Burns Flashcards
Divides the body into 9s or multiples of 9s to calculate total body surface area of burns (TBSA)
ADULTS: The Rule of Nines
A more accurate method of calculating TBSA, used especially for children, based on age
CHILDREN and INFANTS: Lund-Browder chart
- Involves the superficial epidermis
- Pain is minimal to moderate
- Dry, superficial redness, blister free
- No risk of scar formation or contracture
- Healing time is 3-7 days
- Associated with: Mild sunburn or short exposure to heat source, chemical, or hot liquid
Superficial (first-degree) burn
- Involves the epidermis and upper dermis layers
- Pain is significant; wet blistering and erythema are present
- Low risk of hypertrophic scar formation
- Healing time is 1-3 weeks
- Associated with: Severe sunburn, lengthy exposure to a heat source
Superficial Partial-Thickness (Superficial second-degree) burn
- Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands
- Pain is severe, even to light touch
- Erythema is present, with or without blisters
- Burn has a high risk of turning into a full-thickness burn because of infection; grafting may be considered to prevent wound infection
- Client may have impairment of sensation
- Potential for hypertrophic scar or contracture is high
- Healing time varies from 3-5 weeks
- Associated with: Direct contact or lengthy exposure to a heat source
Deep Partial-Thickness (Deep second-degree) burn
- Involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings
- Burn is pain free, no sensation to light touch
- Burn is pale and non-blanching
- Requires skin graft
- Potential for hypertrophic scar and contracture is extremely high
Full-Thickness (Third-degree) burn
- Full-thickness burn with damage to underlying tissue such as fat, muscles, and bones
- Charring is present; may have exposed fat, tendons, or muscles
- If the burn is electrical, destruction of nerve along the pathway is present
- Peripheral nerve damage is significant
- Requires surgical intervention for wound closure or amputation
- Potential for hypertrophic scar is extremely high
Subdermal burn
- Risk of dehydration as one of the functions of skin is it serves as a moisture barrier - risk for dehydration through evaporation
- Hypo- or hyperthermia
- Fluid resuscitation: rapid league of protein-rich intravascular fluid into surrounding extravascular tissues can result in decreased plasma and blood volume and reduce cardiac output
- Cardiopulmonary stability: important if the respiratory tract has sustained a smoke inhalation injury
- Escharotomy and fasciotomy
Medical Management
Emergent phase: 0-72 hours after injury
Sustaining Life
-Wound-dressing products protects the wound against infection, superficially debride the wound, and provide comfort
-Type of wound dressing:
=Topical antibiotics
=Biologic dressing
-> Xenografts - bovine skin, processed pig skin
-> Allograft - human cadaver skin
=Nonbiological skin-substitute dressings - biosynthetic products such as Biobran
Medical Management
Emergent phase: 0-72 hours after injury
Controlling Infection
- Pharmacological; likely use of narcotic analgesics
- Include pain management of any associated injuries (organ injuries or fractures)
Medical Management
Emergent phase: 0-72 hours after injury
Managing Pain
- Infection control
- Pain management
- Proper nutrition and hydration
- Cardiopulmonary stability is maintained
Medical Management
Acute phase: 72 hours after injury or until wound is closed (may be days or months)
-Autograft: transplantation of the person’s own skin from an unburned donor site to the burned receiving site
-Split-thickness skin graft
=Full epidermal and particle dermal layer are taken from donor site
=Chance of graft survival is high
-Full-thickness skin graft
=Full thickness of the epidermal and dermal layers plus a percentage of fat layers are taken from donor site
=Chance of graft survival is less
=The outcome is functionally and cosmetically better if graft adherence occurs
Types of Skin Grafts
Medical treatment continues with skin grafts and reconstruction surgery as needed for movement and function
Medical Management
Rehabilitation Phase
-OT Evaluation: Clinical observations of body parts affected by burns, information gathering on prior functional status
-OT Intervention: Splinting in antideformity positions
=Intrinsics plus for hands
=Opposite client’s posture
=Generally in extension for the neck, elbows, and knees
=Shoulder in abduction and hip in extension
=Anti-frog leg and anti-foot drop for lower extremity
OCCUPATIONAL THERAPY EVALUATION AND INTERVENTION
Emergent Phase: 0-72 hours
Emergent phase OT Intervention: Splinting in anti deformity positions
- Intrinsics plus for hands
- Opposite client’s posture
- Generally in extension for the neck, elbows, and knees
- Shoulder in abduction and hip in extension
- Anti-frog leg and anti-foot drop for lower extremity
- OT Evaluation: ADLs, psychosocial aspects, communication, cognition, ROM, muscle strength, and pain
- OT Intervention: Splinting and positioning in antideformity position, edema management, early participation in ADLs, and client and caregiver education
- Anti-Contracture positioning: Positioning is critical because the position of greatest comfort is usually the position of contracture
- Edema Management
- Early participation in ADLs
- Client and caregiver education
OCCUPATIONAL THERAPY EVALUATION AND INTERVENTION
Acute Phase 72 hours after injury or until wound is closed (may be days or months)
What is Anti-Contracture positioning for Neck
Neck: neutral to slight extension
What is Anti-Contracture positioning for Chest
-Chest and abdomen: trunk extension, shoulder retraction
What is Anti-Contracture positioning for Axilla
-Axilla: shoulder abduction 100° to 120°, slight external rotation
What is Anti-Contracture positioning for Elbow
-Elbow: extension
What is Anti-Contracture positioning for Forearm
-Forearm: neutral to supination
What is Anti-Contracture positioning for Wrist
Wrist
=Dorsal wrist: wrist in neutral to 30° extension
=Volar wrist: wrist on 30° - 45° extension
What is Anti-Contracture positioning for Hand
-Hand: metacarpal, 70° flexion; interphalangeal 0° extension, thumb abducted and extended
What is Anti-Contracture positioning for Hip
-Hip: 10° - 15° abduction, neutral extension
What is Anti-Contracture positioning for Knee
-Knee: extension; with anterior burn, slight flexion
What is Anti-Contracture positioning for Ankle
-Ankle: Neutral to 5° dorsiflexion
Surgical and postoperative phase
- Post operation immobilization period
- Positioning
- Exercise and activity
Immobilization period is generally between how many days?
