Clinical Reasoning for Splint Fabrication

1. Clinical Reasoning for Splint Fabrication SOMAYA MALKAWI, PhD Chapter 6

2. Clinical Reasoning Models in Splinting Splint design and wearing schedule vary because each injury is unique teachers only give one way to do something when in reality  many ways to achieve a goal Therapists Use clinical reasoning when splinting

3. Clinical Reasoning Models / Table 6-1 • Interactive Reasoning: • Narrative reasoning • Pragmatic reasoning • Conditional reasoning • Procedural reasoning

4. Interactive Reasoning Getting to know the person through understanding the impact the hand condition has had on the person’s life Focus is person’s perspective Splint color for a person who is sensitive about appearance

5. Narrative reasoning The person’s occupational story (life history) Activities, habits, roles, routines Dorsal based wrist immobilization splint for a secretary with CTS

6. Pragmatic reasoning Practical factors such as reimbursement, documentation, equipment availability, expected discharge environment, therapist’s values, knowledge, and skills Therapist with no experience might review the literature about one splint. Or refer the client with more experience

7. Person’s whole condition, taking into consideration the person’s life before condition happened , current status, and possible suture status Meaning of having a condition Cooperation of the person Conditional reasoning

8. Procedural reasoning Problem solving the best splinting approach taking into consideration the person’s diagnostically related performance areas, components, and contexts Fabricate the splint based on the condition itself and nothing else

9. CLINICAL REASONING THROUGHOUT TREATMENT REFERRAL THERAPIST/PHYSICIAN COMMUNICATION SPLINT PROVISION

10. Referral • No time for preparation • Quick clinical decisions • Take demographics: • Diagnosis, date of onset • Management, purpose and type of splint • Precautions and instructions • Wearing schedule

11. Therapist/physician communication • Prepare “specific” questions • What splint? For how long • If inappropriate, therapist apply clinical reasoning • See examples (Box 6-1) and (6-2)

12. Splint provision • Categories: • Splints for chronic conditions (hemiplegia) prevent skin maceration and contractures • Splints for traumatic or acute (surgical or non surgical)  tendinitis • KNOW PROTOCOLS and precautions for splinting • Functional splint for CTS?!!!

13. Factors Influencing Splint Approach Age Occupation Expected environment ADL responsibilities Motivation and compliance Cognitive status

14. Splinting Approach and Design Consideration PHYSICIAN ORDERS: YOU DON’T LIKE IT; CALL HIM DIAGNOSIS: TAKING CARE OF THE REPAIRED TISSUE! THERAPIST’S JUDGMENT: YOU THINK, THEN, IT IS YOUR CALL! PERSON’S FUNCTION: WRIST SPLINT FOR A CONSTRUCTION WORKER! TEACHER, LITTLE KID! Check table 6-2 (common positioning choices in splint design based on person’s occupation/function)

15. Splinting Approach and Design Consideration Infection Control procedures Time required to fabricate splint

16. Post fabrication monitoring

17. Monitoring • Pressure. • Skin maceration. • Edema. • Physical and functional status.

18. Evaluation and adjustment of splints

19. adjustments • Accomplished the purpose? • Good biomechanics? • Best materials? • Fluctuating edema? • Does it look nice!!!!!!!!!!!!!!!!!!!!!!!???? • Pressure-free? • Client’s occupation? • Client’s function? • If I have the chance to re do it, what would I change?

20. Splint-wearing Schedule factors Part 3

21. Wearing schedule • No magic numbers or formulas! • Only general guidelines available • Joint limitation! • Improving ROM  decrease wearing time functional. • Lost function, splint is compensating! • Discontinuation of a splint: physician or therapist • No benefit, achieved purpose, compliance DOCUMENTATION