Standard of Care: Wound Care/Integumentary Management



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Standard of Care: Wound Care/Integumentary Management

Physical Therapy management of the patient at risk for or with an integumentary disorder.


Case Type / Diagnosis:

This standard of care will provide guidelines for the management of patients who are at risk for integumentary disruption or who present with partial or full thickness wounds and would benefit from physical therapy intervention. Integumentary management utilizes prevention techniques, as well as direct wound care interventions to promote wound healing. Wound management is a comprehensive team approach that includes procedures used to achieve a clean wound bed and eliminate infection, promote a moist wound healing environment, facilitate autolytic debridement, enhance perfusion and nutrient delivery to the tissues, and protect the wound bed during the healing process. This may involve care during one or all three phases of wound healing (inflammatory, proliferative, maturation), including the management of resulting scar tissue.


This standard will focus on patients at increased risk for impaired skin integrity as well as the following types of integumentary disorders:


  • Pressure Ulcers (ICD-9: 707.0, 707.8)

  • Venous Stasis Ulcers (ICD-9: 443, 454.0, 454.2, 459)

  • Arterial Insufficiency Ulcers (ICD-9: 443, 459)

  • Diabetic Neuropathic Ulcers (ICD-9: 250, 707.1)

  • Surgical wounds and grafts (excluding amputations and burns) (ICD-9: 998.3)

For detailed information regarding the management of a burn or an amputation patient, please refer to the respective Burn or the Lower Extremity Amputation Standard of Care (SOC) as neither diagnosis will be specifically covered in this document.




Indications for Treatment:

The specific practice pattern identified in this SOC is the complete Integumentary Practice Pattern.1 This encompasses the primary prevention and risk reduction for integumentary disorders and impaired integumentary integrity associated with superficial, partial-thickness, and full-thickness skin involvement. The APTA’s Section on Clinical Electrophysiology and Wound Management and Guide for Integumentary/Wound Management Content in Professional Physical Therapist Education2 is an excellent and comprehensive resource that will certainly help both the novice and more experienced clinician cultivate his/her skills during this process. This document from the APTA provides an outline of the necessary contextual background to assist with fully understanding tissue healing and expected outcomes as well as determining and performing appropriate tests and measures, suitable interventions, and complete assessments for this patient population.



Contraindications / Precautions for Treatment:

Depending on the etiology of the integumentary disorder, the specific contraindications and precautions may vary. Please refer to the specific orders in the computer/patient chart or discuss with the appropriate/consulting service (i.e. Plastics or Vascular) if questions regarding the details of an individual patient’s care arise.


For patients with an elevated International Normalized Ratio (INR) of greater than or equal to 3.5, please consult the physician or nurse practitioner prior to initiating mobility.4
The following precautions and/or contraindications have been identified and discussed with the BWH medical staff and stand as the general precautions for the below noted patient situations. These guidelines should be maintained unless otherwise stated in the physician orders.


  • For split thickness skin graft (STSG) or full thickness skin grafts (FTSG) that involve the lower extremity a patient can be expected to remain on bedrest for five (5) days. To prevent shearing or injury to the new graft, no range of motion of the affected limb is allowed until notified by a physician or nurse practitioner. The above information is applicable whether or nor a graft crosses a joint. It is likely that a graft that does cross a joint will warrant further immobilization of the involved joint (i.e. with a knee immobilizer or resting foot splint) to prevent any ROM. Specific weight bearing precautions should be identified with the primary team prior to mobilization. Depending on the site of the graft or the wound, the patient may be non-weight bearing, partial weight bearing, heel weight bearing, forefoot weight bearing, or even weight bearing as tolerated.




  • For donor sites, there is no specific activity, ROM or weight bearing restrictions, although some patients may be more limited by comfort level. Generally the donor sites will be dressed with either Tegaderm™ or Xeroform™ and this dressing should remain in place until it falls off or is taken off by a physician. When mobilizing a patient, it may be necessary to reinforce a Tegaderm™ dressing with Kerlix™ if leaking occurs. However, do not tape the Kerlix™ directly to the Tegaderm™ or leave the Kerlix™ in place once mobilization is complete.




