Trombly- BURN

Question 1

Anti-deformity positions

Answer 1

Positions opposite to common patterns of deformity used to prevent contractures.

Question 2

Blanch

Answer 2

Apply sufficient pressure to interrupt blood flow temporarily: an assessment of capillary flow rate.

Question 3

Deep partial-thickness burn

Answer 3

Thermal injury that destroys cells from the epidermis to the deep dermal layer.

Question 4

Debride

Answer 4

Remove eschar and loose or necrotic tissue to prevent infection and promote healing.

Question 5

Dermis

Answer 5

Layer of skin below the epidermis that contains blood vessels, nerve endings, hair follicles, and sweat and oil glands; supports the regrowth of new epithelial tissue.

Question 6

Epidermis

Answer 6

Most superficial layer of the skin; acts as a barrier. It is continually sloughed and replaced.

Question 7

Eschar

Answer 7

Burned tissue.

Question 8

Full-thickness burn

Answer 8

Thermal injury in which the epidermis

and dermis are destroyed.

Question 9

Superficial burn

Answer 9

Thermal injury that involves only cells in the epidermis.

Question 10

Superficial partial-thickness burn

Answer 10

Thermal injury in which the epidermis and upper portion of the dermal layer are destroyed.

Question 11

Wound contracture

Answer 11

Part of normal healing in which myofibroblasts in the wound bed contract to minimize the skin defect

Question 12

Z-plasty

Answer 12

Surgical procedure in which a Z-shaped incision is made and tissue is transposed to increase tissue length

Question 13

Superficial burns

Answer 13

• damage cells only in the epidermis.
• These injuries are painful and red.
• They heal spontaneously within approximately 7 days and leave no permanent scar

Question 14

Superficial Partial-Thickness Burns

Answer 14

damage cells in the epidermis and the upper level of the dermis.
The most common sign of a superficial partial-thickness burn is in- tact blisters over the injured area
These injuries are also painful because of the irritation of the nerve endings in the dermal layer. Superficial partial-thickness burns heal spontaneously within 7–21 days and leave minimal or no scarring

Question 15

Deep partial-thickness burns

Answer 15

cause cell injury in the epidermis and severe damage to the dermal layer
These injuries appear blotchy, with areas of whitish color interspersed throughout the wound
The injury site is painful.
Pressure sensation is intact, but light touch is diminished
Spontaneous healing of deep partial- thickness burns is sluggish (3–5 weeks) because vascularity in the dermal layer is impaired.
Therefore, the risk of significant scarring is increased For this reason, deep partial thickness burns are often grafted to expedite healing and minimize scarring.

Question 16

Full-Thickness Injury

Answer 16

In a full-thickness injury both the epidermis and the dermal layer are destroyed
These wounds appear white or waxy and are inherently insensate because of the complete destruction of the dermal nerve endings
Full thickness burns require surgical intervention, such as skin grafting since there are no dermal elements to support the regrowth of epithelial tissue. Some burns, such as electrical burns, may damage structures below the dermis, including subcutaneous fat, muscle, or bone.

Question 17

RULE OF NINES

Answer 17

A commonly used technique to determine burn size in adults
Lund Browder = To determine burn size in children and infants, a modification of this technique chart

The percentage of total body surface area (TBSA) that has been burned is used for the following:
• Calculating nutritional and fluid requirements
• Determining level of acuity to establish the level of medical treatment needed
• Classifying patients for use of standardized protocols

Question 18

The percentage of total body surface area (TBSA) that has been burned is used for the following:

Answer 18

• Calculating nutritional and fluid requirements
• Determining level of acuity to establish the level of medical treatment needed (i.e., admission to an inten- sive care unit)
• Classifying patients for use of standardized protocols

Question 19

PHASES OF BURN MANAGEMENT AND REHABILITATION

Answer 19

Emergent Phase
Acute Phase
Rehabilitation Phase

Question 20

Emergent Phase

Answer 20

Medical Management

• Inhalation Injury
• Escharotomy and Fasciotomy
• Dressings
• Infection Control
  Contracture Formation
  Occupational Therapy Assessment During the Emergent Phase
  Occupational Therapy Intervention During the Emergent Phase
• Splinting
• Positioning
  *

Question 21

Medical Management

Answer 21

• This may include fluid resuscitation, establishment of adequate tissue perfusion, and achievement of cardiopulmonary stability.
• Associated injuries, such as fractures, are evaluated and treated during this time.

