling, redness, scaling, oozing or bleeding. 2. Malignant tumors. a. Basal cell carcinoma: slow growing epithelial basal cell tumor, characterized by raised patch with ivory appearance; has rolled border with indented center. Rarely metastasizes, common on face, in fair-skinned individuals. Associated with prolonged sun exposure. '. Squamous cell carcinoma: has poorly defined margins; presents as a flat red area, ulcer or nodule. Grows more quickly, common on sun- exposed areas, face and neck, back of hand. Can be confined (in situ) or invasive to sur- rounding tissues; can metastasize, ©, Malignant melanoma: tumor arising from melanocytes (cells that produce melanin); ficial spreading melanoma (SSM) most ‘common type. (1) Clincial manifestations: “ABCDs” (a) asymmetry: uneven edges, lopsided. (b) borders: irregular, poorly definted edges. (©) color: vaiations or changes in color, black, brown, red, or white. (@) diameter: larger than 6mm. (©) evolving: changing in color, size, shape. oor tender ness (2) Risk factors: family history, intense sun exposure, individuals with fair skin and freckles. (3) Treatment is surgical resection. Prognosis depends on extent of invasion 4d. Kaposi's sarcoma (KS): lesions of endothelial cell origin with red, or dark purple/blue mac ules that progress to nodules or ulcers; associ ated with itching and pain. (1) Common on lower extremities; may involve internal structures producing lymphatic obstruction. (2) Increased incidence in individuals of central European descent, and with AIDS-associated immunodeficiency. HL Skin Trauma Contusion: injury in which skin is not broken, a bruise. Characterized by pain, swelling, and dis- coloration, Immediate application of cold may limit effects. Ecchymosis: bluish discoloration of skin caused by extravasation of blood into the subcutaneous tissues; the result of trauma to underlying blood ‘vessels or fragile vessel walls. Petechiae: tiny red or purple spots on the skin that result from tiny hemorrhages within the dermal or submucosal layers; pinpoint. Abrasion: scraping away of skin as a result of injury or mechanical abrasion (e.g., dermabrasion), . Laceration: an irregular tear of the skin producing ator, jagged wound,IIL. Examination of Integumentary Integrity A. Patient/Client History 1, Complete history: age, sex, race/ethnicity, social/ health habits, work, living, general health status, ‘medical/surgical. Current condition(s)/ chief complaint(s). Functional status/activity level. Medications. Clinical tests. Risk factor assessment. ‘xamination ‘Techniques include observation, palpation, photo- graphic assessment, and thermography. 2. Pruritus: itching; common in diabetes, drug hyper- sensitivity, hyperthyroidism. 3. Urticaria: smooth, red, elevated patches of skin, hives; indicative of an allergic response to drugs or infection. 4, Rash: local redness and eruption on the skin, typi- cally accompanied by itching; seen in inflamma- tion, skin diseases, chronic alcoholism, vasomotor disturbances, pyrexia, medications, e.g., diaper rash, heat rash, drug rash, 5. Xeroderma: excessive dryness of skin with shed- ding of epithelium; can indicate deficiency of thy- roid function, diabetes. 6. Edema: can indicate anemia, venous or lymphatic obstruction, inflammation; cardiac, circulatory, or renal decompensation. a. Determine activities and postures that aggra- vate or relieve edema. b. Palpation, volume, and girth measurements. 7. Changes in nails. a. Clubbing: thickened and rounded nail end with spongy proximal fold; indicative of chronic hypoxia secondary to heart disease, lung can- ccer, cirrhosis. b. White spots seen with trauma to nails. 8. Changes in skin pigmentation, tissue mobility, skin turgor and texture. a, Wrinkling may be due to aging or prolonged immersion in water, dehydration. b. Blistering. 9. Changes in skin color. a. Cherry red: indicative of carbon monoxide poi- soning b. Cyanosis: slightly bluish, grayish, slatelike dis- coloration. (1) Indicative of lack of oxygen (hemoglobin); can indicate congestive heart failure, reve Integumentary Physical Therapy 191 advanced lung disease, congenital heart disease, venous obstruction. (2) Examine lips, oral mucosa, tongue for blue color (central causes) or nails, hands, feet (peripheral causes). . Pallor (lack of color, paleness). (1) Can indicate anemia, internal hemorrhage, lack of exposure to sunlight. (2) Temporary pallor seen with arterial insuffi- ciency and syncope, chills, shock, vasomo- tor instability, or nervousness. 