Ot Treatment Protocols St Barnabas Hospital 2007

7/28/2019 Ot Treatment Protocols St Barnabas Hospital 2007

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OCCUPATIONAL

THERAPY

ST BARNABAS

HOSPITAL

PROTOCOLS

1 | P a g e


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PROVINCE OF EASTERN CAPEISEBE LEZEMPILO/ DEPARTMENT OF HEALTH

ST BARNABAS HOSPITALST BARNABASHOSPITAL

P. O. Box 15Libode5160

Tel: 047 568 6872Fax: 047 568 7100

ST BARNABAS HOSPITALOCCUPATIONAL THERAPY

DEPARTMENTLIBODE

POLICY DOCUMENTS INDEX

Protocol TITLE

1 HEAD INJURY PROTOCOL2 CARDIAC REHABILITATION PROTOCOL3 CEREBRAL PALSY PROTOCOL4 CVA OCCUPATIONAL THERAPY TREATMENT PROTOCOL5 PROTOCOL ON OT INTERVENTION WITH BURN INJURIES

6 SPINAL CORD INJURY OT PROTOCOL7 ASSESSMENT AND TREATMENT OF A PATIENT WITH

ARTHRITIS

8 NEONETAL AND EARLY INTERVENTION PROTOCOL9 FLEXOR TENDON INJURIES PROTOCOL

10 EXTENSOR TENDON PROTOCOL

11 RADIAL NERVE PROTOCOL12 ULNAR NERVE PROTOCOL13 MEDIAN NERVE PROTOCOL14 BOUTONNIERE DEFORMITY PROTOCOL15 MALLET FINGER PROTOCOL16 BRACHIAL PLEXUS PROTOCOL17 CARPAL TUNNEL SYNDROME PROTOCOL18 AMPUTEES PROTOCOL19

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2122

23

24

25

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HEAD INJURY PROTOCOL

PURPOSE:

To provide comprehensive, accurate assessment findings, realisticpatient specific treatment interventions in accordance to nature ofinjury

PROCEDURE

ASSESSMENT

Duration: 1 Hour

A) Background information (nature of injury, medical historyand biographical information)

B) PRE-FUNCTIONAL

Level of consciousness Muscle Tone. Range of movement Co-ordination

Balance Perception Cognition Posture

C) FUNCTIONAL

Mobility Self care (bathing, dressing, feeding, toileting,grooming) Domestic work Work Interpersonal relationships Leisure

See Annexure: Assessment Format

TREATMENT GOALS

Duration: Based on medical and functional prognosis

Improve pre-functional components.

Prevent contractures


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Mobility training (need for mobility aid e.g. wheelchair,walking aid) Prevent contractures (use of splints) Assistive devices to aid with activities of daily living Family counselling in terms of home care Provide recommendations for adaptations to homeenvironment Sensory stimulation Perceptual Training All functional areas Counselling of patients family

PHASE ONE

A) Intensive care phase

1. Physical1. Normalizing muscle tone2. Controlling abnormal reflex activity3. Preventing contractures4. Improving balance, co-ordination, righting reactions.5. Sensory re-education6. Sensory stimulation

B) Psychological1. Reducing anxiety and fear2. Building up IPRS

3. Orientation4. Improving memory and concentration5. Improving motivation and c-operation6. Counseling especially to family

C) Functional

1. All aspects of daily living.

PHASE TWO

Patient now more cooperative and treatment sessions can now belonger and more dynamic. Particular emphasis on retrainingfunctional ability in all spheres especially personal managementand mobility. Patient should be incorporated in a fairly wellbalanced day programme to include occupational therapy,physiotherapy, speech, rests etc.

LATE PHASE

Focus on discharge, home and work. Family counseling, prepare

home programmes. Patient usually comes as out patient regularly,gradually decrease, later monthly checkups until not necessary.


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Home programme

Exercises Correct body positioning Exercises

DESIGNATION: .

SIGNATURE:..................................

DATE:.........................CARDIAC REHABILITATION PROTOCOL

OBJECTIVES To provide uniform OT services for patients with cardiac

conditions

To assist patients with cardiac dysfunction in achieving

maximal functional level of independence

To educate patients and families regarding ongoing treatmentand ensure consistent home management of the patientsafter discharge

To assist the families and patients in adjusting to thedisability and life changes

PROCEDURE

The priority ofassessment and procedures should bedetermined by each individual patients needs

A full assessment can begin during the doctors first physicalexamination of the patient

As a member of the multi-disciplinary team, the OT listens forproblem areas in personal care, social or interpersonal, workand leisure times spheres

The OT can thus already provide comments and information

regarding the doctors immediate referral and enquiry

Before the OT interviews the patient personally, s/he shouldconsult the patients file for results and special evaluations

The OT interview should be planned after the results of thestress ECG and angiogram are known, as treatment will beplanned according to these results, especially regardingenergy saving principles

The OT must always be aware of patients blood pressure,pulse rate and fitness level

The main points to be obtained during first interview include

the following:

The patients psychological condition


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Problems being experienced presently including sleepdisturbances, anxiety, tension, stress, relationships, andworking environment. The patients limited insightregarding his/her condition should be established.

