Re-Eval Progress SOAP Note 11/26/15 6:37 PMRe-evaluation

Typically done when clinically indicated by a change in statuso Medicare will only pay for re-eval if something has changed to

warrant it, otherwise progress note Often tests are re-administered and results are compared with their

initial status Goals and plans revised and new time lines projected

Progress Similar to re-evaluation reports Usually done on a regularly scheduled basis (monthly/weekly/etc) May or may not include updated test scores Response to treatment and progress towards goals Usually shorter than a full re-evaluation note

Progress Report/Note Client Information (Preamble)

o Name, date of birth, gender, applicable medical history and findings, precautions

o Still need applicable PMH and HPIo Date of initial evaluation and date of progress note

completion Subjective

o Quotes on client’s perspectives on progress towards goals

Objectiveo Number of treatment sessions completed at what frequencyo Summary of Ct’s status since last note. May organize info

under headingso Updates on current areas of occupation that are successful

and problematico Re-Evaluation scores (can also be include scores of initial

eval) if tests have been re-administeredo Changes to client prioritieso Summary of any new information (medical, educational, work)o Summary of treatment (number of times seen, what was

accomplished in the sessions) Progress (A Section)

o Summary and analysiso Interpretation and summary of data related to areas of

concernso Comparison of results with previous evaluation results and

judgment on what this means for the cliento Ct. would benefit from…

“Although___ Ct’s progress toward___ is ____ Ct. continues to need ____ may benefit from further tx to address _____

o Revision or continuation of goals (list goals, write met/progressing/discharge) with reasoning behind discharging a goal

o Potential for continued progress towards goals P Section

o Recommendations Changes to service (frequency, duration) New goals Justify continuation of services Recommendations for referral to other professionals if

applicable Remember that we need to link goals to occupation

based interventions

Chart Review Revisited 11/26/15 6:37 PMFirst steps in seeing a new ct. in medical setting

Chart Review Develop Rapport Gather an Occupational history

o History

Intro to Chart Reviewing Skill of being able to glean information for YOU as the OT from

masses of information in a medical chart First step in the evaluation of client in medical setting

Most Important things from Chart Review Basic personal info (name, DOB, etc) Diagnosis + History of Present Illness (HPI) and Past Medical History

(PMH) Physician orders

o Have they ordered OT?o Do they have an activity restriction or precaution?o What is their code status (DNR, DNI, Full Code)

Chart Review: Nice to Know Nursing and other disciplines’ notes Restraints (enclosure bed, seatbelt, mittens) Lab tests and results

Physical Agents/Modalities 11/26/15 6:37 PMPhysical Agent

A means through which energy or physical material is applied to the human body for therapeutic effect

o Thermalo Mechanicalo Electromagnetic

Applied external to human body Generally considered to be passive therapy

o Patient not in control of potential effects Numerous potential effects, most of which occur at the level of

impairment o Paino Strengtho Range of Motion

Modalities generally address the SOURCE of symptoms Occurs at the level of impairment Physical agents do not directly improve functional activity or

occupational performance Patient is responsible for improving function in response to

education, corrective exercise, and functional training Physical agents used alone WILL NOT magically cure the patient

Complementary Role of Modalities Successful patient management often requires treatment of the

source in addition to functional training Modalities can be used as an adjunct to exercise, postural education

and splinting/bracing Modalities are not appropriate/necessary for all patients Must recognize when modalities would be an effective means of

treatment

Physical Agents Therapeutic Use of:

o Heato Cold

o Watero Lighto Electricityo Soundo Mechanical Forces (traction or tape)

Physical Agent Modalities are Used to: Facilitate Tissue Healing

o Ice, some forms of electric current, mechanical modalities,o Can stimulate specific healing mechanismso Can decrease edemao Can reduce physical stress or injured tissue

Augment Muscle Performanceo NMES

Promote Muscle relaxationo TENS for pain relief o Heat to decrease muscle spasmo Biofeedback to promote decrease muscle activity

Provide analgesiao Heat/coldo TENS/Inferential

Why does an OT Need to Know about P.A? They can augment occupational performance and facilitate

treatment in purposeful activity They are often being used BY clients

AOTA Position Paper Modalities should not be used ONLY Should only be an adjunctive treatment in combination with some

treatment to improve functional activity

THERMAL AGENTS Can either deliver heat or cold to biological tissue and can be

classified as deep or superficial

Superficial Heat and Cold

Hot packs, cold packs, paraffin, whirlpool, fluidotherapy Greatest tissue temperature change within a depth of 1cm May be self administered