4. Yellow: indicates jaundice, liver disease: look for yellow color in sclera of eyes, lips, skin With increased carotene intake (carotenemia), ook for yellow color of palms, soles, and face. . Liver spots: brownish-yellow spots may be due ‘o aging, uterine and liver malignancies, preg- f increased pigmentation, sometimes associated with venous insufficiency. 10. Changes in skin temperature: correlates with inter- nal temperature unless skin is exposed to local heat or cold. a. Examine with backs of fingers for generalized ‘warmth or coolness. (1) Abnormal heat can indicate febrile condi tion, hyperthyroidism, mental excitement, excessive salt intake, (2) Abnormal cold can indicate poor circula- tion or obstruction, e.g., vasomotor spasm, venous or arterial thrombosis, hypothy- roidism. b. Examine temperature of reddened areas: local ‘warmth may indicate inflammation or cellulitis. 11 Hydrosis. a. Moist skin (hyperhidrosis), increased perspira- tion, can indicate fevers, pneumonic crisis drugs, hot drinks, exercise b. Dry skin (hypohidrosis) can indicate dehydra- tion, ichthyosis, or hypothyroidism, ¢. Cold sweats: can indicate great fear, anxiety, depression or disease (AIDS). 12.Changes in hair: note quality, texture, distribution. a. Alopecia: hair loss. b. Hypothyroidism see thinning hair; hyperthy- roidism see silky hair. 13. Presence of lesions: note unusual growths. a. Note anatomic location and distribution, ie., gen- eralized or localized?, Exposed or non-exposed surface?, Symmetrical or asymmetrical?192 —. IV. Physical Therapy Intervention for Impaired a Ea cpa eee up to 10cm), Integumentary Integrity. (2) Palpable elevated solid mass: papule (Table 5-1) (small, up to 1.0 em), plaque (elevated, 1.0 A+ Patient/client-related instruction ‘em or larger), nodule (marble-like lesion), 1. Enhance disease awareness, healthy behaviors. wheal (irregular, localized skin edema, e.g., 2. Assist patient to avoid harsh soaps, known irti- hives). tants, temperature extremes, exacerbating factors (3) Elevated lesions with fluid cavities: vesicle or triggers. (cp ito 1.0 cm, contains serons fluid, e.g, 3. Enhance ADL, functional mobility and safety. herpes nimplex); bulla. oc blister (1.0 em or 4. Enhance self-management of symptoms. larger, contains serous fluid, e.g. 2nd B+ Infection Control Practices degree burn); pustule (contains pus, e.g., 1. (Table 5-2). acne). 2. (Table 5-3). ©. Color, C. Therapeutic Exercise Body Composition 1. Strengthening and ROM exercises, a. Height, weight b. Body mass index: skinfold thickness. 3. Body mechanics, postural awareness training. D. Other Systems 4. Gait, locomotion, and balance training. |. Circulation (arterial, venous, lymphatic) 5. Aquatic therapy. a. Heart rate, rhythm, sounds. D. Functional training | b. Blood pressures and flow. 1. ADL training (basic and instrumental) , Superficial vascular sesponses. 2. Activity pacing and energy conservation; stress 2. Respiratory. ‘management. a. Respiratory rate. 3. Skin and joint protection techniques. b. Respivatray pattern. 4. Instruct in safe use of assistive and adaptive 3. Sensory. devices. a. Superficial sensations: sharp/dull discrimina- 5. Prescription, application, and training in use of tion, temperature, light touch, pressure ___ orthotic, protective, or supportive devices. b. Deep sensations: proprioception, kinesthesis. E. Manual lymphatic drainage, therapeutic massage . Pain and soreness. F. Dressings and topical agents (see section on wound 3. Musculoskeletal care) ‘a. Gross range of motion (ROM) including mus- G+ Eleetrotherapeutic modalities Refer to Chapter 10. cle length 1, Electrical muscle stimulation (EMS). b. Gross strength 2. High voltage pulsed current (HPC). 