AROM

Dynamic sitting balance

Dynamic standing balance

Sit to supine

Rolling

Cognitive

Sequencing

Contracture / splinting orthotic management

STG BED Mobility Pt will safely perform bed mobility task with Mod (A) without use of side rail and 10 % Verbal Cues for proper sequencing, for safety awareness, maintaining WB precautions, and for correct foot/hand placement, in order to get in/out of bed, participate in activities of daily living, prepare for transfer and gait activities. Transfer Pt will safely perform functional transfers with Mod (A) and 10% Verbal Cues for push up from arms of chair, for weight shift over center of gravity, for correct hand/foot placement,

Functional activity tolerance

Return to prior level of function / PLOF

Compensatory strategies / precaution

Activity pacing

W/C wheelchair

Gait training

Therapeutic Activities

Therapeutic activities Bed mobility

Neuro Re-Ed

Post-surgical care

Orthotic/Prosthetic Management

Patient and Caregiver training

Functional mobility

Stairs

WHEELCHAIR MOBILITY

WHEELCHAIR MANAGEMENT

WB precaution

Gait analysis

Gait deviation

Positioning

Physical therapy evaluation and re evaluation

Wound

PAIN

WHEELCHAIR

Weekly

Diathermy

CONTRACTURE MANAGEMENT

UE STRENGTH

1. Tx focused on balance strategies and adaptation to postural adjustments with increase awareness of safety. Tx also focused on multidirectional adjustments and multidirectional weight shifting to improve static standing balance activities. Pt. made gains with bed mobility and functional transfer. Pt. still requires verbal cueing to use of techniques and compensatory strategies for initiation of tasks and activities given to the patient. Continue skilled PT services with emphasis on using compensatory techniques to achieve postural control and postural stability Pt/caregiver training provided appropriate verbal cueing to patient on initiation of functional transfer with safety. 2. Tx focused on voluntary postural control during static and dynamic standing balance activities to improve static and dynamic balance response. Tx also focused on gross and fine motor control and coordination training. Pt still requires multidirectional challenges to improve dynamic standing balance and functional mobility. Continue skilled PT services with emphasis on improving dynamic standing balance and improving functional mobility through somatosensory inputs and musculoskeletal challenges. Pt/caregiver training provided on increasing safety awareness during functional transfer. 3. Tx focused on supine movement in bed, scoot up and bridging and changing positions in bed with segmental trunk rotation with maneuvering/positioning legs over edge of bed with use of adaptive device attached to bed such as bed rails. Pt still requires 90% verbal cueing on functional tasks activities and sequencing tasks. Pt. continues to require skilled PT services to improve strength, balance, coordination, endurance, safety awareness, and functional mobility. Continue skilled PT services with emphasis on task adaptation and task modification. Pt/caregiver training on safety transfers. 4. Tx focused on multidirectional leaning with self correct strategies during sitting balance activities. Tx also focus on sit to stand through pushing up on elbow/hand with proper hand placement on wheelchair arm rest. Pt has made gains with bed mobility and functional transfer. Pt. still requires 80% verbal cueing on sitting/standing balance strategies. Continue skilled PT services with emphasis on balance strategies and postural adjustments.

Pt/caregiver training provided with appropriate verbal cueing on functional transfer and safety awareness.

3. Tx focused on supine movement in bed, scoot up and bridging and changing positions in bed with segmental trunk rotation with maneuvering/positioning legs over edge of bed with use of adaptive device attached to bed such as bed rails. Pt still requires 90% verbal cueing on functional tasks activities and sequencing tasks. Pt. continues to require skilled PT services to improve strength, balance, coordination, endurance, safety awareness, and functional mobility. Continue skilled PT services with emphasis on task adaptation and task modification. Pt/caregiver training on safety transfers. 4. Tx focused on multidirectional leaning with self correct strategies during sitting balance activities. Tx also focus on sit to stand through pushing up on elbow/hand with proper hand placement on wheelchair arm rest. Pt has made gains with bed mobility and functional transfer. Pt. still requires 80% verbal cueing on sitting/standing balance strategies. Continue skilled PT services with emphasis on balance strategies and postural adjustments. Pt/caregiver training provided with appropriate verbal cueing on functional transfer and safety awareness. 5. Tx focused on sit to stand transfer providing cues for pushing up from arms of chair, weight shift over COG, proper hand and foot placement and proper sequencing. Stand pivot transfer and Pt requires cueing on timely turns.

