| from the french language meaning “to skim.” This is a slow, stroking movement performed with increasing pressure in the direction of flow in the veins and lymph vessels (centripetal - toward the heart).
Performed with the entire palmar surface of one or both hands or thumb pads or fingers, working either alternately or simulataneously. The hands should mold to the body part being treated and the stroke should be smooth and rhythmic. | Effleurage |
| How should you move during effleurage? | Move from distal to proximal, always maintaining contact with the body with at least one hand. |
| What should the speed and pressure be during effleurage? | speed is slow – roughly 7 inches per second. Pressure should be significant. |
| from the french language meaning “to knead.” Muscles and subcutaneous tissues are compressed and then released. The speed is relatively slow but the pressure is significant. The movement takes place in a circular motion. | petrissage |
| from the french language meaning “to tap.” Characterized by various parts of the hands striking the tissues at a fairly rapid rate. The hands work alternately and the wrists must be kept flexible so that the movements are light, springy, and stimulating. | tapotement |
| purpose of tapotement: | to stimulate the tissues. |
| What is the peak activity for quads during gait? | Single support during early stance phase and just before toe off to initiate swing phase |
| What is the peak activity of hamstrings during gait? | During swing phase |
| Causes for abnormal gait patterns? | - Muscle weakness/paralysis
- joint motion (ROM) limitations
- neurological involvement
- pain
- leg-length discrepancy
- bony changes or abnormalities
- fear |
| Protective pattern to avoid weight bearing, usually due to pain.
- step length on involved side is shortened and more rapid
- shortened, often abducted stance phase
- reciprocal arm swing often decreased during stance phase on painful LE
- if painful area is the hip, person will oftentimes lean over that painful hip during stance phase on LE | Antalgic gait |
| Pattern characterized by staggering and unsteadiness; May be due to cerebellar involvement.
- decreased coordination of movements in extremities
- wider (abducted) base of support
- jerky, exaggerated movements, including reciprocal arm swing movements
- appears to have difficulty walking in a straight line - appears to stagger | Ataxic gait |
| Staggering pattern seen in cerebellar disease/injury | Cerebellar gait |
| Involved LE abducts and swings out during swing phase | Circumduction gait |
| Involved LE is 3-5 inches shorter than the other LE
- high stepping pattern which usually involves excessive PF
- person appears to be walking on the ball of their foot in order to create some length in this shortened LE
- no heel strike or foot flat | Equine or equinus gait |
| Seen in pts with Parkinson’s; diminished movement overall.
- elbows, trunk, and LEs are partially flexed
- little reciprocal arm swing
- stride length is greatly diminished and the swing foot doesn’t step beyond the stance foot
- may be up on toes and pt appears as though they are being pushed forward; narrow base of support, begins slower, then picks up speed which is difficult to control; short shuffling steps | festinating or Parkinsonian gait |
| This will vary depending on severity of neurological involvement and the presence/amount of spasticity.
- person usually presents with an extensor synergy in LE
- typically presents with a flexor synergy in UE
- decreased arm swing on affected side
- abducts affected limb to advance it, swing it around and forward so foot comes to the ground in front of them; longer step length on involved side | Hemiplegic gait |
| Spasticity in hip adductors
- legs cross midline upon advancement so more pronounced during swing phase
- narrowed base of walking support
- trunk May lean over stance leg as swing phase leg swings past it | Scissor gait |
| Seen in someone with cerebral palsy
- stiff movement of perhaps all 4 extremities; toes seem to catch and drag, hips more adducted and medically rotated, hips and knees slightly flexed, ankles are plantarflexed
- pelvis maintains an anterior pelvic tilt and there’s an increased lumbar lordosis
- reciprocal arm swing exaggerated and arms may actually be horizontal during ambulation | Spastic or crouch gait |
| Also called slap foot, tabes dorsalis, or drop foot; problem is weak dorsiflexors
- exaggerated hip and knee flexion.
