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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?"
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.
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.
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.
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).
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
|
|
|
|
|
Elbow
|
|
|
|
|
Shoulder
|
|
|
|
|
Knee
(contracture
goals can also be written for hips, though you obviously won’t splint hips)
|
|
|
|
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).
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
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
