i bc27f85be50b71b1 (142 page)

Nystatin

Cream or powder mixed to solution and

A ::: Effective fungicide against Candida, painless

applied with a dressing

D ::: Frequent reapplication, no eschar penetration

Used on superficial, partial- or full-thickness

burns

Collagenase

Enzyme derived from Clostridium histolyticwn

A:;::: Penerrates eschar, does nor affect healthy

Digests collagen in necrotic tissue

tissue

Applied as an ointment with a dressing over it

D::: Painful, no antimicrobial properties

Used on deep partial- and full-thickness burns

Sources: Data from ET Kaye, KM Kaye. Topical antibacterial agents. Infect Dis Clin North Am 1995;9:547-559; JO Kucan, EC Smoot. Five percent mafenide acetate solution in the treatmem of thermal injuries. J Burn Care Rehabil 1993;14: 158-163; RS Ward, JR Saffle. Topical agents in burn and wound care. Phys Ther 1995j75:526-538; and HS Soroff, DH Sasvary. Collagenase oinonent and polymyxin B sulfare!bacitracin versus silver sulfadiazine cream in partial thickness burns: a pilot srudy. J Burn Care Rehabil 1994; 15: 13-17.

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462

ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• Is there an inhalation injury or CO poisoning?

•

\Vhat are the secondary injuries?

• What is the extent, depth, and location of the burn?

• Does the patient have a condition(s) that might impait tissue

healing?

• Was the burn self-inflicted? If so, is there a history of self-injury

or suicide?

• Were friends or family members also injured?

Inspection alld Palpatioll

To assist with treatment planning, pertinent dara that can be gathered from the direct observation of a patient or palpation include the following:

• Level of consciousness

•

Presence of agitation, pain, and srress

•

Location of the burn or graft, including the proximity of the

burn to a joint

•

Presence and location of dressings, splints, or pressure garments

•

Presence of lines, tubes, or other equipment

•

Presence and location of edema

•

Posture

•

Position of head, trunk, and extremities

• Heart rate and blood pressure, respiratory rate and partern, and

oxygen sarurarion

Clinical Tip

• Avoid popping any blisters on the skin during palpation

or with manual contacts.

•

Do not place a blood pressure cuff over a burn or graft

sire or area of edema.

BURNS AND WOUNDS

463

Pain Assessment

Good pain control increases patient participation and activity tolerance; therefore, pain assessment occurs daily. For the conscious patient, the physical therapist should nOte the presence, quality,

and grade of (I) resting pain; (2) pain with passive, activeassisted, or active ROM; (3) pain at the burn site versus the donor site; and (4) pain before, during, and after physical therapy intervention.

Clinical Tip

• The physical therapist should become familiar with the

patient's pain medication schedule and arrange for physical therapy treatment when pain medication is most effective and when the patient is as comfortable as possible.

• Restlessness and vital sign monitoring (i.e., heart rate,

blood pressure, and respiratory rate increases) may be the

best indicators of pain in sedated or unconscious patients

who cannot verbally report pain.

Rfl1lge of Motio1l

ROM of the involved joints typically requires goniometric measurements. Exact goniometric values can be difficult to measure when the patient has bulky dressings; therefore, some estimation of ROM may

be necessary. The uninvolved joints or extremities can be grossly

addressed actively or passively, depending on the patient's level of

alertness or level of participation.

Clinical Tip

• The physical therapist should be aware of the presence

of tendon damage before ROM assessment. ROM should

not be performed on joints with exposed tendons.

• The physical therapist should always have a good view

of the extremity during ROM exercise to observe for

banding or areas of tissue that appear white when

stretched.

464

AClffE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• The physical therapist should pay attention to the position of adjacent joints when measuring ROM to account for any length-tension deficits of healing skin or muscle.

• The physical therapist should appreciate the fact that a

major burn injury is usually characterized by burns of different depths and types. The physical therapist must be aware of the various qualities of combination burns when

performing ROM or functional activities.

• ROM may be decreased by the presence of bulky dressings. Try to evaluate or perform ROM when the dressings

are temporarily off or down.

Strength

Strength on an uninvolved extremity is usually assessed grossly by

function. More formal strength testing, such as resisted isometrics or

manual muscle testing, is indicated on either the involved or uninvolved side if there is severe edema, electrical injury, or secondary injury.30

Ftmctional Mobility

Functional mobility may be limited depending on state of illness,

medication, need for warm or sterile environment, and pain. The

physical therapist should evaluate functional mobility, as much as

possible, according to medical stability and precautions.

Clinical Tip