- foot slaps at initial contact with the ground secondary to decreased control | Steppage gait |
| Gluteus medius gait; gluteus medius weakness
- Pt will laterally flex trunk and shift weight over stance leg | Trendelenburg gait |
| When one leg is longer than the other or the knee is fused
- Swing leg advances by compensating through the combination of elevating the pelvis and plantarflexing the stance leg when swinging through with the longer it fused knee leg | Vaulting gait |
| Weak hip extensors
- trunk quickly shifts posteriorly at heel strike; sometimes called a ‘rocking horse gait’ | Gluteus Maximus gait |
| Weak knee extensors
- During stance phase, May bring trunk forward of knee creating extreme knee hyperextension | Weak quads gait |
| Sometimes called genu recurvatum gait
- excessive knee hyperextension during stance phase
- knee may snap forward during swing phase because hamstrings can’t control forward movement | Weak hamstring gait |
| - No push off
- shortened step length on noninvolved side | Weak plantarflexor gait |
| ‘Salutation greeting’
- involved hip can’t go into neutral extension let alone actually extend
- trunk and knee is flexed during stance phase on contracture side | Hip flexion contracture gait |
| - Excessive dorsiflexion during stance phase
- early heel rise during push off
- shortened step length on uninvolved side | Knee contracture gait |
| - Usually see a shortened stride length - person appears to pick foot up as a unit
- more trouble with stairs or uneven ground than flat surfaces | Ankle fusion gait |
| Wound in which healing has been delayed or halted altogether for a variety of factors | Chronic wound |
| Types of wounds: | - Abrasion
- puncture
- laceration
- burn
- incision
- ulceration |
| Caused by scraping or friction to the skin’s surface | Abrasion |
| Caused by a sharp, pointed object entering the skin | Puncture |
| Irregular tear of the skin | Laceration |
| A thermal injury caused by various agents | Burn |
| Cut made by a knife or laser, usually for surgical purposes | Incision |
| An infected or non-healing lesion on the skin | Ulceration |
| Phases of wound healing: | - Inflammation
- proliferation
- maturation/remodeling |
| Both a vascular and cellular response to injury. Bleeding is controlled; the body combats infectious agents; lasts a few days. Transudate appears - clear, watery liquid. Blood vessels initially constrict to prevent blood loss but after 30 minutes, vasodilator, being in repair cells and chemicals. Erythema, edema, heat and pain. Normally lasts 4-6 days. | Inflammation phase of wound healing |
| Angiogenesis (formation of new blood vessels), granulation tissue formation, wound contraction, epithelialization. Fibroblasts produce collagen, which is responsible for the scar. Normally last 4-24 days. | Proliferation phase of wound healing |
| matrix laid down during the proliferation phase must be strengthened and reorganized to fit the surrounding tissue. The rosy, pink scar is transformed to a white scar. The scar is only about 80% as strong as the original tissue in that area was prior to injury normally lasts 21 days - 2 years. The healed scar will remain an area of higher risk for breakdown. | Maturation/remodeling phase |
| Wound phase summary: | Stop bleeding—> remove debris —> fill and cover —> scar |
| Wound characteristics that affect wound healing: | - Mechanism of onset
- time since onset
- wound location
- wound dimensions
- wound temp
- wound hydration
- necrotic tissue or present of foreign bodies
- infection
- changes in chronic wounds |
| What areas do wounds heal more slowly? | - Areas over bony prominences
- areas where skin is thicker |
| How do dimensions affect healing of wounds ? | - Circular wounds heal more slowly than square/rectangular wounds
- Square and rectangular wounds heal more slowly than linear wounds
- superficial wounds heal faster than deeper wounds |
| At what temp do wounds heal best? | 37-38 degrees C
or
98.6-100.4 degrees F |
| What type of environment is best for wound healing? | Moist environment |
| Microorganisms invade the tissues and multiply, these cause problems when they reach critical concentration levels | Infection |
| do cells in a chronic or acute wound have a slower rate of metabolism? | Chronic wounds |
| Local factors that affect wound healing: | - Circulation
- sensation
- mechanical stress |
| Inadequate blood flow increases the risk of infection | Circulation factor of wound healing |
| A deficit in sensation results in failure to recognize and relieve pressure, irritation or overt trauma. There is no warning signal or pending tissue damage. This can lead to initial damage or continued trauma. | Sensation factor of wound healing |
| Pressure, shear and friction are extrinsic factors that have been linked to initiating and perpetuating ulcers. | Mechanical stress factor of wound healing |
| Systemic factors that affect wound healing: | - Age
- inadequate nutrition
- comorbidities
- medications
- Behavioral risk taking |
| Inappropriate wound management: | - Pts may try home remedies that delay healing or worsens the wound
- pts may simply have been given limited or incorrect medical advice
- Pt may not understand the importance of an aspect of care
- pt may have limited financial or support services
- letting wound dry out and be exposed to room air and contaminants
- antiseptics are toxic to healing cells
- whirlpool for the treatment of open wounds has decreased dramatically - whirlpool promotes edema, increases risk of infection, and disturbs granulation tissue |
| What does TIME stand for? | T - tissue
I - inflammation/infection
M - moisture balance
E - epithelial edge |
| TIME wound bed summary: | Make sure all necrotic tissue removed from wound —> know that inflammation is normal and necessary —> infection is not normal and should be investigated/addressed asap —> wet a dry wound and dry a wet wound —> ensure that the edges of the wound are free so that the epithelial cheeks will migrate across the wound |
| - pts complain of pain, cramping, burning, aching, worse with elevation.