Question 22

Inhalation Injury

Answer 22

Damage to the upper airway as a result of inhaling either hot particles or nox- ious gases results in an inhalation injury.

Question 23

Inhalation Injury

Answer 23

Damage to the upper airway as a result of inhaling either hot particles or nox- ious gases results in an inhalation injury.

Question 24

Escharotomy and Fasciotomy

Answer 24

Circulation can be compromised when burn injuries girdle a body segment. This is due to the inelasticity of the eschar (burned tissue) combined with increased internal pressure within fascial compartments. Local increase in pressure in the extremities compresses blood vessels and reduces blood flow (Sheridan et al., 1995). Symptoms of increased compartmental pressure include paresthesias, coldness, and decreased or absent pulses in the extremi- ties. In the trunk, inelastic eschar can act as a corset, limit- ing lung expansion and preventing adequate respiration. In both cases, surgical intervention (escharotomy and/or fasciotomy) is required to relieve the pressure and prevent tissue death. An escharotomy is a surgical incision through the eschar, whereas a fasciotomy is a deeper in- cision extending through the fascia. Unless exposed ten- don is present, the escharotomy region can be mobilized during therapy.

Question 25

Dressings

Answer 25

After the initial burn assessment, the nursing staff applies dressings. The functions of dressings include protecting the wound against infection, maintaining contact be- tween the topical agent and the wound, superficially de- briding the wound, and providing comfort for the patient (Grigsby deLinde & Miles, 1995). Debriding is the removal of devitalized tissue from the wound site. Types of topical agents vary widely, although most are wide-spectrum antimicrobials. Examples include mafenide acetate (Sulfamylon), silver sulfadiazine (Silvadene), and 0.5% silver nitrate solution (Duncan & Driscoll, 1991). As a rule, the nursing staff changes the dressings; however, by peri- odically participating in dressing removal and application, the occupational therapist makes opportunities to view the healing wounds. This allows the therapist to monitor healing and adjust the therapy program accordingly.

Question 26

Infection Control

Answer 26

One of the functions of the skin is to act as a barrier against infection (Falkel, 1994). Therefore, a patient with a burn injury is susceptible to infection. It is essential that all staff, family, and visitors adhere to infection control procedures. This includes frequent hand washing, use of gloves when necessary, and avoiding cross-contamination through instruments and equipment (Procedures for Practice 45-1).

Question 27

Contracture Formation

Answer 27

Patients with burn injuries are at significant risk for con- tractures. Wound contracture, a normal physiological response to an open wound (Greenhalgh & Staley, 1994; Staley, Richard, & Falkel, 1994), combined with prolonged immobilization, creates an opportunity for permanent soft tissue contracture. Contractures tend to occur in pre- dictable patterns, usually flexed, shortened positions (e.g., elbow flexion, shoulder adduction, knee flexion) and can considerably limit the patient’s ability to perform activities of daily living. Example decrease elbow extension may limit the patient’s ability to dress.

Question 28

Procedures

Answer 28

Hand Washing
Hand washing is the easiest and most effective thing you can do to prevent infections for you and your patients.
When to Wash
• Before and after all patient contact
• After removing gloves used to perform a task involving contact with blood, body fluids, or infectious material
• After handling possibly infectious devices or equipment
• Before and after preparing and eating food
General Procedure
• Dispense paper towel
• Push up long sleeves
• Wet hands and wrists
• Apply antiseptic solution or soap
• Use friction to clean between fingers, under nails, and palms and backs of hands; effective scrubbing lasts at least 20–30 seconds
• Rinse hands and towel dry
• Turn off faucet using paper towel
• Dispose of paper towel in appropriate trash barrel
• Waterless hand cleaner can be used until hand washing facilities are available

Question 29

Occupational Therapy Assessment During the Emergent Phase

Answer 29

During the emergent phase, the occupational therapist per- forms a screen of the patient’s needs. A full evaluation is de- ferred until after the emergent phase, when the patient is more medically stable. During the screen, the therapist notes the distribution of the burn and which joints are in- volved. This allows the occupational therapist to establish an appropriate splinting and positioning program. It is also during this time that the therapist begins collecting infor- mation regarding the patient’s functional status before ad- mission, including individual interests and social supports.