The OT should listen to the patient effectivelythroughout the interview and reflect the patientsfeelings

ASSESSMENT

Patients basic background information

Include space for specific diagnosis example: Myocardial

infarction/Angina pectoris

Tools used in Cardiac assessment: Heart rate; Blood

Pressure; ECG readings; signs and symptoms of cardiacdysfunction and heart sounds.

Classify pt according to four functional categories.

CLASSIFICATION OF PATIENT

CLAS 1: Pts with cardiac disease but without resultinglimitations of physical activity. Ordinary physical activitydoes not cause undue fatigue, palpitation, dispnea or

anginal pain.CLAS 2: Pts with cardiac disease resulting in slightlimitation of physical activity. They are comfortable at rest.Ordinary physical activity results in fatigue, palpitation,dyspnea, or anginal pain.CLAS 3: Pts with cardiac disease resulting in markedlimitation of physical activity. They are comfortable at rest.Less than ordinary physical activity causes fatigue,palpitation, dyspnea or anginal pain.CLAS 4: Pts with cardiac disease resulting in inability tocarry on any physical activity without discomfort.

Symptoms of cardiac insufficiency or of anginal syndromemay be present even at rest. If any physical activity isundertaken, discomfort is increased.

Chart review: Conduct a thorough chart review if available.Familiarize yourself with the patients condition andunderstand any specific precautions before first pt contact isestablished.

Patient interview

Obtain activity history.

Activity Pre-Admission Current Status


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StatusBed Mobility

Transfers

FunctionalAmbulationSelf-care

Hygiene

Dressing

Bathing

Toileting

Homemaking/Grocery shoppingVocational andAvocational

Endurance(typical day)

Monitored Self-Care Evaluations: Choose a low-level (anactivity that require a low energy expenditure) self-careactivity based on the patients past medical and functionalhistory.

ORTHOSTATS:

Supine Sit Stand Sit SupineHeart rate

BloodpressurePRECAUTIONS AND CONTR-INDICATIONS

Monitor the patient for shortness of breath, chest pain,nausea, vomiting, dizziness and fatigue

Adhere to activity guidelines for the designated MET level(MET = metabolic cost of activity based on rates of oxygenconsumption during the activity).

If an appropriate response to any MET level of activity occurs,

notify the doctor, modify or discontinue the activity andrevise the patients treatment program


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Avoid activities that involve isometric muscle work, strainingand breath holding, or extensive arm holding over head

Be aware that patient who has undergone open-heart surgery

should avoid lateral arm exercises that stretch the chest andpull on the incision

Know the options of referring physicians and facilities beforerecommending that the patient return to prior level of sexualactivity

Be aware that exercises are contra-indicated for the followingconditions

Unstable angina

Resting diastolic blood pressure 120mmHg or restingsystolic blood pressure 200mmHg

Uncontrolled arterial or ventricular arrhythmias

Second or third degree heart attack block

Orthostatic systolic blood pressure drop of 29mmHg ormore

Resent embolism either systemic or pulmonary

Thrombophlebitis

Dissecting aneurysm

Fever greater than 37,7C

Uncompensated heart failure

Primary, active pericarditis

Severe aortic stenosis

Acute systemic illness

Resting heart rate greater than 120 beats/ minute in apatient with a recent MI.

TREATMENT

Patients are usually seen once or twice on an out patientbasis

The main aim of the session/s is to educate the patients with

regards to the following:

Improve the patients and the familys insight into thecondition and the future implications

Information about activity requirements, energy savingskills and principles

Discuss the possible need for lifestyle modification andexplore methods of pursuing these changes

Stress management- maintaining a balance of activities- day and time management- reducing the source of stress- problem solving- relaxation therapy

Assist the patient and his family in their psychologicaladjustment to the disease


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Improve social skills for example, assertiveness ( may)necessitate long term follow up

Work related- suggestions regarding: alternative methods or

alterations in work setting- work visitations, if appropriate

Written information together with the practical execution ofenergy saving principles and stress management can begiven to each patient

The required amount and type of treatment sessions aredetermined by the amount of problems experienced by thepatient and the progress of the patient, for example, duringthe practical execution of the program, the blood pressureand pulse rate must be taken before and after each activity.