THERAPEUTIC EFFECTS of HEAT Vasodilation: increased localized blood flow, which will increase

metabolic rate and healing mechanismso Facilitate long term healing after swelling is reduced

Increased Metabolic Rate Muscular Relaxation

o Can reduce muscle spasm/guarding Analgesia

o Gate control theory of pain controlo Stimulate sensory fibers related to temp sensation therefore

masking pain transmitted by pain fibersSelection Considerations

Hot Packso Can include electric ones/microwave/clinically warmedo PROS:

Good for larger body parts Easy to apply, for patient Comfortable/Can assume multiple positions comfortably

o CONS: Can be burned depending on layers applies Not good for smaller joint, don’t get an even distribution

of heat Unable to exercise or move with application of heat

Paraffino Dip/immerse or dip/wrap(most common) or paint(larger bodyo PROS

Good for smaller joints Fully surrounds the joint Body part can be elevated

o CONS: Cannot move joint

Messy/time consuming Purchas of paraffin/equipment

Not good for larger joint Whirlpool

o PROS Can exercise joint Can get a massaging effect of the water-physical stress

o CONS Risk of infection Joint often in a dependent position. Can increase

swellingTHERAPEUTIC APPLICATION

Client Positiono Positions of comforto Minimize weight of hot-pack if uncomfortableo Think about potential for swelling in a dependent position with

the use of heato Think about position relative to conductivity of the heat

source Laying on hot pack vs. having hotpack lay on you

Intensityo Mild

Small temp change in tissues at the site of the lesion Temp maintained for a short period of time Rate of increase in temp is slow Ex. Hot packs, whirlpool

o Vigorous Highest temp change at the site of the lesion Tissue temp close to tolerance Rapid rise/fall of temp Ex. Paraffin

Durationo Varies-generally between 15-20mino Electric heating pad-Do not fall asleep or leave patient alone!

Monitoringo Monitory every 5min

Subjectively: paraffin (monitor for comfort) Objectively- hot packs (monitory for burns/skin integrity)

CONTRAINDICATIONS Peripheral Vascular Disease Deep Venous Thrombosis Acute Injury (<24-36 hours) Impaired Sensation Impaired Cognition Skin/lymphatic Cancer

THERAPEUTIC EFFECTS OF COLD Vasoconstriction Decreased Metabolic Rate Muscular Relaxation Analgesia

CONTRAINDICATIONS for CRYOTHERAPY Decreased sensation Intolerance to cold Raynaud’s Disease Circulatory compromise/Peripheral vascular disease

Deep Heating Agents Diathermy:

o Use is spotty across country, used in research but not common in practice

Ultrasoundo One of the more common modalitieso Literature is inconsistent about therapeutic effects/benefits

(large variation in parameters used) These modalities can increase tissue temperature up to depts. Of 3-

5cm Typically applied in clinic and requires professional

application/supervision

Therapeutic Ultrasound Form of acoustic energy not audible to the human ear Physiological effects are produced by the absorption of acoustic

energy

Can produce thermal and non-thermal physiological effects in biological tissue

Widely used clinically for the past 50 years for a variety of purposes:o Pain reliefo Tissue extensibilityo Tissue healingo Delivery of Medication (phonophoresis)

Absorption: Occurs best at tendon, ligament, cartilage and boneTHERMAL EFFECTS

Produced by the conversion of acoustic energy to heat Depth of heating depends on the frequency of the ultrasound

o 1Mhz ultrasound beam penetrates 2-5cm of tissueo 3Mhz ultrasound beam penetrate 1-2cm of tissue

For thermal effects, the ultrasound must be delivered in a continuous fashion

Thermal effects produced are similar to those produced by superficial heat

o Increased metabolic rate secondary to increased circulationo Reduction in pain and/or muscle spasmso Increased soft tissue extensibility

Continuous vs. Pulsedo Constant delivery of energy vs. delivery in pulsed

NON-THERMAL EFFECTS OF ULTRASOUND Achieved with pulsed delivery of acoustic energy Believed to be associated with tissue healing and repair Occur secondary to mechanical events that are produced at the

cellular level in response to acoustic energyo Cativation: Formation, growth, and pulsation of gas bubles.