Pt will increase muscle strength grade Pt will improve bed mobility Pt will improve transfer Pt will improve gait using FWW Pt will perform bed mobility task with Patient will increase static standing balance to Good and using ankle, hip and/or stepping strategies 65% of the time to right self and w/o falls, w/o LOB, with good safety awareness and while maintaining good balance in order to reduce the risk for falls and facilitate safety while standing. Patient will increase RLE Strength to 4-/5 to enable patient to safely maneuver in/out of bed, to facilitate improved functional mobility, to facilitate safety during ambulation and to prepare for transfers.

using FWW with ability to right self to achieve/maintain balance, w/o signs/symptoms of inadequate cardiac function, w/o signs/symptoms of inadequate pulmonary function, with stable vital signs, while maintaining oxygen saturation > 98%, while maintaining oxygen saturation >90%, with increase in heart rate of no more than 20 beats per minute, while maintaining heart rate and while maintaining respiration rate

Patient will safely perform bed mobility tasks with CGA with use of siderails and occasional verbal cueing for proper sequencing and for task segmentation in order to get in/out of bed. Patient will increase RLE Strength to 3/5 to facilitate patient's ability to perform gait on level surface with Min (A) and 10% verbal cueing with use of handrails and AD with reduced risk for falls, w/o LOB and with good safety awareness in order to safely return to private residence. Patient will increase static standing balance to Good and using righting reaction 100% of the time to right self in order to reduce the risk for falls, facilitate safe functional mobility w/o LOB and improve ability to safely ambulate w/in environment. SKILLED INTERVENTION Ther Ex: AAROME on BLE, lumbar stabilization exercises to promote good static/dynamic balance. Neuro Re-Ed: and gross motor coordination techniques, facilitation of crossing midline to promote indepence in rolling in bed and proprioceptive techniques to improve safety and decrease fall risk and static/dynamic sitting and static standing balance training,facilitation of weight shift/dynamic stability and facilitation of symmetrical distribution of weight when sitting unsupported and during static standing using hallway rail and postural alignment techniques,techniques to increase upright posture, techniques to improve postural stability, training with emphasis on proximal stability/distal control, techniques to improve functional skill performance and facilitation of upright posture and proper body alignment to increase interaction with environment when patient is up in his wheelchair. Pre-Gait Trg: weight shifting in anteroposterior direction, pre-gait tasks to improve unsupported standing, weight shift to increase unsupported standing, weight shifting in lateral direction and pre-gait activities in parallel bars. Therapeutic Activities: static balance activities during sitting, bed mobility activities to increase functional skills, dynamic balance activities during sitting, facilitation of position in space, facilitation of postural control, ROM techniques to increase functional task performance, strengthening activities to increase functional task performance, initiation cues to facilitate skill performance and dynamic functional activities to increase strength, ROM, flexibility in a progresssive manner. PT/CAREGIVER TRAINING Instructed primary caregivers in safe transfer techniques in order to enhance functional performance in the presence of reduced cognitive abilities with variable carryover demonstrated by caregivers, facilitating the need for further instruction and analysis of caregiver implementation of and patient response to instructions/techniques. Pt Progress and Response to treatment Patient is progressing with current treatment interventions and PT. Noted some active participation in bed mobility and demonstrates improved functional tolerance-as evident by more time tolerated being up in the w/c to participate/interact with other residents during therapy sessions-important to promote environmental awareness.Some improvement in

static/dynamic sitting without support and now able to tolerate static standing, though extensive assistance still required to complete tasks. Pt will further benefit from skilled PT treatment towards reaching established PT short/long term goals.