Compiled by: N. N. Tikilili Assistant Director: Occupational

Therapy

Date: 12 April 2007

Date of review: April 2008

CEREBRAL PALSY PROTOCOL

OBJECTIVES

To assist patients achieve maximal level of function and

independence in ADL within the limitations of their disabilities


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To facilitate normal developmental milestones throughstimulation and handling

To educate caregivers regarding their childrens conditions

and their role in management

PROCEDURE

Management of individuals is done in a multi disciplinaryapproach

On first contact, a patients file should be opened and a filenumber be allocated. The file should be kept on currentpatients file and will only be removed when the patient hasbeen discharged.

Assessment of all referred cases should include:

A) HISTORYq Establish reason for referral e.g. delayed milestones.q Detailed birth history and developmental history.

B) PRE-FUNCTIONAL COMPONENTSq Muscle tone abnormality (hypotonia/spastic muscle)q Poor range of movement (active and passive) as a result of

spasticity.q Abnormal postural patterns, reflexes and righting reactions.

(Based on the above assessment findings, one can deduce the typeof cerebral palsy ie. athetoid, hemiplegic, ataxic, spasticquadriplegic.)

C) DEVELOPMENTAL MILESTONESq Head control (prone ,supine & sitting)q Trunk controlq Mobility

o Rolling

o Pull to sito Sittingo Creepingo Crawlingo Pull to stando Standing

o Walking

q Hand Function- Hands to midline- Reaching- Gross grasp- Releasing

- Manipulating objects- Bilateral hand use


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q Functional Assessment- Feeding- Toileting- Play- General behaviour

q Patients should be reassessed at every contact and progressnote should be noted on the patient file.

TREATMENT

Monthly individual treatment should commence with clearexplanation of childs condition, possible causes, effects andplanned treatment for the child.

Treatment entails the following but is not limited to thementioned

Positioning to facilitate normal movements and preventcontracture formation

Stimulation to reach following developmental milestone

ADL training

Splinting if necessary

Education of caregivers on management of a CP child

Issuing of home programmes

Assistance with regards to school placement

Prevent contracture formation through passive exercises andstretching and massage.

Normalisation of muscle tone through use of weight bearingand passive exercises.

Encourage normal developmental patterns, through

positioning and NDT.

Teach caregiver correct positioning to carry over as a homeprogramme. Useful with feeding and adapted play methods,in order to gain maximum sensory and motor stimulation.

Use of pillows, CP chairs and wedges for positioning.

Specially adapted play activities to encourage motordevelopment and sensory stimulation.

Wheelchairs or buggies are arranged for children with severedisabilities.

Later stages, when child is able to sit independently, hasbladder, bowel control and is able to focus, appropriate schoolplacements are arranged.

Provide positioning for various functional activities that isfeeding etc.

Provide assistive devices in terms of wheelchairs.

Patients should be given home programmes - see attached

on handling CP child


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HOME PROGRAMME

Please see attached booklets:q Handling a CP childq Activities for hand controlq Home programme for self care activities i.e. dressing.

LENGTH OF TREATMENT

Therapy begins as soon as the child presents with delayedmilestones or any abnormality in development.

Therapy is a long, ongoing process.

It largely comprises of out patient therapy and carry - over oftreatment as home programmes.

It is a teamwork approach, together with rehabilitative team,

medical doctors and caregivers.


Therapy

Date: September 2007

Date of review: September 2009


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CVA OCCUPATIONAL THERAPY TREATMENT PROTOCOL

OBJECTIVES

To provide uniform Occupational therapy services for thepatients with CVA / Stroke

To assist patients with CVA/ Stroke in achieving maximalfunctioning level of independence

To educate patients and their families regarding ongoingtreatment and ensure consistent home management of thepatient on discharge

To assist patients and their families in adjusting to thedisability and life changes

PROCEDURE

SCREENING AND ASSESSMENT

The priority of assessment procedures should be determinedby each individual patients needs.

A full functional and physical assessment follows as soon aspossible after the doctors first medical examination of thepatient

The OT must always be aware of the patients blood pressureand pulse rate during assessment. (the pt. should be full

conscious and stable ) Important information relating to patients condition can be

obtained from the patients bed letter, nursing personnel andother team members involved in the management of thepatient

The following information must be obtained during the initialscreening and assessment:

Background information

Clinical history: current and previous medical history


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Social history: Family relationships, roles, lifestyle, supportnetwork, career and responsibilities.

Environmental considerations : Accommodation , layout,adaptations needed,

Functional Abilities: bed mobility, transfers, general mobility,self care, personal hygiene.