May increase cellular activity/functiono Acoustic Streamings: Increase in the steady movement of

fluid around the cell. May increase cell membrane permeability and cell activity

o Micromassage: microscopic, oscillatory movement of body fluid and tiessues. May increase cell activity and stimulate mechanoreceptors of the autonomic nervous system

Cell activity is increase: increase protein synthesis-may augment tissue healing and repair

Most mechanical events have only been demonstrated in the lab, proposed effects in biological tissue are theoretical

CONSIDERATIONS FOR USE OF ULTRASOUND Pulsed vs. Continous Frequency Treatment Time Size of Treatment Area Contact Method/Coupling Agent Power/Intensity Number of Treatments

o If no effect after 4-6 visits, consider another type of treatmentCONTRAINDICATIONS FOR ULTRASOUND

Areas of: Local bleeding, active infection, cancer/malignancy, thrombophlebitis

Over the eyes, reproductive organs and CNS tissue Over the abdomen, low back, pelvis of a woman that is or might be

pregnant Over total joints cemented with methylmethacrylate cement or

have plasticPRECAUTIONS FOR ULTRASOUND

Acute inflammationo Thermal effects can increase inflammatory response, would

want to use non-thermal effect Epiphyseal plates

o May cause damage-literature inconclusive Fracture

o Some evidence that high intensity thermal ultrasound might impede fracture healing

Breast ImplantsEVIDENCE

Considerations for reviewing the literatureo Treatment parameterso Human vs. Animalo In VIVO vs. IN VITRO

o Diagnoseso Randomized controlled trials

In general, thermal effects are supported Non-thermal effects are controversial in vivo and ultrasound is no

better than placebo for pain Wealth of info, decide if evidence supports the use of ultrasound for

patient population

ELECTRICAL STIMULATION Pain Relief

o TENSo Inferential Stimulation

Neuromuscular Stimulationo Strengthening (NMES or Russian)o ROMo Functional Electrical Stimulation (FES)

Medication Deliveryo Iontrophoresis

CLINICAL USE ESTEM NMES

o Muscular strengthening TENS

o Analgesia FES

o Purposeful movement HVGS

o Analgesia Iontophoresis

o Drug delivery Inferential Stim

o Analgesia Russian Stim

o Muscle Strengthening

General Principles of ESTEM

Biological tissue, the current is responsible for the physiological effects ESTEM

Current is defines as the movement of charges particles from one pole to another

Several types of current o DIRECT current

Continuous, unidirectional flow of charged particles Associated with polar physiological effects such as

edema reduction, wound healing Often use to stimulate de-enervated muscle

o ALTERNATING Continuous bi-directional flow of charged particles No net charge in the circuit, therefore no polar effect Frequency of current determines impedance in

biological tissue Often current is delivered in pulses of energy

Higher frequencies will encounter less impedance, lower frequencies will encounter more impedance

TENS Transcutaneous Electrical Nerve Stimulation

o Activates sensory nerves which transmit information more quickly than pain fibers

o May enable patients to move easier allowing you to address function and exercise

o No lasting physiological effects Electrodes surround the area of pain Should feel a buzzing or tingling as opposed to pain Gait control theory of pain relief Portable, can wear up to 23hrs Not recommended during sleeping, showering, driving Several adjustments to prevent accommodation Can change frequency to alter sensation Can also stimulate muscle fibers generating a twitch (massage

effect of muscle contraction)

Depending on intensity, could stimulate body’s natural response to pain (endorphins)

ADVANTAGES TENS Easy to use Client control Portability

Inferential Current Medium frequency current used for pain relief

o Gait control theory of pain reliefo No lasting physiological effecto Theoretically penetrates deeper than TENSo Most devices are not portableo Two channels of electrical current cross producing an

intersecting current that produces physiological effects

CONTRAINDICATIONS to TENS/INFERENTIAL Demand-type Pacemaker Cardiac Disease (avoid stim over chest) Over the carotid sinus Pregnancy (during first trimester) Epilepsy (avoid stim over head/neck)

Neuromuscular Electrical Stiumlation Muscle strengthening and re-education Stimulates action potentials at the target musculature producing a

muscle contraction No rate coding of muscle contractions

o All motor units of a given size fire simultaneously Larger, fast-twitch muscle are stimulated first

o Can lead to more rapid fatigue

Muscle Strengthening Electrical stimulation is thought to strengthen muscles by 2

mechanisms

o Overload: Electrical stimulation allows the muscle to work at a higher intensity that could be volitionally achieved

o Specificity: Improved training of larger, fast-twitch muscles could produce greater strength gains