  • Vacuum assisted closure (VAC) therapy can be used over grafts and directly on wounds to promote healing. If over a graft, the same precautions as listed above are applicable. Check with a physician prior to initiating mobility and/or ROM as well as for specific weight bearing precautions (if any). If the VAC is used over a wound then there should not be any additional activity precautions except for the identified weight bearing precautions. However, it is critical to ensure that the VAC remains on suction (i.e. use of the battery) if the patient is ambulating.

Please note: At this time, the current VAC system used at BWH automatically transitions to battery power when unplugged from the outlet.
In this acute care setting, it is important to note that some guidelines may be different among surgeon/physician given his/her preferred technique or practice. Therefore it is necessary to refer and adhere to that physician’s orders/guidelines for appropriate patient management.

Precautions with modalities: Please refer to the Pulsed Lavage Procedural Guidelines for contraindications/precautions with that particular modality as well and the Surgical Standard of Care for considerations with surgical incisions.




Evaluation:


Chart Review

History of Present Illness (HPI) and Past Medical History (PMH)



  • Reason for admission

  • Onset and duration of symptoms including mechanisms of injury

  • Previous or current medical and/or surgical treatments

  • PMH with specific attention to a history of diabetes, peripheral vascular disease, coronary artery disease, congestive heart failure, spinal cord injury, malnutrition, and a history of smoking

Social History



  • Prior functional level, use of assistive devices and/or adaptive equipment

  • Home environment and current/potential barriers to returning home

  • Family/caregiver support system

  • Family, professional, social, and community roles

  • Patient’s goals and expectations of returning to previous life roles

Hospital Course



  • New or ongoing medical intervention

  • Pertinent lab values (i.e. White Blood Count (WBC), Hematocrit (Hct), INR, albumin, glucose)19

  • Diagnostic testing (i.e. X-ray or MRI for osteomyelitis, angiography for circulation, doppler ultrasound)

  • Overall nutritional status18,22

  • Other Consults: Plastics, Vascular, Ostomy Nurse, Nutrition

Medications


Given that integument issues can arise in any patient determined to be at risk for skin breakdown or potential healing issues, patients may be treated with numerous pharmacological agents that may vary greatly among the individual patients.

Common medications can include antibiotics for local or systemic infections, topical medications, narcotics for pain management, nutritional supports such as total parenteral nutrition (TPN), or possibly insulin for optimal diabetic management should diabetes exist as a comorbidity.



Examination

This section is intended to capture the most commonly used assessment tools for this case type/diagnosis. It is not intended to be either inclusive or exclusive of assessment tools.



.


  • Anthropometric Characteristics including edema (circumferential measurement versus pitting edema scale)

  • Vitals signs- Heart Rate, Blood Pressure, Respiratory Rate, Oxygen Saturation

  • Circulation including capillary refill, Ankle-Brachial Index (ABI)22, superficial vascular responses. The ABI may be documented in the physician’s admission note or in the patient’s history but if not available in the chart this measurement may be done by a therapist.

  • Sensory integrity including light touch, sharp/dull, deep pressure, vibration, temperature, presence of paresthesias or neuropathy. Semmes-Weinstein monofilament testing is especially useful in assessing a diabetic wound17.

  • Skin integrity6- presence of skin breakdown and full wound assessment that includes location, size, shape, odor, drainage, presence of tunneling or undermining, exposed anatomical structures, presence of devitalized tissue or granulation tissue; should also include stage of the wound if a pressure sore or characteristics of the incision (if a surgical patient). Please refer to Appendix 1 “Wound Assessment Handout/Worksheet” in the Integument Resource Manual for further details.

