Continuum of Care of a Patient with Burns

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Introduction

Recovery from burn injury can be long, painful, and traumatic. New disability as a result of scarring or deformities may have an impact on family life, work, school, recreation, and social life. The high incidence of burn injuries and associated with burns morbidity demands effective burn management that requires skills resources to improve the quality of life of burn patients. This article discusses

Factors Impacting Recovery

Multiple factors can impact postburn recovery. The following factors may have a negative impact on successful post-burn recovery:

Medical:

• diabetes (affecting wound healing)
• history of depression (affecting motivation)
• inhalation injury (causing acute respiratory distress or acute respiratory failure)

Psychosocial:

• tabacco use
• avoidant coping
• occupation loss
• current unemployment
• lack of participation in recreational activities
• limited or lack of social support
• unknown discharge destination
• emotional barriers (fear of rejection, embarrassment)
• behavioural barriers (pressure garments)

Ability to adapt to the pre-burn state can be facilitated by (1)good social and peer support, (2) adaptive coping mechanisms , and (3) critical thinking.

Initial Assessment

Burns location and depth:

The burn assessment is based on the system that indicates the need for surgical intervention and describes the depth of the burn and its location.

• The Lund and Browder chart:
  • allows to calculate total body surface area (TBSA)
  • includes areas that are partial- and full-thickness and excludes superficial areas. For a detailed characteristics of burn by depth see this Physiopedia article.

Wound assessment:

• it is important to assess the wound when the dressing is taken down. When assessing the wound without dressing, check for the following wound characteristics:
  • colour
  • wound environment: wet or dry
  • blanchability

Pain assessment:

The depth of the burn determines the degree of pain. The superficial burns resulting in greater pain. The areas of full-thickness burns are usually pain-free. However full-thickness burns are typically surrounded by areas of more superficial injury therefore patients with full-thickness burns can report as much pain as patients who sustained a superficial injury. The pain can last from few days to several months. Burn pain mechanisms vary and requires different interventions. They include the following mechanisms:

• acute burn pain
• inflammatory burn injury pain
• neuropathic burn injury pain

Preoperative Management

Goals

1. To increase functional mobility
2. To prevent pulmonary complications
3. To decrease oedema
4. To initiate proper positioning

Interventions

• Active range of motion
• Patient and caregiver education on:
  • current activities restrictions
  • importance of increasing mobility
  • pain and how to manage it
  • activities restrictions after the surgery

Reconstructive Burn Surgery

Early excision and closure of the burn wound prevents infection and reduces secondary complications due to burn scars. Reconstructive burn surgery restores the function of an affected area thus improving the quality of life for a patient with burn. When choosing between skin grafts, tissue expansion or other tissue repairing techniques, the surgeon must consider the missing tissue area and the effected structures.

General Guidelines:

• patient typically undergoes multiple rounds of surgery
• various surgical procedures may take up to three to four weeks

Surgical Procedures

The International Society for Burn Injury recommends early excision and grafting of deep partial-thickness burns. It shortens the recovery time, reduces pain and improves long-term scar outcomes. In addition early wound closure leads to earlier transition to the rehabilitation program.

The following treatment strategies are used in burn care:

• escharotomies
  • a "full-thickness incision through the eschar, exposing the subcutaneous fat."
  • maintains perfusion through vessels
  • relieves pressure on the nerves thus preserves their function
• surgical excision and debridement
  • there is no movement precautions unless there is tendon exposure
  • rehabilitation team must discuss precautions with surgical team
• allograft
  • graft is from the cadaver skin
  • it is not a terminal grafting technique
  • it allows to cover a large area of the burn
  • patient is allowed to move within 24 hours with no restrictions
• autograft
  • any areas that cross joints covered with autograft should be immobilised for the first five days
  • patient's activity is encouraged. If a patient is immobilised over their wrist and their hand, they should be able to get up and walk
  • activities of daily living can be performed using other hand, while keeping the hand that has been grafted immobilised
  • Custom-made splints will maintain grafted area immobilised:
    • resting hand splint, which will hold the hand in an intrinsic plus position and the wrist in slight extension.
    • elbow brace to hold the elbow in an extended position as this is typically what is first lost after grafting
    • knee brace to hold the knee in an extended position

Splints Schedule

Initial splint schedule after surgery includes (1)keeping the splint on for five days,(2) performing daily splint checks , and (3) taking down the splint at the same time that the postoperative dressings are taken down to visualise the graphs and decide if the splint needs to be continued to use.

Postoperative Management

• maintaining the patient's mobility while protecting the graft sites.
• patient immobilised in certain joints of their body does not mean that they cannot be doing gross functional mobility, such as getting out of bed, sitting in a chair, and walking.
• graft assessment during wound care . Elements to consider are the following:
  • We want to look at how well the graft is adhered, the colour of the graft.
  • Does it look pale or does it have good vascularisation and is pink or red or even purple?
  • And are there any haematomas present?
  • We should always have a conversation with the surgeon at that point if they feel that the graft is healing well enough for us to start doing some targeted mobility in that area.

Interdisciplinary Interventions

• active range of motion, see how that actually looks in wound care with the graft open, and then we progress to passive range of motion and more static stretching interventions.
• independent as possible with his bed mobility, his transfers, and his activities of daily living.
• Also, we want to make sure at this point, his grafts are healing, he's 40 days out from admission, that he is on a good stretching programme.
• performing goniometry in functional positions rather than the standard positions, as this addresses the changes that we see in the cutaneous functional unit when burns are healing.

Stretching

• hold a low-load prolonged stretch. They should see blanching over the joint that's being stretched, and they should hold the stretch for about two minutes. Moisturisation with a water-based moisturiser should always be performed pre and post, and we can also educate on scar massage to also help to break up the skin adhesions and help the skin to glide better during stretching interventions.

• education that we should prioritise for Oleksandr prior to discharge are ensuring that he understands his home exercise programme. We should also educate him on the signs and symptoms of infection and then really the expectations of what the outpatient rehabilitation process will look like. So we know that we will send him home with prefabricated compression garments, but eventually we would like to measure him for custom compression, and we will continue to advance his stretching and remove splints as needed through the outpatient phase.

outpatient and community phase of his rehabilitation process

• Hypertrophic scarring is probably the most common type of scarring that will occur, and this is raised scarring within the bed of the wound. Also, scar banding can be common when grafting and burns have crossed joints and these can commonly occur in the axilla or in the posterior knee and often inhibit joint motion and function and usually require surgical fixation to manage.
• custom compression garments. These should provide 25 millimetres of mercury of compression and be worn for 23 hours a day for at least the first year after burn injury depending on the rate and type of healing that Oleksandr is having.
• scar massage. This can be performed over any area that was burned or grafted. Moisturisation should be performed before and after this and we want to teach the patient to perform it in a vertical manner, a horizontal manner, and circular manner, applying enough pressure to blanch the skin. This can help with hypersensitivity, pliability of the skin, and helping to break up adhesions.
• fine motor skills, as well as that hypersensitivity he's having in his right hand, thinking about incorporating the functional tasks that he will do as an electrician. So practising manipulating wires, doing tasks with the tools that he will use as an electrician and also incorporating in different temperatures and textures of things that he's using with these fine motor tasks to help address some of the complaints that he's having.
• education that we want to give is about sun protection. So we know that after grafting and burns, that skin is new and is at a higher risk for damage from sun.

Resources

• Assessment and classification of burn injury
• x

or

1. numbered list
2. x