Goal Writing and Step by Step Instructions for Management of Joint Contractures and Splinting in SNFs

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I received an email from John who wrote,

"Can you provide me with some specific goals for contractures that are functional, measurable and objective that you've used?"

 

best way to measure contractures

 

Thanks, John, for the nudge...

Allow me to sound off from my soapbox about contractures. We can really write good functional goals if we catch the contractures before they become moderate to severe.

Do not wait until a patient or resident cannot stand up or transfer due to 45 degree knee flexion contractures! Catch them when they are just starting to bend at the knee as they stand. Do not wait until the hand is so tight that the fingernails have broken the skin on the palm.

You can screen everyone in the dining room

at one sitting

by asking the residents 

to open and close their fingers

or straighten their legs or elbows. 

It's really that simple.

You get the idea...

OK. Goal writing, along with step-by-step instructions for splinting Tre-style...

 Caveat: This is not a complete listing of goals. Think about your residents/clients and what functional tasks are important to them. This information may or may not jive with your ideas about splinting and documentation. I have never experienced denials on my documentation or the review process through CMS/intermediaries, and I have been involved in reviewing documentation/managing ADRs as a DOR and an RVP.

 

got to have them!

 

When documenting treatment of contractures with orthotics, you want to document two things:

1) the progression through the splinting process, and

2) the functional response to the application of orthotics.

1) PROGRESSION THROUGH THE SPLINTING PROCESS

You've already determined the person has a joint contracture.

You can't just write one goal for splinting. The process sequences in the following order:    

A) Pick the splint. Measure for it. Order it.

 

Splinting is complex!

If you have questions about how to choose a splint,

email me at treccad@gmail.com

 

GOAL: Client/resident will participate in identification, measurement and ordering of appropriate orthotic to address joint integrity deficits of (contracted joint) by (date).  (written at evaluation)

B) Splint arrives. Fit it. Modify it.

GOAL: Client/resident will participate in fitting and modifications of (ordered orthotic) to (contracted joint) by (date) to increase (contracted joint) AA/PROM for promotion of functional independence or reduction of CG assistance. (written at the first progress note)

...be patient...function is next...

By the way...at fitting and donning, check fit to ensure that two of your fingers fit under the straps; otherwise, you're going to find strap marks on the person when you go to doff the splint.

 

Two fingers should fit under each strap to prevent pressure...

C) Start wear time at 15 minutes on day one. Increase 15 minutes daily until your long-term goal of 3-6 hours.  Stay with the patient through the whole wear period the first three treatments of wear.

Don't slap a splint on for 2 or 3 hours on day 1!

You'll lose any hope of compliance if you do

because your patient/client/resident will be

in pain.

Note: not every resident is capable of tolerating 6 hours of daily splint wear. Over the years, I have seen 2-3 hours/daily work just fine if the orthotics are applied consistently. The key is staff education and consistency.

GOAL: Patient will increase wear time of (orthotic) to (time daily, i.e. 3 hours) for promotion of low-load passive stretch to (affected joint).

2) THE FUNCTIONAL RESPONSE TO THE APPLICATION OF ORTHOTICS

As you increase wear time and improve joint integrity/AA/PROM, you will progress toward development of more functional goals. I have also used photography of the affected joints with resident and family approval to provide a visual aid to document improvement in joint integrity.

...and now, function:

GOAL: Patient will:  (pick your functional activities below)..

Joint	Action	Functional Gain  (LOA = level of assistance)	Area of Improvement
Hand Fingers	Improve grasp of utensils at meals Improve grasp on toothbrush or brush  Increase ability to straighten fingers (go to 3rd column)	To feed self with (LOA To groom  self with (LOA)	To prevent  fingernails from digging into palm for promotion of optimal skin integrity. Document presence of fingernail marks or photograph hand. To promote accelerated healing of wound in palm. Make sure wound  info is documented. Photograph.
Elbow	Straighten arm (to degrees)     Straighten arm (to degrees) (go to 3rd column)	To brush hair with (LOA) To dress UE with (LOA)	To reduce CG burden when dressing UE from () to () To promote optimal skin integrity and (%) reduction in size of wound of elbow crease (for severe contractures and wounds in elbow crease)
Shoulder	Lift arm (to degrees)                     Lift arm (to degrees) (go to 3rd column)	To dress UE with (LOA)  To reach overhead into kitchen cabinets To reach for car door when transferring to/from car To lift items from shelves into cart at grocery store	To reduce CG burden when dressing UE  To reduce CG burden to provide hygiene under arms during bathing
Knee (contracture goals can also be written for hips, though you obviously won’t splint hips)	Straighten legs to (degrees)    Promote improved standing posture and WB through B LE’s (go to 3rd column)	To promote increased standing tolerance and stability during LB clothing management To promote improved posture and standing tolerance to (# of min) while standing at sink to groom.	To reduce CG burden during toilet transfers from () to () To promote optimal stability during sit to stand for reduced risk of falls from wheelchair  (or bed or toilet) – this is for people with documented fall histories – make sure to analyze surfaces from which they have fallen - in addition to other factors...

 

4) Always assess the skin integrity and document the skin condition in daily note after orthotic wear.

 

DAILY TX NOTE: (Client) wore B Flex Knee orthotics for 45 minutes while supine in bed  to provide passive low-load stretch for optimal knee extension and positioning of LEs during naptime. Skin was assessed following doffing of splints; reactive hyperemia (redness) was observed over patella areas and blanchable erythema resolved within (time frame, i.e. 30 seconds).

 

About reactive hyperemia:  (this is normal during splinting)

Usually, reactive hyperemia is the first visible sign of ischemia. When the pressure causing ischemia is released, skin flushes red as blood rushes back into the tissue. This reddening is called reactive hyperemia, and it's due to a protective mechanism in the body that dilates vessels in the effected area to increase blood flow and speed oxygen to starved tissues. Reactive hyperemia first appears as a bright flush that lasts about one-half or three-quarters as long as the ischemic period. If the applied pressure is too high for too long, reactive hyperemia fails to meet the demand for blood and tissue damage occurs.

About blanchable erythema: (you want the skin to blanche. If it stays completely red, you have a Stage I pressure sore developing, and you need to contact the nurse.)

Blanchable erythema can signal imminent tissue damage. Erythema results from capillary dilation near the skin's surface. In the patient with pressure ulcers, the redness results from the release of ischemia-causing pressure. Blanchable erythema is red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed. Tissue exhibiting blanchable erythema usually resumes its normal color within 24 hours and suffers no long-term damage. However, the longer it takes for tissue to recover from finger pressure, the higher the patient's risk for developing pressure ulcers.

 

My favorite company, ACP, who provides modalities in SNFs, used to handle orthotics. They now provide orthotics through Orthopedic Rehab Products, a Hangar company. They can send you a DVD of all their order forms, which include criteria for the specific conditions indicated for each splint, as well as other administrative forms necessary for ordering splints. (Good info for another post...)

anyway, call Monica or Miranda at ORP at 800.652.1136. They'll be happy to send you a DVD catalog/order forms. (hours: 8-4;30 MST)...

I am in the process of packing for a 2-week excursion to Guatemala to practice medical Spanish, so I have to close! I do hope this post helps you with splinting and goal writing. Drop me a line if you have questions or you want more goal ideas.

Hasta luego,
Tre