  • Skin Characteristics- trophic changes such as thickened nail beds, calluses, shiny or dry skin, skin color, hair growth, texture, pliability, temperature, recent or old scarring from prior/healed ulcers, evidence of infection

  • Pain11- location, type, intensity, use of visual analog scale (VAS), pain at rest, pain with dependent positioning

  • Range of Motion including passive/active assisted and active range of motion (P/AA/AROM) as well as presence of contractures or deformities

  • Strength

  • Neurological function including abnormal tone

  • Postural alignment and bony prominences

  • Gait

  • Functional Mobility: bed mobility, transfers, ambulation, stairs

  • Mental Status/Cognition: level of consciousness/alertness, orientation, ability to follow commands, knowledge of pathology, safety awareness

  • Risk Assessment Scales: Braden Scale7,10,12,21, Norton Scale12,21

Please note: At BWH, the Braden Scale is usually completed by a nurse for all patients upon admission on the Nursing Assessment Form.

Assessment:
The primary goal when addressing this population is to provide an individualized and integrated plan of care which minimizes risk for further integumentary disruption, promotes wound healing, and maximizes mobility, thus allowing patients to return to their highest level of functioning in home, work, and community environments. Secondary goals are to serve as a resource for both patient and family and to assist with the discharge and referral process.
Potential impairments include, but are not limited to:


  • Impaired skin integrity

  • Impaired sensation

  • Impaired circulation

  • Edema

  • Impaired ROM

  • Impaired strength

  • Impaired balance

  • Impaired motor function

  • Impaired tone

  • Impaired functional mobility including bed mobility, transfers, ambulation

  • Impaired endurance and activity tolerance

  • Impaired mental status (cognition, arousal, attention, memory, barriers to learning)

  • Pain

The predicted outcome for this patient population is to maximize their skin integrity and ability to return to their previous life roles as well as the reduced risk of developing integumentary disorders. The ability to achieve this outcome is shared by a team and the steps taken may include the debridement of devitalized tissue, infection and inflammation control, nutrient delivery to the tissues as well as the body’s overall nutritional status and the promotion of wound healing8. This will also involve using the appropriate physical therapy intervention, modality, assistive device, orthotic, and/or adaptive equipment, as each patient’s individual needs dictate.


The rehabilitation prognosis may be modified by any of the following factors:

  • Nature and extent of pathology

  • Ongoing and/or active medical treatment or surgical intervention

  • Presence of comorbidities or secondary impairments

  • Overall health and nutritional status

  • Barriers to returning to previous living environment

  • Patient compliance or adherence to the intervention program

  • Patient’s coping mechanisms to altered functional status, anticipated disease process, cosmetic/body image issues, and pain issues

  • Teaching and learning considerations

  • Patient’s own goals

Goals should be measurable and individualized for each patient, taking into consideration the patient’s status and their own goals. Timeframes will vary based on the extent of the integumentary disruption and the patient’s current status and functional level. Suggested goals may include:




  • Reduce the risk/prevent skin breakdown

  • Reduce necrotic tissue in the wound bed (i.e. debridement)

  • Promote wound granulation

  • Reduce edema in the extremities

  • Promote good circulation

  • Promote sensory awareness and good skin care habits

  • Maximize ROM of upper and lower extremities

  • Maximize strength

  • Maximize independence with functional mobility

  • Maximize patient knowledge, participation, and compliance with the prescribed program

Treatment Planning / Interventions

Established Pathway ___ Yes, see attached. _X_ No


Established Protocol ___ Yes, see attached. _X_ No

Interventions most commonly used for this case type/diagnosis.

This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Prevention of integument issues is in itself as much of an active intervention as the below noted hands-on techniques. Identifying those patients at risk based on past or current medical history and educating them on the principles of good skin care is paramount in the primary prevention of developing a wound that will ultimately require medical attention.
Once a disruption in skin integrity occurs, no matter the etiology, successful healing is largely based on the ability to relieve pressure from the affected area, ensure and/or restore adequate arterial blood flow to the area, and treat infection of the soft tissue via by debridement and/or antibiotics5.

Physical Therapy intervention is focused on the following:




  • Improve/Prevent Alteration in Skin Integrity

  • Positioning to prevent excessive/prolonged pressure

  • Mobility techniques to minimize shearing and friction on the skin

  • Prescription of air mattresses, seating cushions, and resting splints to relieve pressure. For example, Rolyan™ foot drop splints can be obtained directly in the PT department; Multi-Podus boots® can be ordered from Compass Healthcare, a local medical equipment vendor.