Pt will safely perform bed mobility task with Min (A) without use of siderails and Occasional Verbal Cues for weight shift over center of gravity and for proper sequencing in order to prepare for transfer, get in/out of and prepare for gait activities. Pt Progress and Response to treatment Patient's condition has potential to improve as a result of skilled rehab.Patient shows significant gains in bed mobility and demonstrates increase active participation during sit to stand transfers. - compliant with toe touch weight bearing during transfers and pre-gait training inside parallel bars. Patient is cooperative with treatment and been pre-medicated for pain prior to PT/OT treatment. Patient shows half grade increase in BLE strenght. Continued PT will warrant further improvement in patients functional potential and recommends continued direct skilled PT treatment as per POC. Pt Progress and Response to treatment Noted improvement in bed mobility, some active participation noted during sit to stand transfers, and now able to ambulate short distance with use of assistive gait device, provided with sufficient rest breaks in between activities and instructions to pace self during task performance. Patient to continue with PT as per established POC for further improvement of functional capacity.
Progressive gait training Postural sway on initial standing Segmental trunk rotation Supine movement in bed scoot up in bed/bridging Changing position in bed/pressure relief/bridging Bending knees to facilitate pelvic rotation for rolling/position change /pressure relief Unilateral leg bend with mass extension to facilitate pelvic rotation for initiation of rolling Crossing midline Maneuver/position legs over edge of bed with use of compensatory strategies Come to sitpush up in elbow/hand to achieve sitting Sitting ability to self correct, righting responses, protective extension(present /delayed) Multi-directional leaning on firm or compliant surface with self-correction strategies Unsupported sitting with multi-directional leaning challenges Scoot at edge of bed/incremental scooting forward/backward/sidewayspelvic rotation Hand/foot placement Come to standing postural sway Remember: Do NOT admit a resident for "restraint reduction." Identify impairments that may cause resident to use a restraint and treat the problem or provide compensatory Istrategy training or environmental/behavioral/task adaptation/modification. Assess for appropriate adaptive and/or assistive devices to achieve highest level of function. Identify the reason the resident is at risk for falls and/or is using or may use a restraint Underlying medical conditions/co-morbidities (e.g., Parkinson's disease' with excessive tremoritone or festinating gait with "x" falls in a week; postural hypotension with dizziness and balance loss with position change; urinary urgency and inability to transfer without mod assistance; spinal deformity with

muscle imbalance requiring wheelchair positioning devices to free UEs for bilateral manipulation tasks) Side effects from medication (e.g., dizziness, fatigue) Impaired mobility from inactivity, illness Past history of falls/fear of falling Decreased ROM/contractures and/or strength (consider modality use) Balance/coordination deficits/dyskinesia Abnormal tone (e.g., hyper-/hypo-tonicity, flaccidity) Gait deviations/inappropriate use of assistive gait device Postural instability/alignment (e.q., kyphosis, scoliosis, muscle imbalance, pelvic obliquity) Pain (consider modality use) Leg length difference Vision deficits (e.g., visual field cut, blindness) resulting in inability to safely maneuver in environment and/or avoid hazards/obstacles, thereby increasing risk for falls Vestibular considerations (e.g., head turning while walking in order to scan environment read signs) Altered sensation (e.g., diminished protective sensation in diabetic feet with increased fall risk) Cognition (e.g., Sundowner's syndrome, anxiety, wandering/pacing behaviors, unfamiliar environment) Inability to adjust attentional demands during multi-step or multi-task performance Time of day fall occurs (e.g., afternoon/increased agitation, after meals) Fall management/restraint reduction strategies Stabilize medical conditions/medication responsesitime of medication delivery Establish bowel/bladder programs (consider modality use) Assess/train appropriate adaptive bathroom equipment (e.q., grab bars, elevated toilet seats) Nutrition consultation/ability to self-feed/adequate hydration Vision/hearing evaluations/compensatory strategies for low vision/hearing loss Compensatory strategies for sensory loss Range of motion/strengthening exercises Balance recovery/strategy training to address all components of balance (e.g., anticipatory, reactive) Achieve postural stability/head and trunk controllability to adjust COM over BOS Normalize tone/inhibit abnormal tone/patterns of movement Address gait deviations Assess and train correct utilization of assistive gait devices/adaptive equipment Establish mobility programs (e.g., walk to dine) Train in multi-step and multi-task performance/attentional demands Assess for proper footwear/orthoses. Address leg length difference. ~ Remove environmental hazards/adapt environment for safety/ensure ability to identify obstacles and safely maneuver around or avoid them during functional mobility Cognitive training/behavior modification/control agitation and/or anxiety via activity regime Reduce/eliminate pain through positioning/exercise/modality use Allow adequate time for functional task performance/task adaptation . Establish and implement a daily schedule with use of compensatory memory strategies Strategies to compensate for sensory system loss (e.g., use of touch/sound with blind resident) Adapt environment for safety/keep necessary items within reach/ensure adequate lighting Behavior modification strategies to address anxiety, fear of falling Rationale for training Improve trunk stability Improve biomechanical alignment Improve symmetrical weight distribution Improve awareness and control of center of mass (COM) and limits of stability (LOS) Improve musculoskeletal responses necessary for balance (e.g., functional ROM, strength) Promote use of normal balance strategies during static and dynamic activities Improve utilization of sensory (somatosensory. visual, vestibular) systems for balance and challenge CNS sensory integration mechanisms