Muscle Strengthening: INDICATIONS Increase strength in a weak muscle

o –post-operative applicationso Prevent (reduce) disuse atrophy by imposing muscle

contractions in muscles that may not be able to be contracted volitionally

o Muscle re-education and target training Motor control

OTHER APPLICATIONS Functional Electrical Stimulation

o Electrical current used to provide functional movement or maintain functional postures

o Goal is to facilitate controlled functional muscular activity or maintain postural alignment on a continuing basis or until recovery from dysfunction occurs

Range of Motiono Electrical stimulation can be used to maintain ROM about a

joint by alternating contractions of agonist and antagonist muscles

o Can increase ROM by applying estim in conjuction with a static stretch

CONTRAINDICATIONS OF ELECTRICAL STIMULATION Demand cardiac pacemakers Malignant tumors Unstable fracture Thrombophlembitis Specific anatomic locations

o Anterior necko Eyeso Trans-thoracic o Superficial metal implantso Abdomen, lower back or sacrum of a pregnant female

PRECAUTIONS Obesity

o Current does not conduct well through adipose tissue, would have to increase intensity which would increase stimulation of pain fibers

Osteoporosis Epilepsy Impaired sensation Skin irritation/sensitivity Impaired cognition

Iontophoresis Technique that uses electrical stimulation to drive charged

chemicals with medical value across a permeable membrane Direct Current: Polar effects

o Like charges repelo Negatively charged medications will be driven through skin if

stimulated by a negatively charged electrodeo Non-invasive way to deliver medication

ACUTE CARE 11/27/15 10:33 AMOTs in Acute Care

Respond to MD referral “orders” for evaluation within 24hrs Perform simultaneous evaluation, intervention and discharge

planningo Triageo Ensure plan of care is appropriate for the acute care setting

Identify need and make recommendations for continued services along the continuum

o OT? Additional? Community resources? Identify AE/DME needs and home modifications Educations DO NO HARM

o Fall Prevention Impact Readmisision

Daily Workflow Morning caseload organization and distribution Morning caseload management and prioritization

o How do you decide who to see first? Evals vs. treatments? Lunch/Re-group/Education/Meetings Afternoon caseload management and prioritization End of day caseload organization Evals tend to be prioritized over treatments

Evaluation Overview (OTPF) Occupational Profile Pain Cognition UE ROM/MMT/Tone Sensation/Coordination/Visual Perception ADLS/IADLS Functional mobility Static and dynamic balance Patient’s goal and Plan of Care (POC) Goal is to complete in 25-30min

Intervention Examples ADLs/IADLs Cognitive impairment AE/DME training Precaution training Caregiver training HEP Activity training-energy conservation, activity pacing, self-

management Education

Common Challenges Short length of stay Time restrictive Lack of schedule and competing for availability, managing

interruptions Medical instability/change in status Limitations of physical setting Appropriateness of MD orders and timing of referral “The Unknown” Precautions, protocols

o Will not always be written in chart Infection prevention Managing lines/medical devices Consideration of spontaneous recovery

Foundational Medical Knowledge Vital Signs

o HR, SpO2, BP, RRo Gauge pt’s activity tolerance and physiological response to

activity: guide treatment/evaluation for appropriateness and when to increase/decrease

Lab Values Indication of the client’s overall health, if therapy is medically

appropriate or why occupational performance is affected

Ex: Hemoglobin: can cause anemia, fatigue, dyspneao Troponin: watch for trending up, can indicate active MI

Precautions Needs to come from the MD, often the therapist has to contact the

MD to be clarified Are they weight-bearing, active range of motion, just pendulum?

Procedures Have an impact on medical stability

o Cardiac catherization: bedrest 2hrso Pacemaker: bedrest for 2hrs following removalo Skin graft: can be bedrest for 3-5 dayso Fasciotomy: can be weightbearing as tolerated

Medical Equipment Impairs occupational performance, often have to come up with

compensation strategies or teach within restrictions, Can increase time of sessions, need caregiver training, consider difficulties of donning when pt. goes home

Medical Lines Systems ApproachRespiratory

Can take pulse manually to check against pulse oximeter, if pulse reading correctly good chance oxygen is as well

Oropharyngeal Airwayo Purpose

Maintain an Open airway Keeps the tongue away from the back of the throat Faciliatates suction of the airway

o Therapy Considerations If comes out call nurse immeditately If gurgling call RN for suctioning