  • Prescription of splints/orthotics for appropriate weightbearing and pressure relief/off-loading of an involved limb. Although BWH readily stocks post-op shoes for both heel and forefoot weight bearing, the key to reducing repetitive trauma and pressure on an existing wound to allow healing is use of total contact casting (TCC)17. In some cases the use of a reinforced walking boot rendered irremovable or use of a posterior walking splint can be used instead of a full cast 17. All 3 of these devices do need to be applied by a trained and knowledgeable clinician (i.e. PT, ortho tech, physician, nurse practitioner). To date the gold standard for sustainable off-loading and treatment of diabetic neuropathic foot ulcers is total contact casting5,14,20. However, appropriate consideration needs to be given in the acute care environment prior to use of TCC given the nature of acute wounds, prevalence of infection and potential for increased edema. The wound may need to be more accessible than total contact casting allows for frequent assessment and/or treatment.

Please refer to Appendix 2 “Splints available for use on Inpatients” and Appendix 3 “Algorithm in lower extremity splinting in patients with potential for active skin issues” to assist in the decision making process when choosing an appropriate device. The main issues to consider when choosing a splint include level of functional mobility and the need for protection, pressure relief, and joint/limb immobility.





  • Edema Management

  • Exercise/AROM/PROM

  • Positioning/elevation (especially for venous stasis ulcers)

  • Compressive bandaging (i.e. TEDS, ace wrap)- for venous stasis ulcers9,17




  • Therapeutic Exercise

  • Exercise program to include supine, sitting, standing P/AA/AROM for bilateral upper and lower extremities, as appropriate

  • Progress intensity, frequency, and duration



  • Endurance Training

  • Increase out of bed tolerance

  • Progress time, distance, frequency of ambulation

  • Recommend appropriate activity schedule to patient, other healthcare providers, and family members




  • Gait Training

  • Gait training for patients with weight-bearing restrictions

  • Gait training for patients with gait abnormalities

  • Assistive device prescription, as appropriate




  • Functional Mobility Training

  • Bed mobility: rolling side-to-side, supine-to-sit, sit-to-supine

  • Transfers: bed to chair, wheelchair, commode

  • Ambulation

  • Stair training




  • Pain Management11

  • ROM

  • Positioning

  • Relaxation

  • Pain medications as prescribed by physician




  • Modalities- for mechanical debridement and direct wound care13,15,16,17,21,23

  • Whirlpool

  • Pulsed Lavage

  • Ultrasound (used for the reduction of inflammation and the promotion of the proliferative phase of healing including scar management

  • Electrical Stimulation/Iontophoresis

  • Vacuum-Assisted Closure (VAC)

  • Hyperbaric Oxygen

Of the above listed modalities, pulsed lavage is the only modality the BWH physical therapists use on a regular basis. Please refer to the Rehabilitation Department’s procedure for full details on performing pulsed lavage on inpatients. This modality replaces its hydrotherapy predecessor, the whirlpool, as it has shown itself to be a more beneficial, efficient, and cost effective form of hydrotherapy intervention in the acute care setting16. Although ultrasound13,22,23 and electrical stimulation13,15,22 may have demonstrated some laboratory results, further clinical evidence and well-controlled studies specifically addressing efficacy in the acute care population may be needed for selected use of these modalities. It is possible that these modalities may be more beneficial in the later stages of healing and thus not often selected at BWH given our primary goals of eliminating infection and promoting a clean wound bed via debridement. VAC is widely used at BWH as a reliable form of adjuvant therapy but is under the direct responsibility of the physicians. Hyperbaric oxygen may also be effective for the healing of certain wounds but overall is a very costly modality and not widely used given the lack of availability or accessibility to the hyperbaric chamber.13