Evaluation considerations Direction of balance loss Amount of support required (e.g., able to sit/stand unsupported. requires support of one hand) Righting reactions/protective extension: absent, present, present but delayed Ability to regain balance/self-correct using ankle, hip and/or stepping strategies Standardized tests results (e.g., Berg, Tinetti, TUG, Functional Reach) Interventions Adjustment of center of mass (COM) over base of support (BOS) Postural alignment/adaptation to gravity, surfaces and visual conditions Train direction of limits of stability and body position in space Train perception of stability limits by altering surface and/or visual orientation input Control of gaze and center of mass Adjustment of position/postural alignment and stability for terrain and visual deficits Multi-directional weight shifting 10 improve dynamic stability (e.g., A-P, lateral. hip circles) Multi-directional weight shifting with varied foot patterns to alter base of support Unilateral/single limb stance and/or tandem stance eyes open/closed Alter somatosensory contexts to decrease surface over-dependence (e.g., carpet, grass, sand) Alter visual input to challenge balance responses (e.g., low light, distort visual input, strobe light) , Alter vestibular input to improve dynamic balance responses (e.g., stand on foam, head turns, read signs) Multi-task performance (e.g., using cane and carrying plate of food or glass of water) Voluntary postural control static/dynamic) Anticipatory postural adjustment to a predicted disturbance {e.g., obstacle negotiation/avoidance, surface changes, crowds). Ability to integrate postural control with voluntary movement. . Reactive postural adjustment (e.g., sudden obstacle in path). Responding nonvolitionally to an unexpected disturbance of the COM/BOS. Training in ankle, hip, stepping strategies with accurate foot placement Bilateral integration/manipulation Crossing midline Gross and fine motor control/coordination training Isolated movement/techniques to gain selective motor control Inhibition of abnormal reflex activity Facilitation/inhibition of patterned/synergistic motion Enhance use of vestibular information by reducing the availability of accurate visual and somatosensory inputs for spatial orientation Improve verticality and alignment by augmenting sensory feedback (e.g .. mirror) Proprioceptive Neuromuscular Facilitation {PNF) Compensatory strategies Recognition of ineffective postural strategies Achieve adequate EOS and utilize strategies throughout functional tasks - Widen when turning or sitting: Widen in direction of expected force Lower center of mass (COM) when greater stability needed Assistive devices for gait assist or to increase somatosensory input Rely on intact senses Recognition of unsafe environments/situations Focus vision on stationary objects rather than moving objects Minimize head movements during more difficult tasks

 Supine move men I in bed.... scoot up in bed/bridging Changing position in bed/pressure relief/bridging Linen manipulation Bending knees to facilitate pelvic rotation for rolling/position change/pressure relief Unilateral leg bend with mass extension to facilitate pelvic rotation for initiation of rolling Crossing midline Segmental trunk rotation Maneuver/position legs over edge of bed with use of compensatory strategies (e.g., hemiplegia) 4 Come to sit. .. push up on elbow/hand to achieve silting Adaptive equipment attached to bed or at bedside to facilitate corning to silting (e.g. rope, webbing, belt, wheelchair) Sitting: ability to self-correct, righting responses, protective extension (present/delayed) Multi-directional leaning on firm or compliant surface with self-correction strategies Unsupported sitting with multi-directional leaning challenges Scoot at edge of bed/incremental scooting forward/backward/sideways.. pelvic rotation Hand/foot placement Position wheelchair/lock brakes/swing leg rests/remove armrest/position sliding board Come to standing.... postural sway on initial standing Push to stand.... Postural adjustment with forward lean/adequate posterior shoulder girdle strength for shoulder depression to achieve standing Stand/turn/pivot. .. facilitation of balance recovery strategies with direction change ... trunk/pelvic rotation Use of balance strategies (e.g. ankle, hip, stepping) to minimize fall risk Back up to touch chair upholstery with legs prior to sitting Controlled sitting/eccentric contraction LEs.... hand placement on wheelchair armrests. - Trunk rotation in wheelchair to access self-care/dining supplies Self-correct position in wheelchair Ischial pressure relief.. ..Braden Scale or Pressure Ulcer Risk Assessment use Multi-directional leaning with ability to achieve postural control of COM over BOS Postural adjustment/achievement of head/trunk control throughout task ... COM over BOS Weight shift during seated/standing activities Graded cueing (type/percent) for task set-up, initiation, progression, problem solving, anticipatory responses, completion Sequencing/structuring task Attention to task/distractibility Ability to multi-task/attentional demands Adaptive equipment assessment, training. modification, safety (e.g., side rail, overhead trapeze, sliding board, FWW) Environmental modification/adaptation ... consider amount/type of distractions Task adaptation/modification for co-morbidities {e.g., COPD, diabetes, CVA, CHF, HTN, vision, Parkinson's disease, THR. osteoporosis) Task adaptation/modification to address pain, joint instability/protection, energy conservation, splint wearing, cognition Technique modification and refinement to reduce patient anxiety and enhance safe response and performance Postural alignment/control throughout task taking musculoskeletal issues into consideration (e.g. kyphosis, scoliosis, pelvic obliquity, leg length difference) Compensatory strategy training for visual perceptual deficits, neglect, sensory loss, unilateral weakness, cognitive deficits Safety (e.g., spontaneous sitting, hazard/obstacle identification, identification of unsafe situations)