- wounds appear more regular, may be due to trauma, granulation tissue will be pale if present, perhaps black eschar, perhaps gangrene, little drainage.
- surrounding skin will be thin and shiny, absent hair growth, thickened and yellow nails, pale, dusky or cyanotic skin
- decreased or absent pedal pulses
- cooler to touch
- keys to healing ulcers: moisturize dry skin, avoid adhesives, reduce friction on skin, pad ischemic tissues, keep wound bed moist, debride necrotic tissue when present, avoid compression, choose footwear carefully, pt education | Arterial insufficiency ulcers |
| - less pain than in arterial; improved with elevation
- wound: more irregular shape, red wound bed, fibrous yellow or glossy coating over wound bed, copious drainage
- surrounding tissues: edema, cellulitis, dermatitis, darkened skin areas, feel normal or warm to touch
- keys to wound care: moisturize dry skin, choose absorptive dressings, use skin sealants, apply compression of appropriate, pt education | Venous insufficiency ulcers |
| - tender or painful if sensory nerves are intact
- occurs over bony prominences
- wound appearance: deeper ulcers covered with black eschar; may have exposure of tendons, bone, etc; tunneling/undermining common; may drain profusely
- surround tissues: wound surrounded by a ring of erythema, non-blanchable erythema, warm to touch
- keys to healing: moisturize skin, avoid excessive moisture, keep wound moist, debride if necessary, control infection, minimize shear and pressure forces, proper nutrition, pt education | Pressure ulcers |
| Stage 1 of pressure ulcers: | Skin still intact but presents with a non-blanchable redness over a bony prominence. Warning sign - this pt is at risk |
| Stage 2 of pressure ulcers: | Partial thickness skin loss - presents as a shallow open ulcer with a red or pink wound bed, no slough |
| Stage 3 of pressure ulcers: | Full thickness skin loss - may see sub-q fat but will not see bone, tendon, or muscle. May include undermining or tunneling. |
| Stage 4 for pressure ulcers | Full thickness skin loss with exposed bone, tendon, or muscle |
| Unstageable pressure ulcers | Full thickness skin or tissue loss but depth of wound is unknown |
| - little or no pain
- plantar aspect of foot
- wound appearance: round, punched out lesion, surrounded by a callus rim, little or no drainage, little necrosis
- around the wound: dry, cracked, callus
- normal pulses
- Normal or increased temp | Neuropathic ulcers |
| What is important about position when measuring wounds? | Maintain consistency in pt position as position can appear to alter the size of a wound |
| How do you document wound location? | Using anatomically correct terminology. (Right or left, over a bony prominence, anterior vs posterior, lateral vs medial) if more than one wound use ‘wound a’ and ‘wound b’ |
| How is wound size determined? | By direct measurement, tracings, photography, or percent of total body area. |
| A narrow passage way or a large wound with small opening. Measure by inserting a probe until meeting resistance and measure undermining by inserting a swab into the wound parallel to the skin until resistance is met. | Tunneling/undermining |
| Wound edge rolls and curls under itself back toward the periphery of the wound. This means the epithelial tissue is migrating down the sides of the wound instead of across. | Epibole |
| A temporary framework of vascularized tissue that fills the wound void. Typically looks like a raspberry, red, and bumpy. | Granulation tissue |
| Yellow or tan in color and has a stringy or mucous like consistency | Slough |
| Black, necrotic tissue that may either be soft or hard. | Eschar |
| The appearance of tissue at the perimeter of the wound. Note distinctness, thickness, color, attachment to base of wound. | Wound edges |
| Clear to yellow and watery drainage | Serous |
| Red to brown drainage | Sanguinous |
| White to pale yellow and has a creamy appearance drainage | Purulent |
| What does colored drainage indicate? | Possible infection |
| What are the 2 consistencies of drainage and what do they mean? | - thin or watery - normal
- thick - possible infection |
| What are the amounts of drainage? | - None
- minimal
- moderate
- copious |
| what is the structure and quality of a periwound? | - Scaling, rough, or cracked skin
- waxy appearance