Physical sensory impairments: tonal problems, pain, sensoryproblems and hemiplegia

Cognitive impairments: short term memory, attention andconcentration, executive functioning

Perceptual difficulties: body image, dyspraxia, agnosia andunilateral neglect

Communication difficulties: dysarthria, expressive andreceptive aphasia

Psychological impairments: mood, liability, adjustment to

disability, feelings about self and others Motivation and attitude

TREATMENT

PROTOCOL ON OT INTERVENTION WITH BURN INJURIES

PURPOSE:To provide comprehensive assessment findings, formulate realisticpatient treatment interventions in accordance to nature of injury.

PROCEDUREASSESSEMENTA) Background information (nature of injury, medical history andbiographical information)

B) PRE-FUNCTIONAL1. Pain

2. Range of Movement

3. Muscle strength

4. Endurance

5. Function limited due to extent of burns

C) FUNCTIONAL1. Mobility2. Self care (bathing, dressing, feeding, toileting, grooming)

3. Domestic work

4. Work


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5. Interpersonal relationships

6. Leisure

TREATMENT GOALS

1. Maintain joint mobility2. Maintain general muscle strength and endurance

3. Maintain or improve functional ability

4. Promote psychosocial adjustment to pain and body imagechanges.

5. Improve pre-functional components

6. Prevent contractures (use of splints)

7. Scar management (pressure garments)

Pressure GarmentsEarly StagesApply garment as soon as possible, usually 3-4 weeks after burn or

grafting.The doctor usually recommends. Any open or tender areas can be

padded or bandaged and the garment worn over this.The first garment is usually lined with a soft material and is not verytight.

Intermediate stageThe skin is stronger and no longer needs dressing. Garment tension

increases.

Rehabilitation StageGarment tension is strong to decrease keloid/ scar formation.May need to make new garment every 3-4 weeks due to short

lifespan omaterial

PRESSURE GARMENTS

Selection of Garment Design

The following should be considered. Location of burn Location grafts/donor site

Stage of healing

Tensile strength of healed burn

Wearing Regime1. Should be worn 23-24 hours per day, only remove when bathing

or eating (if wearing face mask)2. Two sets of garments should be provided, ie. Wear one, wash

one


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3. Garments should be worn inside out to prevent seams fromcausing pressure sores.4. Avoid rolling or creasing of the garment as this could causeswelling.5. The tighter the garment, the more effective it is.

Washing Regime1. Hand wash in luke warm water using mild detergent2. Don't wring or iron garments3. Don't hang out to dry in the sun or in front of a heater. This is toprevent the elastic from perishing too quickly.

Guidelines to patients on the use of pressure garments1. Explain to patient purpose and importance of pressure garmentusage.

2. Counsel patient on the consequences of non adherence topressure garment therapy and provide booklet on pressure garmentcare.3. If swelling or loss of sensation or cyanosis of the skin occurs, thepatient must be advised to discontinue wearing and contact his/herOT as soon as possible.4. Advise the patient that after several hours of wearing, the burntareas may become darker in colour. This is a natural reaction topressure on the skin and the patient need not become anxious overthis.5. Inform the patient hat blisters may sometimes occur during the

healing process. These areas must be covered in padding beforeapplying the garment.NOTE: blisters caused by application of pressure garments shouldresult in discontinuation of pressure garment wearing.6. If there is discomfort (eg in contracted areas), foam inserts maybe applied. If this continues, the doctor may be consulted forcontracture release.7. If the patient should lose or gain considerable weight, it willreduce the efficiency of the garment or cause it to become tootight. Adjustments will need to be made by the therapist.8. Advise patient not to use petroleum lotions or vitamin E oil whilewearing garments as this reduces the efficiency of the garment bydestroying the fabric elastic.9. Advise patient on out patient follow-up

Usually once a month for approximately 8 months.Thereafter, depending on progress, every 2-3 months

All garments must be brought to any appointments so that allcan be checked and altered if necessary.

Provide a contact telephone number should the patientexperience any problems


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Advise the patient that when the burn scar has matured andis no longer active , the garments be slowly discontinued, e.g.12 hours on, 12 hours off

Home programme: Pressure garment care and usage Prescribed exercises

Massage technique for scar management


Therapy

Date: September 2007



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SPINAL CORD INJURY OT PROTOCOL

OBJECTIVES:

To provide uniform OT service to all patients with Spinal CordInjuries (SCI)

To assist the patients with a SCI to achieve and maintain

maximum independence in their community, after beingrehabilitated in a spinal unit

PROCEDURE:The most important initial indicator: level of lesion (partial/complete & stable/ unstable fracture of the vertebrae)

ACUTE PHASEPhysical assessment should include:

Muscle strength

ROM

Endurance

Hand function

Posture Balance

Bladder and bowel status

Skin integrity(pressure points or areas)

Neurological assessment should include:

Sensation

Muscle tone

Reflexes

Psychological assessment should include: Level of creative ability, where appropriate.