 Caregiver training principles.... hand placement, skin integrity, tone Provide somatosensory, visual, vestibular challenges to balance . Simulate DC environment to provide comprehensive skill/safety training prior to DC

Don't forget Biofeedback

So your patient has contraindications to using electrical stimulation and you want to work on strengthening. It doesnt matter if you are in physical therapy, occupational therapy or speech-language pathology, its frustrating. Youd really like to enhance your exercise program and motivate your patient with some high-tech wizardry, but you cant, right??? WRONG!! Our Vectra Genisys Electrotherapy systems come with a Surface Electromyography (sEMG) feature. Essentially, its biofeedback. All the usual contraindications to the introduction of electrical current into the patients body are thrown out because no electrical current flows when you are using sEMG (be careful here, because current does flow to the patient if you choose the sEMG +Stim feature but thats another story!). Contraindication to the use of sEMG alone would be an unstable cardiac patient or other patient who should not elicit a val salva type maneuver. The effort put forth by the patient during a biofeedback session might cause an increase pressure that could be dangerous. In applying sEMG what you are doing is placing the units electronics on the surface of the skin and measuring the action potential in a muscle or group of muscles below the electrodes its a reading of the patients muscle fiber recruitment via the patients own electrical activity. This reading is beneficial in many ways. First, it provides objective, quantifiable, and documentable evidence of muscle activity particularly providing evidence of gains too small to be noted through standard manual muscle testing; thus providing evidence of the efficacy of exercise program instruction and follow through. Secondly, sEMG provides invaluable motor learning opportunities for the patient. Again, measurements of progress that are so small (microvolts) are amplified visually and aurally providing greater feedback to the patient than his/her own senses are capable of providing. Add to that the attempts of trying to hit or exceed the target bar and youve got a real motivator. And if its relaxation youre looking for, sEMG can help you there as well. Suppose youve got a patient who continually muscle guards or is highly anxious you can use the readings on the visual scale to tell your patient how well they are doing trying to relax and reduce the tension in the muscle(s). He/she simply tries to lower the number and the number of bars he/ she sees on the screen. Lets look at some of the features: The alarm settings there are three (3) of them. Alarm below this keeps the alarm ringing until the patient generates enough muscle activity to hit the target bar when that level of activity is sustained above the target level the alarm remains silent. This setting is good for several reasons

