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.

Factors Impacting Recovery

Multiple factors can impact postburn recovery. The following factors may have a negative impact on successful 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)

On the other hand, ability to adapt or ‘bouncing back’ to the pre-trauma state can be facilitated by (1)good social and peer support, (2) adaptive coping mechanisms , and (3) critical thinking.

Initial Assessment

1. Burns location and depth
   • a chart called the Lund and Browder. The Lund and Browder is used to calculate total body surface area, or TBSA, and includes areas that are partial- and full-thickness and excludes superficial areas. In looking at Oleksandr's Lund and Browder, we are able to get a good idea of if burns are crossing joints and areas that he may need surgical intervention.
2. Wound assessment without dressing
   • colour, if they are wet or dry, blanchability, and then also assess pain. We know that the less pain there is, the deeper the burn, which indicates that the person is more likely to require surgical intervention for healing.

Preoperative Management

Goals:

1. To increase functional mobility
2. To prevent pulmonary complications
3. Oedema management
4. Initiate proper positioning

Interventions:

• active range of motion
• patient and caregiver education about:
  • activities restrictions and need to increase mobility
  • pain and how to manage it
  • activities restrictions after the surgery

Reconstructive Burn Surgery

Early excision and closure of the burn wound is sometimes described as the greatest advance in the treatment of patients with severe thermal injuries." Reconstructive burn surgery has greatly improved the quality of life for burn patients by restoring function and appearance to the affected areas. This type of surgery may involve skin grafts (Figure 2), tissue expansion, and other techniques to repair damaged tissue and minimise scarring "

General informations:

patient typically undergoes multiple rounds of surgery

various surgical procedures may take up to three to four weeks

Surgical Procedures

• escharotomies
• surgical excision and debridement
  • no movement precautions unless there is tendon exposure
  • discuss precautions with surgical team
• Allograft
  • Cadaver skin
  • Not a terminal grafting technique
  • Use 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
  • 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

splint schedule, initially after surgery, the splint should be kept on for five days with daily splint checks performed and then the splint should be taken down at the same time that the postoperative dressings are taken down so that the therapist can visualise the graphs and decide if the splint needs to be continued to use and if the patient is clear to begin some active range of motion.

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.

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