Endotracheal Tubeo Purpose

Maintains an open airway to assist with breathing

Protects the airway while on the ventilatoro Therapy Considerations

Ct. may have restraints to prevent from pulling it out, can work with a pt on restraints but responsible for ensuring they don’t pull it out

Call RN immediately if they pull tube out Ventilator

o Purpose A mechanical device that provides artificial ventilation

of the lungso Therapy Considerations

Can ambulate using portable ventilators Tracheostomy tube

o Purpose Maintains an open airway to assist with breathing Protects vocal cords and prevents tracheal necrosis

during prolonged intubationo Therapy Considerations

Consult speech to see if appropriate for speaking valve if starting to talk around trach or vocalize

Nasal Cannulao 1L= 24%, 2L=28%, 3L=32%, 4L= 36%, 5L= 40%, 6L=44%

High Flow Nasal Cannulao 6L up to 15Lo Need to continuously monitor O2 throughout session, if O2

sats drop, wait for them to return prior to returning to activity Face Mask

o 35-55% Non ReBreather

o 6L=60%, 7L=70% etc, 10=100% Tracheostomy Collar

o Amount of oxygen supplied is dependent upon device attached to it

Chest Tubeo Purpose

To drain fluid or air from pleural or mediastinal space

o Precautions Keep below the level of the chest Check for air leaks

o Therapy Considerations If chest tube comes out, coverage drainage with sterile

gauze and call for RN Can move pt. to a portable suction machine

CardiacSigns of working too hard: dizziness, blanched skin, sweating, SOB, agina, heart palpitations etc

Electrocardiogramo Purpose

Evaluate heart rate and rhythm Often connected to a monitor that includes oxygen

saturation readings, blood pressure, respiratory rate, and temperature

o Therapy Considerations Ensure documentation of vital signs throughout the

session Reconnect/stick sticker back on or apply a new one if it

comes off Pacemaker

o Purpose Artificially pace the heart rhythm Endocardial: (traditional pacemaker with wires into the

heart) Standard precautions of UE movement below 90degrees, may be non-WB on that side

Epicardial: (temporary pacemaker with wires outside the heart) no precautions other than don’t drop the box

o Therapy Considerations Monitor signs and symptoms in addition to vitals

Implanbale Cardioverter-Defribrillatoro Purpose

To shock the heart when in v-tacho Therapy Considerations

Need to know the heart rate settings for when the device is set to shock the pt.

Ventricular Assist Device (DENNY FROM GREY’S)o Purpose

A mechanical circulatory pump inserted in the body Must always be connected to a power source

o Therapy Considerations Be certified to tether/untether and understand alarms Ensure that the drive line is not pulled

VascularCommon comorbidities of vascular disease: obesity, diabetes, cardiac diseaseDeep Vein Thrombosis (DVT) prevention: mobility, sequential compression devices (SCDs)

Intravenous Line (IV)o Purpose

To provide direct access to the circulatory system when administering fluids and medications

o Therapy Considerations Call RN if alarms or disconnects (DON’T DISCONNECT

TO WORK with ct) Central Catheter

o Purpose Provides long term direct access to administer fluids

and medications and draw bloodo Therapy Considerations

Do not take blood pressure in the arm it is located in Arterial Line

o Purpose Provides a continuous measure of arterial blood

pressureo Therapy Considerations

If located in the wrist, do not perform any ROM If located in the groin, ct. is not to perform hip flexion

greater than 30degrees Dialysis Catheter

o Purpose Used to remove toxic materials from the system due to

kidney impairment Maintains fluid and electrolyte balance

o Therapy Considerations Do not take blood pressure if placed in the arm No hip flexion greater than 30degrees if placed in the

groin Patient Controlled Analgesic (PCA) & Epidural

o Purpose Pain management

o Therapy Considerations Check for sensation with epidural Monitor blood pressure (Can lower) Do not push it for the patient, they must do it on their

own, hand it to them Gastrointestinal (G-Tube)

o Feeding tube in stomach, careful during dressing, gait belt placed under the arms instead of the stomach

Dobhoff Tubeo Purpose

To administer food and medicationso Therapy Considerations

Keep the head of the bed elevated to 30degrees during a feeding

If ct. accidentally pulls the tube partially out, put the feeding on pause and call RN to assess (could cause aspiration)