if youve set the patient up to exercise under supervision but you arent observing the patient the continually ringing alarm will tell you that the patient isnt working. The continuous alarm can also motivate the patient to work harder to turn it off. Alarm Target this setting allows the alarm to ring when the muscular activity is achieved and sustained in the range from 10% below to 10% above the target level. Use this setting when you want the patient to work to a certain level but not exceed the maximum of the range perhaps to avoid overachieving and damaging tissue. Alarm Above when this option is set, the alarm will ring as long as the muscular activity is sustained above the target level. A real motivator for those patients who need that extra push to achieve! Setting the target value again, there are three (3) choices. Target Max this setting establishes and sets the target bar value based on the highest level of activity measured during a 10 second test. While the unit counts down the 10 seconds the patient performs multiple repetitions of the activity (exercise) that will be performed during the sEMG session. The strongest repetitions value is then recorded as the performance target. You are given an opportunity to edit this value. You would do this based on your interpretation of the patients performance during test. If you feel the patients effort was too much, you can downgrade the value and vice versa. The value is then set and the white bar on the sEMG screen represents that value. This option is good for exercise programs where the goal is hypertrophy rather than muscle endurance. Target Average this is a 15 second test. The only difference from the description above is that the machine will average the values of the repetitions of muscle activity performed throughout the 15 minute test. This setting accounts for muscle fatigue and would be beneficial to use for a patient needing work on muscle endurance. The values would be lower than those of Target Max and thus more achievable repeatedly over the course of an entire exercise session. Target Manual this option allows the clinician who has used the sEMG previously with a patient to manually adjust the target value without the tests based on prior knowledge of the patients performance. Its that simple! Pick your options, program the unit, and set the patient to work! Should you have any questions please dont hesitate to ask!! -- Team TOPAZ

Understanding Pressure Ulcers

What do you need to teach your patients caregivers?
In looking at what information is pertinent for an untrained caregiver to know and understand about pressure ulcers the following can be used as a basis for that caregiver education: Pressure ulcers are common and frustrating problems that

can lead to a longer hospital or nursing home stay, and/ or slow down the recovery from medical illnesses. Several studies estimate their prevalence among older adults residing in long-term care facilities to be as high 28%. Infections like cellulitis, osteomyelitis, and sepsis are morbid complications of untreated pressure ulcers. Increased mortality has also been associated with chronic non-healing pressure ulcers. The treatment of pressure ulcers in the United States is estimated to cost more than $1 billion annually. A pressure ulcer, also called decubitus ulcer or bed sore is usually caused by prolonged external pressure that damages the skin and underlying soft tissue over a bony prominence such as the lower spine, buttocks, hips, and heels. Unrelieved pressure on the skin like sitting or lying in the same position squeezes tiny blood vessels that starve the skin of oxygen and nutrients leading to tissue death and formation of a pressure ulcer. Anyone who must stay in a bed, chair, or wheelchair because of illness or injury is at risk of developing one or more pressure ulcers. Other contributing factors for developing a pressure ulcer include sensory loss, shearing or friction forces, changes in mental status, exposure to constant moisture, bladder and bowel incontinence, heat buildup, taking certain medications, chronic illness (like diabetes, circulatory problems), poor nutrition, and age. Healthcare providers use Stages to describe pressure sores. How a pressure sore is treated may depend on its Stage. Stage 1 - The skin is not broken but the color of the skin changes. The redness of a Stage 1 pressure sore is nonblanchable, which means that the skin does not turn pale when you press on it. The skin may also feel firmer, warmer, or cooler than the skin around it. Pain or itching may be felt in the area. At this stage, protecting the area from further pressure may relieve the pressure sore. Stage 2 - The top layer of the skin and the skin just below it are damaged. The skin may be broken (like a cut or a scrape) or have a blister. Stage 3 - The damage to the tissue has gone into the fatty layer, and looks like a crater. The crater under the skin may be wider than the opening in the skin. Stage 4 - The pressure sore is a deep wound that goes down into muscle or to the bone. Unstageable - The base of the wound or wound bed is covered by slough (soft yellow, tan, gray, green, or brown dead tissue) and/or eschar (hard tan, brown, or black dead tissue) that prevents the full depth of the ulcer from being seen. Suspected Deep Tissue Injury - When there is a blood blister present or the area of intact skin has a maroon, or purple discoloration. It is usually painful, boggy, mushy, firm, warm or cold to touch. This is indicative of damage to tissue that lies deeper than the skin, but not yet to the skin itself. Suspected Deep Tissue Injury may begin at home prior to a hospital or nursing home stay and only comes to light during the stay as the individual becomes more sedentary due to illness or injury. Prevention of a pressure ulcer is the first step in healing one as repeated pressure will continue the tissue breakdown process, so caregivers need to learn to recognize some of the signs that might help in that prevention: LOOK for changes in skin color over bony areas. It may appear reddened and may not blanch (turn white) when