There are wound management interventions that our physical therapy department is not directly involved in but are performed in the acute care setting by other team members (i.e. physicians and nurses). These include appropriate dressings, autolytic debridement, sharps or surgical debridement, and use of the VAC. Other than iontophoresis, any other type of medicated wound care is done by a nurse or a physician. For specific wound care products and dressings used at BWH for pressure sores please refer to the Nursing Care Practice Manual.3 For a more general guide to topical antiseptics, antifungals, and antibiotics as well as a reference guide to wound care product categories please refer to Appendix A and B in Sussman and Bates-Jensen’s book entitled Wound Care.22

Patient / Family Education




  • Instruct patient/family/caregiver in following:

  • Pressure relief and appropriate positioning

  • Appropriate skin care and frequent skin checks

  • Smoking cessation

  • Independent therapeutic exercise, ROM, and endurance programs

  • Safe mobility techniques (including precautions), activity progression, encouraging maximal independence

  • Discuss realistic expectations regarding wound healing, functional level, appropriate level of assist required by patient, anticipated rehabilitation progression

Frequency & Duration


Patients will have follow-up physical therapy treatments based on individual need. The frequency of treatment for each patient will be determined by the acuity of his/her impairments, functional limitations and the intervention chosen. Please refer to the BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting4 as well as the Pulsed Lavage Procedural Guidelines for further direction, taking into consideration that frequency and duration will be dependent upon the chosen intervention and goal(s) of intervention.

A patient may benefit from intervention from the following services or clinician:



  • Occupational Therapy

  • Nutritionist

  • Ostomy Nurse

  • Care Coordination

  • Social Work



Re-evaluation

Re-evaluations are to be performed under the following circumstances: all physical therapy goals are met, a significant change in medical status occurs, the patient is discharged from services or the facility, and/or the patient fails to respond to physical therapy intervention. A re-evaluation should be performed at least once every ten days. Ongoing wound assessment will determine the necessity of pulsed lavage intervention but please refer to the Pulsed Lavage Procedural Guideline for tips on when the discontinuation of the above modality may be warranted.



Discharge Planning

Discharge planning occurs on an individual basis, depending on the patient’s medical, physical, and social needs. Discharge planning is a coordinated effort that occurs with the physician, nurse practitioner, nursing staff, care coordinator, physical and occupational therapists, and the patient and his/her family.


If the patient continues to have significant impairments and functional limitations and/or ongoing medical or wound care needs at the time of discharge from the acute care facility, the patient may be discharged to an extended care facility (i.e. an acute or sub-acute rehabilitation facility or skilled nursing facility). The patient will continue to progress towards the physical therapy goals at this inpatient facility, as appropriate.
If the patient has met all inpatient physical therapy goals and the wound care needs can be managed in a home setting, the patient may then be discharged home with or without services. Consider the following resources for continued wound care management, therapy and/or services:


  • Visiting Nurse Association (VNA) to include home nursing and home PT

  • Outpatient PT


Authors: Merideth Donlan, PT 2/06 Reviewed by: Lina Penikas, PT


Ethan Jerome, PT


Updated: Merideth Donlan, PT 7/09 Reviewed by: Melanie Parker, PT


Barbara Odaka, PT
REFERENCES

1. American Physical Therapy Association. Guide to Physical Therapist Practice, 2nd Edition. 2001. 595-681.

2. APTA’s Section on Clinical Electrophysiology and Wound Management Guide for Integumentary/Wound Management Content in Professional Physical Therapist Education
3. BWH Nursing Care Practice Manual
4. BWH Guidelines for Frequency of Physical Therapy Patient Care in the Acute Care Hospital Setting: Integumentary Practice Pattern.
5. Boulton, AJ. Pressure and the diabetic foot: clinical science and off loading techniques.

Am J Surg. 2004 May;187(5A):17S-24S.
6. Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, Lavery LA, LeMaster JW, Mills JL Sr, Mueller MJ, Sheehan P, Wukich DK. Comprehensive foot examination and risk assessment. A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Phys Ther. 2008 Nov;88(11):1436-43.
7. Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: an update on this easy-to-use tool that assesses a patient's risk. Am J Nurs. 2005 Jun;105(6):70-2.
8. Brem H, Lyder C. Protocol for the successful treatment of pressure ulcers. Am J Surg. 2004 Jul;188(1A Suppl):9-17
9. Brem H, Kirsner R, Falanga. Protocol for the successful treatment of venous ulcers. Am J Surg. 2004 Jul;188(1A Suppl):1-8.
10. Brown SJ. The Braden Scale. A review of the research evidence. Orthop Nurs. 2004 Jan-Feb;23(1):30-8.