Stage of grief

Insight

Support structure

Taking the above assessment into account, the Therapist must planthe patient treatment.

ACUTE PHASE: (SHOCK PHASE, IMMOBILIZED IN BED)


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Ward rounds will be done with multi-disciplinary teamdiscussing patient and treatment

Immobilization stage: NO flexion, rotation or extension of

spinal cord or neck

Positioning: position to prevent shortening of muscles orcontractures (specifically important for the muscles below SClesion)

Pressure care: position patient on ripple-mattress, sheepskinetc. if available

Splinting: for high SC lesion anti-deformity splints

Active ROM at joints, which are able to move

Passive ROM at joints, which are unable to move

Light ADL activities e.g. eating, writing and self care

Assistive devices: universal cuff

Psychological support: assist patient to develop insight intothe diagnosis and prognosis

ACTIVE: (SITTING UP, MOBILIZATION AND REHABILITATION)

Bed mobility and transfers

Sitting in wheelchair: develop upright tolerance

Wheelchair mobility training

High priority in this phase should be pressure relief indifferent positions

Start bladder and bowel regime in conjunction with the

medical team Sexual counselling: see attachment on sexuality

Active and passive ROM exercises should be maintainedregularly to prevent contractures

Splinting: continuous splinting, necessary (e.g. tenodesissplint)

Static and dynamic balance in sitting

Physical endurance and co-ordination, especially with C& Tlesions

Muscle strength: progressive resistive exercises and

activities applied to innovative and partially innovativemuscles

Assistive devices and adaptive methods for ADL activities

e.g. button hook, wash mitten, universal cuff, transfer board,adaptive dressing methods etc

Psychological support & improvement of social skills andcommunication especially with caregivers and familymembers

REHABILITATION PHASE: (PREPARATION FOR DISCHARGE)

Work adjustments, home environment adaptations


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Consultation with employer to discuss possible ways ofaccommodating patient in the workplace

Family education

Home visits, where appropriate

Discharge patient with necessary assistive devices Follow-up at rehabilitation outreach clinic or OPD

COMPLICATIONS THAT COULD OCCUR DURING TREATMENT

ORTHOSTATIC HYPOTENSION: due to lack of muscle tone

in the abdomen and lower extremities, pooling of blood inthese areas with resulting in decreased blood pressure whenthe patient suddenly changes position (especially supine toupright). The patient will present with dizziness, nausea andloss of consciousness. Patient needs to be tipped backwardsand legs elevated until symptoms have subsided

AUTONOMIC DYSREFLEXIA: this is a phenomenon seen inpatients whose injuries are above T4-T6 level. It is caused byreflex reaction of the autonomic nervous system in responseto some stimulus, such as a distended bladder, fecal mass,bladder irritation, rectal manipulation, thermal or pain stimuli,and visceral distension. The symptoms are immediatepounding headache, anxiety, perspiration, flushing, chills,nasal congestion, hypertension and bradycardia. Autonomicdysreflexia is a medical emergency and life threatening. Thepatient should not be left alone. It is treated by placing the

patient in an upright position and removing anythingrestrictive such as elastic stockings to reduce blood pressure.The bladder should be drained or leg bag tubing should bechecked for obstruction. Blood pressure and other symptomsshould be monitored until back to normal. Occupationaltherapists must be aware of symptoms and treatmentbecause dysreflexia can occur any time after the injury.

If autonomic dysreflexia occurs during a treatment session, thetherapist should position the patient upright and get a doctorimmediately


Therapy

Date: 12 September 2007


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PROTOCOL ON THE ASSESSMENT AND TREATMENT OF APATIENT WITH ARTHRITIS

PURPOSE:

To provide comprehensive assessment findings, formulaterealistic patient treatment interventions in accordance tonature of injury.

PROCEDURE

ASSESSEMENTA) Background information (nature of injury, medical history andbiographical information)

B) PRE-FUNCTIONAL1. Life style analysis

2. The OT gains clear insight into all activities of daily living of thepatient and analyze those specific tasks, which result in


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excessive stress to the joints. Assess how the working day canbe re-structured in order to provide more rest and minimalactivity. Determine patients support systems. Is the familywilling to co-operate and take over chores at home?