pressed. There could also be signs of bruising, rashes, opening in the skin, abrasion or blister. TOUCH the skin and check if the skin feels warm or cool. The affected area may also feel firm, boggy (feels like its filled with fluid), itchy or painful. Be sure to ask a member of the nursing staff for more detailed information and education about what else can be done help prevent pressure ulcers from starting or worsening. A brief review is offered here: Check the skin several times a day. Use long handled mirrors to check areas that are hard to see. Keep skin clean and dry. Use mild soaps and warm water to gently clean skin. Never rub or massage the area. Do not use cleansers that can dry out the skin (harsh soaps and alcohol). Use lotion or moisturizers if needed. Moisture from sweating, wound drainage, or urine can increase the risk of skin damage. Briefs or pads or that are highly absorbent will help and should be changed right away after a bowel movement or urination. Moisture barrier products can also be used. Change position often. Depending on the individuals body type, he or she will tolerate a turning schedule of two to five hours (turning from side to back to other side). The length of time between turns can be gradually be increased by adding 15 - 30 minutes to the amount of time in a given position and then checking for redness. Protect the skin over bony areas. Use pillows or foam wedges for positioning and support, for instance: placing pillows between the knees to prevent them from pressing on one another when lying sideways, or under the legs from midcalf to ankle to keep heels from touching the bed when lying supine, and buy special pads or a cushion for the chair or wheelchair that are made of foam, gel, water or air to decrease pressure on buttocks and hips. Pay special attention to correct posture and position. Resting directly on the hipbone when side-lying will put excessive pressure on the hipbone. Instead tilt forward or backward a little. Sit up straight in a chair or wheelchair. Ask a physical or occupational therapist to prescribe the best wheelchair for the individuals circumstances.

Topaz Times
See Ulcers on page 7
Seeking Professional Care Professional care of a pressure ulcer involves an initial and subsequent assessments with possible treatment via removal of dead tissues (debridement), wound cleansing and dressing changes; and the prevention, diagnosis and treatment of infection. These treatments are provided by physicians, nurses, and/or physical therapists that are specially trained in the treatment and management of wounds. Physical therapists can provide additional treatments for chronic, non-healing pressure ulcers of all Stages using therapeutic modalities such as ultrasound, short wave diathermy and electrical stimulation. Medicare however, limits this care to just Stage 3 and 4 pressure ulcers.

 Ultrasound facilitates wound healing by accelerating the normal wound healing process, promotes growth of new tissues, skin and blood vessels. It also increases blood flow into the area to improve nutrient and oxygen supply needed to heal the wound. Shortwave Diathermy also facilitates wound healing by improving local blood circulation, decrease edema, elevates skin threshold, increase cell function and activity; and eliminates waste products in the area that delays healing. Electrical Stimulation is used to stimulate production of new skin and underlying tissues by improving protein and DNA synthesis, increase cutaneous blood flow, alleviates pain, reduce edema, improve oxygenation and proven to have an antibacterial effect. Talk to an occupational therapist about a plan that balances work, play, and rest, and to analyze the relationships of the different risk factors to particular daily activities in both the home and work environments. Working in concert with the physical therapist, they can prescribe exercises to increase strength and balance that will increase mobility, improve posture and to enhance functional independence. Based on their thorough physical and cognitive assessments, occupational therapists will be able to identify appropriate assistive devices and equipment to redistribute or reduce pressure therapeutic surfaces) as well as provide education postural awareness while in bed or wheelchair.

MDS 3.0 Documentation Tips

Examples of Skilled Services Provided During Modality Treatments
As we have just transitioned to the new MDS 3.0 it is prudent to stop and refresh those thoughts we had generated in preparation for the transition. No, not those thoughts! The ones we had about what time can be counted toward the MDS when a modality treatment is being provided. As we recall, setup time (treatment preparation time) whether it is performed by a therapist, assistant, or aide is counted toward the MDS. Thats not to say that this is skilled time, as we do recognize that the services of an aide are not skilled, however CMS has included setup time in the countable time for MDS purposes. In addition to setup time or treatment area preparation time there is skilled time that a therapist or assistant will spend prior to initiating a modality treatment. This includes pre-treatment assessment of the patient in order to determine treatment parameter settings as well as positioning the equipment/device and/or patient for the treatment in order to achieve the goal determined by the pre-treatment assessment. For example, a patient with a diagnosis of muscle spasm in the lower back would be assessed each day for appropriateness of continued treatment with IFC. Having determined that it is appropriate to continue the therapist would assist the patient into a comfortable position for treatment that would not place additional stress on the lower back, apply the electrodes, set up the electrical stimulation unit for the IFC treatment, and commence treatment adjusting the treatment parameters to the patients tolerance. All of those activities up until the timer on the electrical stimulation unit