11. Coulling, S. Fundamentals of Pain management in Wound Care. Br J Nurs. 2007 Jun 14-27;16(11):S4-6, S8, S10


12. Defloor T, Grypdonck M. Pressure ulcers: validation of two risk assessment scales.
J Clin Nurs. 2005 Mar;14(3):373-82.
13. Hess CL, Howard MA, Attinger CE. A review of mechanical adjuncts in wound healing: hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen, and electrostimulation.
Ann Plast Surg. 2003 August; 51(2):210-8.

14. Katz IA, Harlan A, Miranda-Palma B, Prieto-Sanchez L, Armstrong DG, Bowker JH, Mizel MS, Boulton AJ. A randomized Trial of Two Irremovable Off-Loading Devices in the Management of Plantar Neuropathic Diabetic Foot Ulcers. Diabetes Care. 2005 Mar; 28(3): 555-9.


15. Kloth LC, McCulloch JM. Promotion of wound healing with electrical stimulation.
Adv Wound Care. 1996 Sep-Oct; 9(5):42-5.
16. Leudtke-Hoffman, KA, Schafer, DS. Pulsed lavage in wound cleansing. Physical Therapy. 2000 March; 80(3):292-300.
17. McCulloch J. The Integumentary system- repair and management: an overview. PT Magazine. 2004 February; 12(2): 52-72.
18. Mechanick J. Practical aspects of nutritional support for wound-healing patients.
Am J Surg. 2004 Jul;188(1A Suppl):52-6.
19. Paz JC, West MP. Acute Care Handbook for Physical Therapists 2nd Ed. Boston, MA. Butterworth Heinemann. 2002
20. Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA, Leporati E, Scire V, Teobaldi I, Del Prato S. An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers. Diabetes Care. 2007 Mar;30(3):586-90.
21. Schoonhoven L, Haalboom JR, Bousema MT, Algra A, Grobbee DE, Grypdonck MH,

Buskens E. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ. 2002 Oct 12;325(7368):797.


22. Sussman C and Bates-Jensen BM, editors. Wound Care: A collaborative Practice Manual for Physical Therapists and Nurses, 2nd edition. Aspen Publishers, Inc. 2001.
23. ter Reit G, Kesseks AG, Knipschild P. A randomized clinical trial of ultrasound in the treatment of pressure ulcers. Physical Therapy 1996 Dec;76(12):1301-11.

Appendix 1: WOUND ASSESSMENT
Maceration: Yes No Shape:____________________ Size (cm): length ________ width _______ depth _______

Clinical Parameter

Slight

Mild

Moderate

Moderate/Severe

Severe

Depth (cm)

Edges


Undermining


Type of Necrotic Tissue


Extent Necrotic Tissue
Exudate Type

Exudate Amount
Surrounding Skin Color

Peripheral Tissue Edema


Extent Granulation Tissue


Epithelialization



intact skin

none clearly visible



<2cm

none

none
none or bloody

none
pink/normal

minimal firmness

around wound

skin intact or

partial thickness

100% wound

covered


partial thickness skin loss

outline visible, attached,

even with wound base

2-4cm involving



<50% of wound

white/gray

or yellow slough

<25% wound bed
serosanguinous, thin,

watery, pale, red/pink


scant
bright red or blanches to touch

non-pitting edema extends



<4cm around wound

bright beefy red, 75-100% of wound filled &/or tissue overgrowth


75-100% covered &/or epithelial extends >.5cm into wound bed

full thickness (or mix of partial and full) skin loss, not through underlying fascia
well defined, not