- thin, fragile, transparent, macerated
- calluses, scar formation |
| Characteristics to make note of with a periwound: | - structure and quality
- color
- condition of hair and nails on body part
- edema
- temp
- circulation
- sensory integrity |
| The removal of necrotic tissue, foreign material and debris from wound. Decreases the risk for infection and promotes healing. Do not do when vascular status is in question. | Debridement |
| Purposes of debridement: | - Decrease concentration of pathogens
- increase effectiveness of topical antimicrobials
- eliminate any physical barrier to healing
- decrease wound odor |
| methods of debridement: | - sharp
- autolytic
- enzymatic/chemical
- mechanical
- sterile maggots
- surgical |
| use of forceps, scissors, scalpel to debride | sharp debridement |
| allowing the body to heal itself during debridement | autolytic debridement |
| use of exogenous enzyme agents to remove necrotic tissue to debride | enzymatic/chemical debridement |
| use of force (whirlpool or scrubbing) to debride | mechanical debridement |
| scalpels, scissors, lasers in a sterile environment to debride | surgical debridement |
| Common topical antibacterial/antifugal agents: | - bacitracin
- garamycin
- sulfamylon
- silvadene
- neosporin
- mycostatin |
| common antiseptic agents: | - acetic acid
- hibiclens
- dakin's solution
- hydrogen peroxide
- betadine |
| hand washing, sterile instruments, and clean gloves to manage infection | clean technique |
| handwashing, sterile instruments, and sterile gloves to manage infection | sterile tehcnique |
| What types of dressing are necessary if the wound is dry? | choose dressings that either add moisture or prevent the evaporation of moisture present in the wound. |
| what types of dressing are necessary if the wound it wet? | choose dressings that absorb or wick away moisture from the wound. |
| how fast does a moist wound heal? | 3-5 time faster than a dry wound |
| a dressing that comes in contact with the wound. | primary dressing |
| a dressing that is placed over the primary dressing | secondary dressing |
| types of dressings: | - gauze
- transparent/semipermeable films
- sheet hydrogels
- semipermeable foams
- hydrocolloids
- alginates
- antimicrobial dressings
- other dressings |
| highly permeable and nonocclusive. Come in rolls, squares, sheets, strips. Typically 2 or 6-ply. Can stick to a wound. May be impregnated with a substance designed to hold moisture in the wound. Used for packing wounds. | Gauze |
| thin, flexible, sheets of transparent polyurethane with an adhesive backing. Permeable to water vapor, oxygen and carbon dioxide but not to bacteria and water. May be left in place for 5-7 days. Don’t use on patient with frail skin. Keeps wound moist, waterproof, and transparent. Example = tegaderm | Transparent/semipermeable films |
| moisture retentive. Usually comes in a sheet. Not adhesive so you would also need a secondary dressing. Encourages autolytic debridement. | Sheet hydrogels |
| polyurethane foam with a hydrophilic wound side and hydrophobic outside. Non-occlusive to the wound bed. Highly absorbent. Comes in many shapes and sizes. | Semipermeable foams |
| contain hydrophilic particles such as pectin, gelatin with a strong film or foam adhesive backing (example = duoderm). Absorb exudate; waterproof and impermealble. Cannot be used in the presence of infection. Encourages autolytic debridement. | Hydrocolloids |
| dressings made of salts and other substances extracted from seaweed. Will absorb exudate and can be used in the presence of infection. Requires a secondary dressing. | Alginates |
| a medical treatment in which the entire body is placed under increased atmospheric pressure while the patient breathes 100% oxygen. Treatment is 5-7 times a week for a time period of 90-120 minutes per treatment session. | Hyperbaric oxygen therapy |
| the application of sub-atmospheric pressure to a wound to remove exudate and debris from wounds. Delivered via a suction pump attached to the wound via a special type of dressing. Theory is that the pressure stretches the edges of the cells inciting them to divide more prolifically. | Negative pressure wound therapy |
| Other methods used to promote wound healing: | - Hyperbaric oxygen therapy
- Negative pressure wound therapy
- Electrical stim
- Surgical revascularization |