begins running would be skilled services that are part of setup and should be counted on the MDS. After the timer begins running there are different aspects of treatment for each modality during the course of treatment that are considered skilled and should be included in the time applied toward the MDS. Ultrasound is simple. All aspects of an ultrasound treatment are considered skilled. Only the skills, knowledge, and judgment of a therapist/assistant can ensure a safe and effective treatment. We have received specialized training in the appropriate speed of movement of the sound head, the technique for good coupling of the sound head to the patient, in determining the size of the area to be treated to achieve our goal, and the adjustments to be made during treatment according to patient tolerance, to name just a few of the skills employed. We also assess the patient at the end of the ultrasound treatment to determine effectiveness of the treatment. All of that time should be counted toward the MDS, and dont forget the setup time!! Shortwave Diathermy is a little different. It has long been considered a supervised modality. CMS has stated that when the residents condition is complicated and the skills, knowledge,... and judgment of the therapist are required for treatment, then those minutes associated with skilled therapy time may be recorded on the MDS. So it is left to the clinician to determine when the skill occurs in a shortwave diathermy treatment as CMS states that not all time in the treatment is necessarily skilled. Some examples of skilled service provided after treatment setup and pre-treatment assessment would be: - Thermal treatment temperature testing to determine appropriate intensity setting: Documentation Example: Performed treatment temperature testing multiple times throughout treatment to determine treatment tolerance. No change in intensity needed during treatment. - Assess skin in treatment area multiple times throughout treatment: Documentation Example: Interrupted treatment to assess tolerance through visual inspection of skin in treatment area. Mild erythema and moderate perspiration noted. Wet single terry cloth layer replaced with dry single layer. - Modifying position when treatment goal is increasing ROM: Documentation Example: Paused treatment at mid-point to reposition patient into position of greater stretch in order to take advantage of increased circulation and increased soft tissue extensibility already achieved. Electrical stimulation when used for pain management follows along the same pathway as shortwave diathermy. There will be portions of treatment that are skilled and portions potentially that are unskilled. However, not all of electrical stimulation treatments follow this path because other interventions such as exercise or functional activities, etc. may be taking place simultaneously with the electrical stimulation and the time spent providing those treatments will be skilled. Some examples

of skilled services provided during an electrical stimulation treatment are: - Assess appropriateness of electrode placement and intensity setting: Documentation Example: Paused treatment several times during the course of estim session to perform visual inspection of skin under electrodes. No changes in skin noted. - Documentation Example: Performed visual observation of muscle contraction in NMES treatment after patient shifted position. Tetany no longer being achieved. Repositioned patient for comfort, reapplied electrodes, set intensity to achieve tetany at comfortable level for patient. - Assess maintenance of clean field throughout treatment: Documentation: Wound site assessed after patient movement to determine if clean field still being maintained. No interference in clean field noted. Patient counseled to notify therapist of discomfort to allow therapist to help in repositioning without interruption of clean field. The most important thing to remember as we move forward under MDS 3.0 is to document. Document, document, document. We can provide all these skilled services and many more, yet, if we dont write them down they didnt happen.... - TEAM TOPAZ

Physical Therapy Nursing Supportive Documentation

Rehab Activity Suggested Nursing Observation/Documentation
Ambulation Address the patients ability to ambulate on the unit. Include distance and any assistance required. This could include staff or a device such as a walker. (Example: Ambulated in hall with the assistance of a CNA. Patient ambulated 25 feet to and from the bathroom with a walker and assistance of one.) Transfers Discuss the patients ability to transfer and how much assistance if any is required. (Example: Patient transfers from bed to chair with the assistance of one CNA. Patient requires cueing not to bear weight on left leg.) Bed Mobility Describe the patients ability to move about the bed including positioning devices used and assistance provided. (Example: Patient rolls side to side with use of the side rails with minimal cueing. A pillow is placed between knees.)

Supine to sit Describe the patients ability to sit up from a recumbent position. Include any assistance required as well as a description of any compensatory techniques. (Example: Patient needs assist of 2 to stand. Unable to bear weight on legs. Needs support at knees to keep from buckling.) Balance Discuss the patients ability to sit or stand without loss of balance. This should include any compensatory devices or assistance required. (Example: patient attempts to take several steps unassisted when transferring from bed to chair, but balance is unsafe and patient is at risk for falling.)