Nasogastric (NG) Tubeo Purpose

To administer food and medication Also can be connected to suction to remove stomach

contentso Therapy Considerations

If you need to ambulate to bathroom you can clamp the NG tube and mobilize as needed

Jackson Pratt (JP) Draino Purpose

A suction drain to evacuate fluids from a wound Can be located at any incision area (stomach, back,

neck, arm)o Therapy Considerations

Pin to gown prior to mobilizationUrinal & Rectal

Working with ct. with hernia repair and notice bloody stool on bed, stay calm, remove the pad behind the pt and return the pt to bed, Call RN

Foley Cathetero Purpose

Evacuation of urine from the bladder Can be indwelling, condom or suprapubic

o Therapy Considerations Keep below the level of the kidneys Ensure the line is secured to the ct. (thigh strap for

indwelling) Rectal Tube (Flexi-Seal, Dignicare)

o Purpose Evacuation and collection of feces and gas Most commonly used with ct. that have C.Diff

o Therapy Considerations A ct. will often have loose stool from around the tube

Neurology Intracranial Pressure Monitor

o Purpose Measure pressure surrounding the brain

Normal 4-15mmHgo Therapy Considerations

Keep the head of the bed elevated to 30degrees Keep head in neutral Only mobilize when clamped

Restraints

Anything the pt. cannot physically or cognitively remove is considered a restraint

Must come from an MD order. RN must assess every 2hrso Wrap Around Belt: usually goes around lap in chair, ensure

non skid surface underneath themo Roll Belt: used in bed to where pt. can roll side to side and

even sit edge of bed but can’t get out of bed as restraint goes around the bedframe

o Mitten: ensure snug enough that can’t remove with teet or batting it off, can open and check for capillary refill at fingers of mitten

o Soft Limb Restraint: goes around wrist or ankle and connects to a non-movable part of bed or chair (not on the bedrail that can come down)

o Freedom Limb Restraint: much like an air splint, prevents from elbow bending. Allows for full range of motion of arm but not to reach face

Discharge SOAP Note 11/27/15 10:33 AMCan be narrative or SOAPUsed to SUMMAIZE changes in the ct. abilitiesMake recommendations for follow-up care or other services

Preamble Ct’s name, age, gender, diagnosis, precautions, HPI/PMH Identify as a discharge summary with date

o It is not a discharge evaluation or a single point in time that you are writing about!

Subjective Quote or summary statement from the ct. about the overall

outcome of treatment or some specific improvement made

Objective Date of initial and final service Frequency and number of sessions seen Summary of interventions used Summary of progress towards goals Initial and discharge status re: occupations and scores on

standardized assessments Has been educated, now performing, try to use present tense, now

doing Many use tables to show comparison status/scores

Assessment outcomes of goals (met or not met with reason for not being met) Don’t necessarily have to list every goal if they met them all, or only

a few were unmet Can include “ct. is ready for discharge from skilled occupational

therapy services” List all LTG goals!

Plan Recommendations for continued therapy/services Can include:

o Follow up services with another discipline or OT at the next level of care

o Home exercise programs that should be continued o Adaptive equipment recommended for homeo Levels of supervision/assist that you recommend for various

ADLSo Certain ways you recommend the ct. do their activities

Orthotics & Splinting 11/27/15 10:33 AMPurpose of Positioning

Prevent deformity or contractures Prevent or manage edema Prevent/manage decubitus Support weak extremities Support/Immobilize body part for healing Safety & protection of a body part Increase function Increase eye contact Maximize available motor skill Break up abnormal tone patterns Manage agitation

Effects of Improper Positioning Cause contractures Pressure sore Decubitus ulcers Edema Poor Posture Pain Soft tissue shortening Poor participation in therapy Poor communication Poor eye contact Decreased function Changed mental status Changed behavior

History and Definition Splint

o Rigid or flexible appliance used for immobilization, restraint or support

Orthosiso A force system designed to control, correct or compensate

Classification

Purpose of Applicationo Prevent deformityo Support, protect or immobilize jointso Correct an existing deformityo Provide directional control for coordination deficits; correct

deformity and enhance functiono Serve as a base for attachment of devices

External Configurationo Bar Splintso Spring splintso Contoured splintso Combinations