4, Neuromuscular. a. Coordination, een Tana PRACTICE PATTERNS: INTEGUMENTARY b. Gait, locomotion, balance. Finials Masia abllataielteablisniLl E. Functional PATTERN A: Primary Preventoik Reston for rtegumentary Disorders 1 Beene PATTERN B: impaired rtogumentary egy Associated wth Super a. Activities, positions, postures that produce or Skin involvement reduce trauma to skin. PATTERN C: b. Safety during functional activities. © dos Sen mchene onc Fomano €. Assistive, adaptive, protective, onhotic or pros- thetic devices that produce or reduce skin rau- ma, d. Likelihood of trauma to skin. PATTERN D: mired integumentary Integrity Associated with Fl-Ticknass ‘Skin volvement and Scar Formation PATTERN E: impaired integumentary Itogrty Associated with Skin lnvaverent Extending ito Fascia, Muse, or Bone and Scar Formation ‘From Guide to Physical Therapist Practice, €0 2 Phys Ther 61:595- 688, 20013. Transcutaneous electrical nerve stimulation (TENS): relief of pain. H. Physical agents and modalities Refer to Chapter 10. 1. Sound agents: ultrasound, phonophoresis. 2. Hydrotherapy: aquatic therapy, whirlpool tanks, 3. Light agents: ultraviolet. 4, Mechanical modalities: compression therapies. V. Burns A. Tissue injury or destruction: results from thermal, chemical, electrical, or radioactive agents, B. Pathophysiology: burn wound consists of three zones. 1. Zone of coagulation: cells are irreversibly injured, cell death occurs. 2. Zone of stasis: cells are injured; may die without specialized treatment, usually within 24-48 hours. 3. Zone of hyperemia: minimal cell injury; cells should recover. C. Degree of burn: bums are classified by severity, lay- ers of skin damaged. 1. Superficial bum (first degree): damage is to epi- dermis only. a. Characterized by erythema, slight edema, ten- derness; no blistering. b. Full healing in 3-7 days. 2. Superficial partial thickness burn (second-degree bum): epidermis and upper layers of dermis. are damaged. a. Characterized by blisters, inflammation, severe pain, b. Healing in 7 to 21 days. 3. Deep partial thickness burn (second-degree burn): severe damage to epidermis and dermis with injury to nerve endings, hair follicles, and sweat glands. a. Characterized by red or white appearance, edema, blistering, severe pain. b, Healing occurs through scar formation and reepithelialization, in 21-28 days. 4. Full thickness bum (third-degree): complete destruction of epidermis, dermis, and subcuta- neous tissues, may extend into muscle. a. Characterized by white, gray, or black (charred) appearance; dry surface, edema, eschar (scab or dry crust); little pain (nerve endings are destroyed). b. Removal of eschar; grafting is necessary due to destruction of dermal and epidermal tissue. c. Risk of infection is increased. Hypertrophic scarring and wound contracture are likely to develop without preventive measures. Integumentary Physical Therapy 193 (1) Hypertrophic scar: a raised scar that stays within the boundaries of the burn wound; characteristically red, raised, firm. (2) Keloid scar: a raised scar that extends beyond the boundaries of the original burn wound; red, raised, firm. 4, Subdermal burn (fourth-degree): complete destruction of epidermis, dermis, subcutaneous tissues; also involves muscle and bone; e.g., elec trical burn; prolonged contact with flame. a. Extensive tissue damage; destruction of vascu- lar system, may lead to additional necrosis. b. Course unpredictable. cc. Requires extensive surgery; amputation may be necessary. 4. Additional complications likely with electrical burns, e.g., ventricular fibrillation, acute kid- ney damage, spinal cord damage. D. Extent of burned area 1. Rule of Nines for estimating burn area (estimates are for adult patients). Head and neck 9% Anterior trunk 18% Posterior trunk 18% ‘Arms: each 9% Legs: each 18% . Perineum 1% 2. Percentages vary by age (growth) for children: use Lund-Browder charts for estimating body areas. 3. Classification by percentage of body area burned. a. Critical: 10% of body with third degree burns and 30% or more with second degree; compli- cations common, e.g., respiratory involvement, smoke inhalation, b, Moderate: less than 10% with third degree ‘burns and 15-30% with second degree. ¢. Minor: less than 2% with third degree burns and 15% with second degree burns. ‘Complications of burn injury 1. Infection: leading cause of death; gangrene may develop. 2. Shock. 