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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.