3. Pain4. Range of Movement

5. Muscle strength

6. Endurance

7. Hand Function

8. Balance

C) FUNCTIONAL1. Mobility

2. Self care (bathing, dressing, feeding, toileting, grooming)3. Domestic work

4. Work

5. Interpersonal relationships

6. Leisure

TREATMENT GOALS1. Prevent joint stress , pain and deformity (Educate patients on

joint protection principles)1

2. Maintain joint mobility

3. Maintain general muscle strength and endurance

4. Maintain or improve functional ability

5. Develop adaptation and problem solving skills to deal withchanges to lifestyle.

6. Promote psychosocial adjustment to chronic disability, painand body image changes.

7. Improve pre-functional components.

8. Prevent contractures9. Mobility training (need for mobility aid e.g. wheelchair,

walking aid)

10. Prevent contractures (use of splints)

11. Assistive devices to aid with activities of daily living.

12. Application of ergonomic principles.

13. Provide recommendations for adaptations to homeenvironment

1


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GENERAL PRINCIPLES1. Never work beyond the patients pain threshold, i.e. Workingwithin the limits of the pain is acceptable but the moment theintensity of the pain becomes worse with activity the patient shouldstop what s/he is doing.

2. Re-define your daily activities or routines with your OT, to ensurethat they can include a work rest work process throughout the day.

3. Never perform activities which result in excessive stress to theaffected joints, rather try another method or use other parts of thebody to compensate e.g. instead of pushing self up from chair withwrists use forearms. Alternatively, where necessary get familymembers to take over those chores for the patient.

4. Always ensure that affected joints are resting in the mostcomfortable and normal position possible. At night place a pillowbetween knees and thighs of patient and pillows for forearm andwrist may also help to ease the pain.

5. Daily exercise routine based on exercises given by yourPhysiotherapist and Occupational therapist is important. Gentlewalking on flat green grassy terrain and swimming are excellentactivities.

Home programme:

1. Implementation of joint protection principles2. Practice energy conservation.

3. Ergonomic adaptation to home environment.


Therapy




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NEONETAL AND EARLY INTERVENTION PROTOCOL

OBJECTIVE:

To provide uniform OT services to all babies at riskTo implement a programme for babies at risk in order to ensure that theyreceive optimal treatment

PROCEDURE:

Doctors at neonatal unit must refer babies with the following diagnoses toOT, using the OT referral form.

o Babies with birth complications

o

Premature babieso Prolonged hospitalisation

o CP

o Congenital deformities/ birth defects

o Hydrocephaly

o Microcephaly

o Erbs palsy

o Klumpkes palsy

The therapist then signs the referral form on the space provided, toindicate that the referral has been taken note of, and then assesses the

baby within 24 hours of referral The Therapist opens a file for the baby where the referral and all the

assessment forms will be kept

For all babies, the Neonatal assessment form and developmentalchecklist will be used for assessment purposes

After assessment, individual treatment takes place and then on dischargefrom the hospital, babies are referred to Early Intervention Clinic for followup.

Individual treatment will include:o Consultation / counselling about the condition/ problem to

caregiver, as well as prognoseso Discussing treatment goals and what therapy will entail mainly

promotion and preventative unless diagnoses requirerehabilitative intervention

o Discussing frequency of follow up sessions

o Discussion on the role of caregiver in therapy

o Explanation of basic stimulation areas and issuing the

stimulation sheeto Give opportunity for questions and clarity

o Book baby for EI Clinic

o First follow up appointment must be approximately 1 monthafter being discharged from the hospital


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On each follow up visit, the baby must be reassessed according tomilestone development using the developmental checklist: 0 12 months

Babies are seen until they are 9 months of age or discharged whennormal trends of development are picked up on 3 consecutive visits

The babies that get discharged from EIP must be noted and a dischargesummary is to be given to the mother filled in duplicate, one copy filed inthe department

Babies over 9 months of age that still need to be followed up, will bedischarged from EIP and booked for either CP clinic or individual therapy.


Therapy




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FLEXOR TENDON INJURIES PROTOCOL

In these injuries, the pulleys are supplied. They are applied toeach of the fingers involved at the time of operation.

The posterior slab is applied with the hand in position offunction with the wrist in a neutral position.

No dressing is applied over the fingers involved.

Occupational therapy is instituted immediately to teach thepatient to use the pulley, that is to allow the patient to extendhis finger and pulley to flex the finger.

Therapist will first assess the patient before teaching pulley.

Therapist must open the file and record the findings as wellas progress.

When the patient is conversant with the technique, he isdischarged if wound is clean.

Weeks after the operation, the pulley, sutures and the plaster

are removed.

A protective plaster slab is applied to wrist in a neutralposition.

The patient is referred in a weeks time that is 1 month afteroperation, to occupational therapy department.

Therapist must assess the patient again and can start withnon-resistive exercises.