3. Pulmonary complications. a, Smoke inhalation injury from inhalation of hot gases, smoke poisoning; results in pulmonary edema and airway obstruction; suspect with bums of the face, singed nose hairs. b. Restrictive lung disease from burns of the trunk. ©. Pneumonia. meee ge194 4, Metabolic complications: increased metabolic and catabolic activity results in weight loss, negative nitrogen balance, decreased energy. . Cardiac and circulatory complications: fluid and plasma loss results in decreased cardiac output. F, Burn healing 1. Epidermal healing: retention of viable cells allows for epithelialization to occur (epithelial cells grow and proliferate, migrate to cover the wound). a. Protection of epithelial cells is critical. b. Loss of sebaceous glands can result in drying and cracking of wound; protection with mois- turizing creams important. 2. Dermal healing: results in scar formation (injured tissue is replaced by connective tissue); scars are initially red or purple, later become white. a. Inflammatory phase: characterized by redness, edema, warmth, pain, decreased range of motion; lasts 3-5 days. b._ Proliferative phase: fibroblasts form scar tissue (deeper tissues); characterized by wound con- traction; reepithelialization may occur at ‘wound surface if viable cells remain. ¢. Maturation phase: scar tissue remodeling lasts up to 2 years (A) Hypertrophic scar may result. (2) Keloid scar may result; more common in young women and those with dark skin. G, Emergency burn management 1. Immersion of burned part in cold water (if less than half the body burned and injury is immedi- ate); cold compresses may also be used. 2. Cover bum with sterile bandage or clean cloth; no ointments or creams. H. Medical management Asepsis and wound care. a. Removal of charred clothing. b. Wound cleansing. ©. Topical medications (antibacterial agents): can be applied without dressings (open technique); reapplied daily. (1) Silver nitrate: acts only on surface organ- isms; applied with wet dressings; requires frequent dressing changes. (2) Silver sulfadiazine: common topical agent. (3) Sulfamylon (mafenide acetate): penetrates through eschar, 4. Occlusive dressings (closed technique): dress- ings are applied on top of a topical agent. (1) Prevents bacterial contamination, prevents 2. Establish and maintain fluid loss, protects the wound. (2) May additionally limit ROM. way, adequate oxygena- tion, respiratory function. 3. Monitor. a, Arterial blood gases, serum electrolyte levels, urinary output, vital signs. b. Gastrointestinal functi support. provide nutritional 4, Pain relief, e.g., Morphine sulfate. 5. Prevention and control of infection. a. Tetanus prophylaxis. b. Antibiotics. ¢. Isolation, sterile techniques 6. Fluid replacement therapy. a. Prevention and control of shock. bb. Post shock fluid and blood replacement. 7. Surgery. a. Primary excision: surgical removal of the eschar. b. Grafts: closure of the wound. (2) Allograft (homograft): use of other human skin, e.g., cadaver skin; temporary grafts for large burns, used until autograft is avail- able. (2) Xenogratt (heterograft): use of skin from other species, e.g., pigskin; a temporary graft. (3) Biosynthetic grafts: combination of colla gen and synthetics. (4) Cultured skin: laboratory grown from patient's own skin. (5) Autograft: use of the patient's own skin. © Split-thickness graft: contains epidermis and upper layers of dermis from donor si (7) Full-thickness graft: contains epidermis and dermis from donor site. €. Surgical resection of scar contracture, e.g. Z- plasty (a surgical incision in the form of the letter Z used to lengthen a burn scar). 1. Physical therapy goals, outcomes, and interventions 1, Burn wound care, Infection control techniques at all times. a. Immersion in hydrotherapy tank. (1) Debridement: the excision of loose, charred, dead skin, (2) Wet removal of dressings. (3) ROM exercises, early mobilization. (4) Anti-infection agents are added to assist in infection control.b. Sharp debridement: excision of eschar using sterilized surgical instruments (forceps, scalpel. scissors), Autolytic dressings or enzyme use are other selective means to help remove eschar. 