attached to wound base

2-4cm involving

>50% of wound

loosely adherent

yellow slough

25-50% wound bed
serous, thin, watery, clear

small
white or gray, pallor

or hypo-pigmented
non-pitting edema extends >4cm around wound

bright beefy red, <75%

and >25% wound filled

50-75% covered epithelial tissue extends <.5cm

into woundbed


obscured by necrosis

as previously, edges

rolled under thickened

>4cm any area


adherent soft black eschar


51-74% wound bed


purulent, thin or thick,

opaque, tan/yellow


moderate
dark red or purple

and/or non-blanchable


pitting edema extends

<4cm around wound

pink &/or dull, dusky red

&/or fills <25% of wound

25% to less than

50% wound covered


full thickness skin loss with extensive destruction/damage to muscle/bone
well defined, fibrotic, scarred, hyperkeratotic

tunneling &/or sinus track formation

firmly adherent hard black eschar

75-100% wound bed


purulent, thick, opaque,

yellow/green with odor


large
black or hyper-pigmented

crepitus &/or edema extends

>4cm around wound

no granulation tissue present




<25% wound covered



Appendix 2: Splints available for use on inpatients:

The main 4 main goals of splinting include maintaining a specific level of functional mobility and the need for protection, pressure relief, and joint/limb immobility. Each of the below noted splints used at BWH focuses on 1 or more of these goals.





  1. Is the splint used in bed only?



  • Rolyan™ foot drop splint


-Indications: Pressure relief and positioning; used to prevent foot drop in the sedated and/or weak patient by keeping the foot in a neutral position

-Pros: stocked in the PT department, comes in 2 widths: regular and extra wide to accommodate for a large extremity, significant edema, extensive dressings, etc; blue padding can be cut or modified, prevents internal/external rotation of the LE

-Also comes as an adjustable foot drop splint to accommodate patients who cannot get into neutral right away whether from a plantarflexion contracture or have ROM precautions (i.e. no dorsiflexion) following a surgical procedure

-Cons: splint is bulky, difficult to use in sidelying, cannot be used for standing or ambulation, difficult to use in patients with hypertonicity and/or spasms

-How to Obtain: order in computer under “Ortho Tech” if just need splint;

can also go under PT order if active PT is needed




  • Foot Drop Positioner (Foam)

-Indications: Pressure relief; used in supine to prevent pressure on heel and/or calf as well as prevention of foot drop

-Pros: soft and easy to don/doff; can modify/cut to avoid pressure on specific areas of the LE, latex-free

-Cons: not effective in use of patients with hypertonicity

-How to Obtain: floor can call the Service Center to obtain




  • Tib-Fib Splint

-Indications: Pressure relief; used in supine only to prevent foot drop

-Pros: edges can be modified with a cast saw

-Cons: runs narrow so not good for a larger or edematous LE, not as much padding as the Rolyan or a multi-podus, does not prevent internal/external rotation of the LE

-How to Obtain: order in computer for Ortho Tech




  • Multi-podus Boots®

-Indications: Pressure relief, Protection, Activity; also used for foot drop as well as limb protection due to its sheepskin padding; often used with vascular patients or for those patients who need additional padding (i.e. patients with heel decubitus ulcer)

-Can be used in supine, for transfers or ambulation short distances (i.e. to bathroom) but it is generally not an ambulatory splint unless the ambulation version of the foot plate is ordered (foot plate is firmly attached in place in this version)

-How to Obtain: Not stocked at BWH; ordered from local vendor- Compass Healthcare (617-566-6772); floor calls to order; need to know approximate shoe size

  1. Is your patient ambulatory (with or without weightbearing precautions)?





  • Post-op Shoe (flat)

-Indications: Protection, Activity; often used in patients with ulcers or who have undergone vascular surgery and/or toe amputation and need protective footwear to ambulate; promotes heel weightbearing

-How to Obtain: Ortho tech or PT order in computer; generally also need to know a patient’s weightbearing status




  • Heel Weightbearing Boot (post-op shoe with significant heel lift)

-Indications: Protection, Activity; as above with post-op shoe but strongly promotes heel weightbearing during ambulation

-Precautions: given the height of the heel lift, need to assess a patient’s balance as this can causes a discrepancy in leg length affecting pt’s balance and gait