After 6 weeks the therapist can do active resistance

exercises.

The therapist can assess the active and passive movements.

The therapist can construct and design a splint.

The patient may require active and passive splints for areanalysis or any further treatment.


Therapy



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EXTENSOR TENDON PROTOCOL

OBJECTIVES:

PROCEDURE:

These injuries are normally caused as a result of trauma.

Tendons involved are the following: EDC, EIP, EIP, EDM, EPL, EPB,

ECRL, ECRB, ECU.

The extensor tendons are divided into zones 8 zones

The prognoses and treatment differs from one zone to the next


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ZONE 1 AND 2: (DIP and middle phalanx) Injuries at this level are to the terminal extensor tendon and often leads to

the development of Mallet finger deformity

These injuries are sometimes repaired surgically, but often simple

reapproximation of the tendon through immobilization allows the tendon

to heal without surgical repair

The DIP is immobilised for 6 weeks: either closed by means of splints or

open with K- wires

TREATMENT

0 6 WEEKS

The DIP joint is immobilised in 0 to 15 hyperextension by means of astatic splint

The splint is worn continuously for 6 weeks post-injury (24 hours a day)

The DIP joint should be kept in extension when the splint is removed to

clean the hand. Exercises are performed to maintain range of movement

of uninvolved joints.

6 7 WEEKS

Initiate gentle AROM with emphasis


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CARPAL TUNNEL SYNDROME PROTOCOL

OBJECTIVES

PROCEDURE

Signs and symptoms

Weakness or clumsiness in the use of the hands.

Hyperaesthesia or Para aesthesia in the distribution ofmedian nerves aggravated by use.

Awakening from sleep with pain in the wrist or numbness offingers

Symptoms intermittent

Proximal migration of pain might occur.

+ Phalen test any onset of numbness in less than a minuteis considered diagnostic of carpal tunnel syndrome.

+ Tunnel sign ( median distribution)

Decreased sensibility in the median nerve distribution and

thenar atrophy are advanced signs

Treatment / Conservative

Splint the wrist in neutral position to be worn 24 hour a dayfor4 weeks and thereafter only at night for another4weeks

Patient is to avoid repeated wrist flexion

Ultrasound (physiotherapy)

No response is an indication for operative treatment

Post operative treatment


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Hand and wrist can be splinted in slight dorsi-flexion for 5days

Wrist flexion should be avoided for 10 days

Reduce oedema with active mobilisation, elevation,compression, or contrast baths

Scar management

Activity modification

Strengthening and back to work from4 weeks post op

Grip strength assessment and intervention from 6 weekspost op

Sensation assessment and intervention from 3 months post

op

BURNS PROTOCOL

OBJECTIVES

To provide uniform OT services for patients with burnsconditions

To assist patients with burns in achieving maximal functionallevel of independence

To educate patients and families regarding ongoing treatmentand ensure consistent home management of the patientsafter discharge

PROCEDURE

Upon referral, the Therapist has to check the history includingseverity and location of burns, need for splinting andpositioning to prevent contractures.

The therapist has to conduct an assessment on rangeavailable and functional abilities.

The Therapist also has to start building rapport with the

patient for emotional support.

Treatment at this stage entails the following:

- Education of staff and patient on correct positioning- Activities to encourage PROM to maintain joint range- Maintainance of available skills


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PHASE 2: day 3 to a week a patient must attend OT daily forcontinuous assessment on ROM, muscle strength, sensation,motivation and emotional adjustment and treatment.

Active movements start

BURNS PROTOCOL FOR BOTH ADULTS AND CHILDREN

1. IN PATIENTS

PHASE ONE

After admission day 1 of the patient the occupationaltherapist introduces himself/herself and briefly discuss therole of O.T, scare management, positioning and pressure

garment. Therapist with team members attends ward rounds where

appropriate referral will take place.

Therapist can also do her /his informal ward rounds whereappropriate referral in order to screen the patients.

Therapist will assess the severity of the burns, correct

positioning and determine the need for splinting wherepossible to prevent contractures and prevent joints frombecoming stiff.

Therapist will also maintain a full range of movements by

doing passive movements. Building a relationship for later co-operation (emotional

support).

Education of patient and staff in the ward on importance ofcorrecting positioning.

Pictures can be put against the wall of the patient to remindthe patient and nursing staff. Note must also be made in thefile.

PHASE 2

Within 3 days to a week a patient will be attendingOccupational Therapy treatment daily. Continuousassessments are done throughout their stay in hospital.

These assessments include: range of movement, sensation,and muscle strength, conation (motivation and emotions).Healing of wounds.

Therapist will start with active movements and exercises.