2. Rehabilitation: prevent or reduce the complica- tions of immobilization. a. Exercises to promote deep breathing and chest expansion; ambulation to prevent pneumonia. b. Positioning and splinting to prevent or correct Integumentary Physical Therapy 195 deformities. (1) Anterior neck: common deformity is flex- ion; stress hyperextension; position with firm (plastic) cervical orthosis. (2) Shoulder: common deformity is adduction and internal rotation; stress abduction, flex- ion, and external rotation; position with an axillary splint (airplane splint) (3) Elbow: common deformity is flexion and pronation; stress extension and supination; ‘TABLE 5-2 - STANDARD PRECAUTIONS WANDWASHING 1. Wash hands after touching blood, body tid, secretions, excretions, and contaminated items, whether or not gloves are worn. 2 Wash hands immediatly ater removing gloves, between patient con- tacts, and when otherwise indicated to reduce transmission of microor- anisms, 5. Wash hands between tasks and procedures on the same patient to prevent crass-contamination of diferent body sts. 4. Use plain (nonantimicrobil soap for routine handwashing 5. An antimicrobial agent or a waterless antiseptic agent may be used for specie circumstances (hyperendemic infections) as defined by infection, Control Loves 1. Wear gloves (clean, unstrile gloves are adequate) when touching blood, body fis, secretions, excretions, and contaminated items; put on clean loves just before touching mucous membranes and nonntact ski. 2 Change gloves betwoen tasks and procedures on the same patent after contact wth materais that may contain high concentrations of microor. anisms, 3. Remove gloves prompty afer use, before touching uncontaminated ems and environmental surfaces, ané before going on to another patient; wash hands immetiatly after give removal to avoid transfer of microorganisms to other patients or environments. [MASK AND EYE PROTECTION OR FACE SHIELD 1. Wear a mask and eye protacton ora face shield to protect mucous ‘membranes of the eyes, nose, and mouth during procedures and patent-careactvtes that are likely to generate splashes or sprays of ‘lod, ody fuid, secretions, and excretions. own 1. Wear a gown (a clean, unsterte gown is adequate) to protect skin and ‘prevent soiling of clothing during procedures and patiet-care actives ‘hat ar likely to generate splashes or sprays of blood, boty fds, secretions, and excretions, 2 Selecta gown that s appropriate forthe ectivity and the amount of uid likely tobe encountered. ‘3. Remave a sailed gown as soon as possible and wash hands to avoid transfer of microorganisms to ater patients or environments PATIENT-CARE EQUIPMENT 1. Handle used patent-care equipment soled with bood, body fis, ‘secretions, and excretions in a manner that prevents skin and mucous ‘membrane exposures, contamination of cothing, and transfer of microorganisms to othr patients or envionment. 2. Ensure that reusable equipment isnot used forthe care of another Patient uni it has been cleaned and reprocessed appropriatly. 3. Ensure that single-use items are iscarded property. ENVIRONMENTAL CONTROL 1. Follow hospital procedures forthe routine cae, cleaning, and disinfec- tion of envionmental surfaces, beds, bedrails, bedside equipment, and ‘ther frequently touched suraces. ‘UNEN 1. Handle, transport, and process used linen soled with bood, body ids, secretions, and excretions in a manner that prevents skin and mucous ‘membrane exposures and contamination of Cothing, and avoids transfer ‘of microorganisms to other patients or environments. ‘OCCUPATIONAL HEALTH AND BLOODBORNE PATHOGENS 1. Prevent injures when using needles, scalpel, and other sharp instru ‘ments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles. 2, Never recap used needles, or otherwise manipulate them using both hands, or use anyother technique that involves directing the point of @ needle toward any part ofthe body; rather, use either a one-handed scoop” technique ora mechanical device designed for holding the nee- de sheath 3. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. 4, Pace used disposable syringes and needles, scalpel bades, or other ‘harp ems in appropriate puncture-resistant container for transport 10 the reprocessing area ‘5, Use mouthpieces, resuscitation bags or other venation devices as an alternative to mouth-to-mouth resuscitation. ‘PATIENT PLACEMENT 1. Use a private room for 2 patient who contaminates the envionment or who does not or cannot be expected to) assist in maintaining appropri- ate hygiene or environmental contr 2. Consut infection Control i a private room is not avaiable From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Part Il Recommendations for Isolation Precautions in Hospitals. February 1997.