-How to Obtain: as above with Post-op shoe


  • Forefoot Weightbearing Boot

-Indications: Protection, Activity; as above with post-op shoe but promotes forefoot weightbearing

-How to Obtain: as above with post-op shoe




  • Aircast Walking Boot

-Indications: Immobility, Activity; used to immobilize ankle in neutral while allowing weightbearing, generally used in orthopedic injuries, can also be used for positioning

-Pros: comes in 2 lengths: short (mid-calf), and long( just below the knee), can adjust the air cushions inside the splint for more/less contact

-Precautions: Skin issues/pressure sores due to total contact

-How to Obtain: ortho tech order in computer




  • Pre-fab Ankle Foot Orthotic (AFO)

-Indications: Activity; Used to assist/support the foot for ambulation; generally used for a patient with foot drop (from nerve damage, stroke, etc) or LE weakness

-Pros: stocked in the PT department, can begin gait training inhouse if patient has the appropriate footwear to use with this orthotic

-Cons: These are minimal resistance AFOs (trimline posterior to the malleoli) and do not usually provide sufficient inversion/eversion control if this is lacking. If hypertonia is present this may not provide sufficient support in maintaining neutral position. If inadequate knee control is present they may not prevent knee buckling

-Precautions: should do frequent skin checks in patient with existing skin integrity issues or with impaired sensation.

-How to Obtain: PT Consult- BWH stocks pre-fabricated ankle foot orthotics. If the in stock version does not accommodate the patient, first consult the orthotist for an upgraded version of the pre-fab splint. If significant issues are present and the patient is not be able to be properly fit with a pre-fab or an upgraded version of the pre-fab then a custom fit may be required by the outside orthotist. This requires casting of the LE to make a custom molding of a splint.


  • Total Contact Casting (TCC)

-Indications: Immobility, Pressure Relief; use for pressure relief and/or sustained off-loading of an involved limb (especially in the treatment of diabetic neuropathic foot ulcers)

-Pros: gold standard for the treatment of diabetic neuropathic foot ulcers to allow for healing; can ambulate with this cast if a cast boot is applied over the cast itself

-Cons: limited access to the wound since it should stay in place 5-7 days for maximal effect

-How to Obtain: must be applied in conjunction with ortho tech or MD as a cast is placed on the patient




  • Bivalve Cast

-Indications: Immobility, Pressure Relief; as above with total contact casting except that the cast can be removed for dressing changes, etc; the posterior portion of the cast can also be used as a resting splint in supine

-How to Obtain: Ortho tech order to place bivalve cast

Created 6/09
Appendix 3: Algorithm for Lower Extremity splinting in patients with the potential for or with active skin issues


Is the pt bedbound

or non-ambulatory?


Yes No



Does the pt need protective footwear?






Does the pt transfer

bed to chair only? Yes No




Consider: Consider:

Yes No Post-op Shoe Aircast Walking Splint

Heel Weightbearing Shoe Pre-fab afo

Forefoot Weightbearing Shoe Total Contact Cast

Multi-podus w/ ambulatory plate Bivalve Cast

Consider: Consider:

Multi-podus boot Rolyan Foot Drop Splint

with removable Foam Foot Drop Positioner Does the pt need to be immobilized

foot plate Tib Fib Splint or have restrictions on ROM?



Do specific areas of the

limb need pressure relief

Does the Splint need to be adjustable? No Yes or sustained offloading?



Yes Consider: Consider:

Pre-fab afo if foot drop is present Aircast Walking Boot Yes

Consider: Adjustable Rolyan for plantarflexion contactures Total Contact Casting (TCC)

Foam Foot Drop positioner can be cut to relieve pressure Bivalve Cast Consider:

Tib Fib splint can be cut with cast saw (Of note: place cast boot over TCC

casts for ambulation) Bivalve Cast


Of Note: Consider these potential weightbearing orders: FWB/WBAT, PWB, NWB, heel weightbearing, forefoot weightbearing



Standard of Care: ___Wound Care________________

Copyright © 2009 The Brigham and Women's Hospital, Inc., Department of Rehabilitation Services. All rights reserved






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