Active and Passive movements helps with: active bold flow to

help the healing process, decrease swelling, prevent stiffness


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contracture joints, improve functional abilities to help thepatient to be more independent, better endurance andmaintenance of muscle strength, lessen the pain.

Patients are treated individual or in a group throughmeaningful activities. Treatment in groups can be done in the

morning or afternoon (Time for group depends on thetherapist and ward schedule.

Files are opened all information is recorded.

SKINGRAFTS

First 7 days after skin graft there is no mobilization.

Splinting should be done over major joints.

After 7 days therapist can start with active movements.

2. OUT PATIENTS

Patients should be given an appointment 4 weeks after

discharge to come back to follow up.

On this appointment the following should be checked:

Range of movement in all affected limbs.

Healing skin ( no open wounds can be covered withpressure garments)

Measure the pressure garments (deduct 15% for adults

and 10% for children in beginning phase) called the ruleof 9.

Patients are seen every 4 weeks for follow up until 4months thereafter only every 8 weeks.

Supply the patient with 3 garments and renew first setevery 3 months if needed.

Explain to the patient how to care for their garments.

If the patients are not using the first sets, not to supplywith more set until that they are using it 24 hours aday.

Purpose of a pressure garment is growing, it helps todecrease scar hypertrophy, and prevent deformities.

Discharge the patient if his hyperopic scar has beenachieved.

Pressure garments should be used for at least 24months ( 2 yrs) if stopped to early hypetrophic scarscan develop again


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Therapy



AMPUTEES PROTOCOL


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OBJECTIVES

To provide a uniform OT services for all patients.

To assist patients to achieve maximal level of functionand independence in ADL within the limitations of theirdisabilities.

PATIENTS REFERED TO OT

Patients with the following conditions should be referred to OT

Upper limber amputees

Finger amputees

Both unilateral and bilateral lower limber amputees

WHEN SHOULD PATIENTS BE REFERED TO OT

If possible all patients should be referred before amputation is donefor correct assessment of their abilities and counselling, otherwiseall should be referred as soon as possible after amputation.

PROCEDURE

All referred patients should be seen immediately

Assessment should include the following: stump condition,position of the stump, psychosocial adjustment toamputation, range of movement, contractures, functionallimitations and abilities.

If patient is referred before amputation, counselling shouldbe carried out to explain and prepare patient for amputation.

OT management is as follows

Upper limb amputations

Correct stump bandaging

Stump hygiene

Positioning

Patient education and counselling

Balance and postural retraining

Dominance retraining if necessary

Functional retraining

Sensory retraining/desensitization if necessary

Finger amputation

Oedema reduction

Patient educational counselling

Hand function training


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ROM training

Lower limb amputation

Correct stump bandaging

Stump hygiene

Positioning

Patient education and counselling

Balance and postural retraining

Dominance retraining if necessary

Functional retraining

Mobility retraining:- bad mobility- transfers- wheelchair training

patients are seen as both in and out patients


Therapy




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ERBS PALSY PROTOCOL

OBJECTIVES

To provide uniform OT services in the management of babieswith Erbs palsy

To implement a programme where babies with Erbs palsycan receive treatment immediately and thus prevent

permanent disability

PROCEDURE

Screening of all referred cases to include looking for thefollowing symptoms:

- Arm hangs limply.- Arm in internal rotation.- Forearm in pronation.- Fingers flexed.- Moro reflex and biceps jerk absent on affected side.

Assess the babys range of movement in the shoulders andnormal development of the baby.

Educate the caregiver on what Erbs palsy is and what causedit.

Show the caregiver how to do abduction-external rotation

exercises. These exercises should be done at least 10repetitions, 3 times daily. Both shoulders are abducted at 90,the elbows flexed at 90 and the dorsal surface of the armsshould touch the surface of the bed. These exercises can bedone every time the caregiver changes a nappy.

Give follow up dates.

If there is no improvement after 3 months refer thecaregiver to orthopaedic surgeon for possible surgicalintervention.


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BACK PAIN PROTOCOL

OBJECTIVES

To provide a standard guide in the prevention andmanagement of back pain.

PROCEDURE

Identification of patients from wards and out patientdepartment

Referral to physiotherapy.

Intervention:

a. Education on:- Diagnosis and prognosis- Posture- Back saving principles in functional activities.- Ergonomics- Adjustments to home environment.- Use of assistive devices.b. Training on pain management strategies:- Relaxation therapy- Energy saving principles and day planning.

c. Issuing of appropriate assistive devices Refer to orthopaedic center for orthosis e.g back brace.

Refer to nearest orthopaedic clinic for intervention byorthopaedic surgeon if necessary.


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Documents

Ot Treatment Protocols St Barnabas Hospital 2007