Mechanical Characteristicso Static

No moveable parts Maintain desired position Immobilize or restrict movement Used acutely or as night splints

o Serial Static Design may appear to be static Rigid to maintain a position Allows progressive modification Provides slow, progressive, mobilization

o Dynamic Utilize elastic components Exert a force to increase/alter ROM (soft or springy end

feel) Static+base+outrigger/traction device Diverse design and application

o Static progressive Function similar to dynamic splints Uses ineleastic components Torque applied to position joint close to end range Works with a hard end feel

o Dynamic & Static Orthoses Increase joint motion

Decrease or prevent contractures Provide stretch to scar tissue Improve hand function Aid fracture alignment Provide support Restore muscle balance (dynamic only)

Materialso Plastico Plastero Metals & High Temperature Materialso Others

Anatomico Faceo Trunko Upper extremityo Lower extremity

Component Terminology Forearm bar or trough

o Longitudinal part proximal to wristo Supports weight of hand

Metacarpalo Supports transverse metacarpal archo Allows full MP joint motion

Hypothenar Baro Supports ulnar aspect of transverse metacarpal arch

Deviationo Prevents ulnar or radial deviation of wrist or fingers

Outriggero Part extended from main body of splinto Provides positioning for dynamic assists or traction devices

Lumbrical Baro Over dorsal proximal phalangeso Prevents MP extension or hyperextension

C Baro Fitted in thumb-index web space

o To maintain increase/distance between the first and second metacarpal bones

Opponens baro Positions thumb in abduction and opposition

ASHT Classification System Articular vs. Nonarticular Location Direction Mobilization vs. Immobilization vs. Restriction (blocking) Type Design Options

Descriptive Nomenclature SystemHow:

Static Dynamic Serial-static Static progressive

Where Location of base Location of Action

Why Action/Purpose

Example: How: Dynamic Where: Hand-based, acting at index PIP finger Why: Extension

Descriptive Name: Hand based dynamic index finger PIP extension splint

Fabrication Process P= Pattern Creation R= Refine pattern O= options for materials C= Cut and heat

E= Evaluate fit while modeling S= Strapping and components S= Splint finishing touches

Issuance & Checkout Guidelines Evaluate splint fit and effectiveness Determine wearing tolerance Make adjustments Provide written guidelines Ongoing reevaluation of fit, effectiveness

Hand Splinting Criteria & Considerations Fitted early after trauma or injury Quickly and cleanly constructed Efficient and adequate support Simple, direct design Lightweight and cosmetically acceptable Free of pressure areas and comfortable Durable and easily cleaned Easily applied, removed and adjusted

Principles of Hand Splint Design Follow lines and contours of the body Avoid/accommodate bony prominences Preserve arches of the hand Do not restrict joint or parts unnecessary Avoid bulky splints Incorporate mechanical principles

Patternmaking Techniques Tracing outline of part and marking landmarks on pattern material Tracing outline of countralateral part and landmarks on pattern

material Take specific measurements to form a pattern shape or to

determine length and width of splint components (for stretchable materials or larger body parts)

Options for Patternmaking Materials Paper towel Plastic Bag Aluminum foil Surgical glove Tape measure

Options for Tracing on thermoplastic Awl Pencil Light colored grease or china pencil Ink may smear, dark grease pencil line must be cut off

Guidelines for Issuance & Checkout Evaluate splint fit and effectiveness Determine wearing tolerance Make adjustments Provide written guidelines Ongoing reevaluation of fit, effectiveness

Wearing schedule considerations Goals/Purpose Anticipated compliance for patient or caregiver? Variables affecting client’s tolerance? Assistance required to don/doff? Necessary to apply or remove for function Frequency of hygiene activities & exercise?

Time Schedule Individual based on positioning device and other physical

characteristics General guidelines: Initially every two hours Monitor closely particularly with those who have impaired sensation

or mental status. Adjust the schedule as the patient either improves or declines

Increase to 3-4hrs depending on individual’s need. Max wear time usually 10-12hrs with removal for hygiene & exercise

Generally not worn for 24hrs

Orthotics written instruction should include: Purpose of the splint Donning & doffing the splint When & how long the splint should be worn Care & cleaning of the splint Precautions Exercise Program Who to contact/what to do if a problem is noted

Client/Caregiver behavior objectives for STG Describe purpose of splint & wearing schedule Demonstrate ability to independently apply and remove splint Describe splint care Demonstrate exercise program Describe precautions

Coordination Coordination with nursing and other discipline’s schedules Usually OT develops the program and instructs nursing, family, or

patients to carry out the program Monitor the program and change accordingly