3 and 10 days or until graft adherence is confirmed
Immobilization period of donor site is how many days?
2-3 days if no active bleeding occurs
Walking is usually not resumes until how many days?
5-7 days after grafting in lower extremities
- Exercise and movement of the uninvolved extremities should be continued
- Movement of the other joints involved should be continued if able to avoid tension on grafts
- After immobilization period, start with gentle AROM to avoid shearing of the new grafts
Surgical and postoperative phase
Exercise and activity
Rehabilitation Phase: Wound is healing, and wound closure is stable
-Skin conditioning
=Skin lubrication is for?
=Use skin massage to?
=Avoid what?Skin lubrication should be performed several times a day to prevent dry skin from splitting because of shearing forces or overstretching during movement and exercises
Use skin massage to desensitize the hypersensitive grafted sites or burn scars. Massaging a tight scar band can reduce shearing forces and prevent splitting of immature or problematic scar tissue
Use sunblock or sun protective clothing; avoid unprotected sun exposure
What is compression therapy for?
Initiate compression therapy for both edema control and scar compression
Use of compression garments is indicated for all donor sites grafted sites, and burn wounds that take more than 2 weeks to heal spontaneously
Types of temporary interim pressure bandages or garments?
- Elastic bandages
- 3M Coban wrapping of the fingers
- Elasticated tubular support bandages
- Thigh-high or knee-high thromboembolism-deterrent hose (TED Hose)
- Spandex bicycle pants
- Isotonic gloves with impression silicone, elastomer, closed-cell foam, or silicone pad inserts
When should client be taught perform skin lubrication and massage?
as pretreatment skin care before exercise and activity program
Rehabilitation Phase: Wound is healing, and wound closure is stable
Therapeutic exercise and activity
- Exercise and activity should be progressively graded to regain strength and activity tolerance
- Client needs to be taught to perform skin lubrication and massage as pretreatment skin care before exercise and activity program
- Includes daily stretching, resistive exercise, activity to tolerance, and coordination activities
Rehabilitation Phase: Wound is healing, and wound closure is stable
Splinting
- Continue anti-contracture positioning to prevent contracture formation
- Use dynamic splint or serial casting to reverse disabling or disfiguring contracture formation. For the hands, attend to extensor tendon injury and web space contracture management
- Splint of volar surface of hand for dorsal or volar hand burns for better positioning and comfort
Outpatient and community reintegration phase
Scar management
How long does maturation of scar takes?
1 to 2 years
Outpatient and community reintegration phase
Psychosocial Adjustment
- Client may experience symptoms of post-traumatic stress disorder
- An adjustment period may be needed, especially if disfigurement or contracture has occurred
- Client may require counseling, support group, training in pain management, relaxation, and stress management
Contracture
- Results from tight scar band, hypertrophic scar, or prolonged immobilization
- Addressed with early implementation of anti-contracture positioning, continuous exercise and activity programs, and serial splinting programs to prevent or reverse deformity
Hypertrophic Scar
- Scar is most apparent 6-8 weeks after wound closure
- It is most active in the initial 4-6 months
- Because of increased vascularity, the scare becomes firmer and thicker and rises above the original surface level of the skin
- It can happen at the donor site, at the original burn area, or with a mound that does not close spontaneously after 2 weeks
- Apply compression therapy early, and continue it until the scar matures in 1-2 years
- Use scar gel peds and/or inserts to provide compression to scar
Heterotopic Ossification
- Is the formation of bones in abnormal areas. Typically occurs in soft tissue around the joint or joint capsule
- Common areas in which it occurs are the elbow, knee, hip, and shoulder
- Loss of ROM is rapid, and pain is localized and severe
- Hard end feeling during PROM activity
- Once diagnosis is confirmed, discontinue passive stretching (including use of dynamic splint) and begin AROM exercise within the pain-free range to preserve as much joint movement as possible
- Heterotopic ossification usually requires surgical intervention if functional activity is limited
Pain
- Interferes most with the rehabilitation process
- Respect pain
- Coordination with nursing on scheduled pain management; breakthrough pain relief can improve compliance with therapy program
- Educate the client and family on the importance of frequent ROM exercise and activity in spite of pain to prevent deformity formation
- Teach the client proper skin care and lubrication to avoid maceration of skin because of friction and shear during exercise and activity
- Reinforce pain management and stress reduction management techniques throughout the whole continuum
Heat Tolerance
- Loss of the ability to sweat may occur as a result of loss of sweat glands with split-thickness skin graft
- Client may sweat excessively in the unburned areas
- Special accommodations and modifications (air conditioning) may be required at home or in the work or school area
Pruritus (persistent itching)
- May lead to skin maceration and reopening of the wound as a result of scratching
- Use of a compression garment, maintenance of skin lubrication, and use of cold packs and antihistamine medications may alleviate itching
