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The skin at grafted areas, as well as at donor site areas, is
more fragile than normal skin. These areas should be ace
wrapped figure-of-eight style to provide support against
venous pooling when the patient is being mobilized Ollt of
bed. Without this extra support, the skin is more prone to
shearing at graft sites and subcutaneous bleeding.
BURNS AND WOUNDS
465
Physical Therapy Intervention
Goals
The primary goal of physical therapy intervention for patients with
burn injuries is to maximize function with ROM exercise, stretching,
positioning, strengthening, and functional activity. General considerations for physical therapy intervention by impairment are listed in Table 7-9.
Basic COllcepts for the Treat",ellt of Patie"ts with Btlnt Injtlry
• The patienr with a burn can have multisystem organ involvement and a hypermetabolic state; thus, the physical thetapist needs to be aware of cardiac, respirarory, and neurologic status, as well
as musculoskeletal and integumentary issues.
•
Fluid resuscitation and pain medications can affect blood pressure, heart rate, and respiratory pattern and rate, as well as level of alertness. MonitOring these variables will help the therapist gauge
pain level and determine how aggressively to intervene during the
therapy session.
• The parienr with a burn requires more frequent re-evaluations
than other patient populations, because the patienr's starus and
therapy intervention can change dramatically as swelling decreases,
wound debridement and closure occur, hemodynamic and respiratory stabiliry are achieved, and mental status improves. The goals and plan of care need to be updated throughout the patient'S
admission, as activity may be temporarily restricted after surgical
grafting.
• A porrio,1(s) of the plan of care is often held for 4-7 days after
skin grafting to prevent shearing forces on the new graft. Shearing
can disrupt the circulation to the graft and cause it to fail. Grafts
over joints or areas with bony prominences, as well as grafts on the
posterior surfaces of the body, are at greater risk for shear injury.
• Time frames for physical therapy goals vary widely and are
based heavily on TBSA, the location of the burn, age, and preexisting functional starus.
466
AClffE CARE HANDBOOK FOR PHYSICAL THERAJ'ISTS
Table 7-9. Physical Therapy Considerations for Burn Injury
Variable
Considerations
Decreased ROM
Mosr patients have full ROM on admission bur may
and alrered limb
readily begin to exhibit decreased ROM due [0 edema,
position
pain, and immobilization.
ROM of uninvolved joints may also be decreased
secondary to the process of rota I body edema.
Devices rhar can help to properly position rhe patient
include splints, abduction pillows, arm boards
attached to the bcd, pillows, and blanket rolls.
Incorporate the use of a modality (i.e., pulley) in[O
stretching activities.
Decreased
Active exercise is preferred unless sedation or rhe
strength
patient's level of consciousness prevents it.
Active exercise (i.e., proprioceptive neuromuscular
facilitation) provides muscle conditioning, increased
blood flow, edema reduction, and contraction
prevention and helps reduce hyperrrophic scar
formation.
Decreased
Prolonged bed rest (sec Appendix I-B) may be necessar)'
endurance and
for weeks or months secondary to medical status or to
funcrional
accommodate grafting, especially of the lower extremity.
mobiliry
The use of a tilt table for progressive mobilization from
bed rest rna)' be necessary if orthostatic hypotension or
decreased lower-extremity ROM exists.
Assistive devices may need adaptations (i.e., platform
walker) CO accommodate for ROM and strength
deficits or weight-bearing restrictions.
Consider the use of active exercise (i.e., resroraror) thar
addresses cardiovascular conditioning while increasing
ROM and strength.
Risk for scar
Healing of deeper burns and skin-grafted burns is
development
accompanied by some scarring.
H)'perrrophic scarring can be decreased by the use of
pressure garments, silicone gel sheets, ROM, and
massage.
Patienrlfamily
Parienrlfamily educarion emphasizes information about
knowledge
the role of physical therapy, exercise, positioning, pain
deficit related to
and edema control, and skin care.
burns and
Education before discharge is of the utmost importance to
physical therapy
improve compliance, confidence, and independence.
ROlvl
range of
=
mOl ion.