Question 30

Occupational Therapy Intervention During the Emergent Phase

Answer 30

Occupational therapy in the emergent phase focuses on the prevention of early contracture formation through the use of splints and positioning programs. It is ideal to ini- tiate occupational therapy intervention as early as 24–48 hours after burn because collagen synthesis and contrac- ture formation begin during the initial response to ther- mal injury (Evans & McAuliffe, 1995; Institute for Healthcare Quality [IHQ], 1997).

Question 31

Splinting

Answer 31

Ideally, splints are fabricated and applied in the initial visit, and a positioning program is established and commu- nicated to the team. Table 45-1 describes common contracture patterns, anti-deformity positions, and appropriate splints. Generally, any joint involved in a su- perficial partial-thickness injury or worse has the potential for contracture and is usually splinted. Splint wearing times are determined by the patient’s ability to use the involved extremity. That is, a decrease in active movement indicates the need for increased splint wearing time. For example, a heavily sedated patient cannot perform active movement and, therefore, requires splinting at all times except for ther- apy and dressing changes. An alert patient who can use his or her affected extremity for functional tasks, such as self- feeding or prescribed exercises, may require the use of splints only at night. Splints are applied over the burn dress- ing and secured with either gauze wrap or Velcro straps.

Question 32

Positioning

Answer 32

Anti-deformity positioning, which is used as an adjunct to splinting for prevention of contractures, can be initiated in the first visit. For example, if a patient is unable to be fit- ted with a custom wrist extension splint, supporting the hand on a rolled pillow can, at least temporarily, maintain appropriate joint position. Elevating the upper extremi-ties can also help to minimize upper extremity edema. Elevation can be done with foam wedges, pillows, or spe- cialized arm troughs attached to the bed. A risk of upper extremity elevation is the potential for brachial plexus strain. Symptoms of brachial plexus strain include tin- gling, numbness, and cold fingers.

Question 33

Splinting

Answer 33

Ideally, splints are fabricated and applied in the initial visit, and a positioning program is established and commu- nicated to the team. Table 45-1 describes common contracture patterns, anti-deformity positions, and appropriate splints. Generally, any joint involved in a su- perficial partial-thickness injury or worse has the potential for contracture and is usually splinted. Splint wearing times are determined by the patient’s ability to use the involved extremity. That is, a decrease in active movement indicates the need for increased splint wearing time. For example, a heavily sedated patient cannot perform active movement and, therefore, requires splinting at all times except for ther- apy and dressing changes. An alert patient who can use his or her affected extremity for functional tasks, such as self- feeding or prescribed exercises, may require the use of splints only at night. Splints are applied over the burn dress- ing and secured with either gauze wrap or Velcro straps.

Question 34

Acute Phase

Answer 34

The acute phase begins after the emergent phase and con- tinues until the wound is closed, either by spontaneous healing or skin grafts (Grigsby deLinde & Miles, 1995). The acute phase can last several days to several months, depending on the extent of the burn and the amount of grafting required.

Question 35

Support and Psychosocial Adjustment in the Acute Phase

Answer 35

All patients with burn injuries, regardless of age, exhibit some of the same psychological responses, including with- drawal, denial, fear of death, regression, anxiety, depression, and grief (Wright, 1984). In addition, various factors can in- fluence a burn patient’s psychological status. These include emotional trauma arising from the hospital stay, the length of the hospital stay, adjustment to physical changes, adjust- ment to others’ reactions, and location and depth of the burn injury (Baker et al., 1996; LeDoux et al., 1996). Baker et al. (1996) refer to two stages of psychosocial recovery: the first alert stage and the pre-discharge stage. Performance can vary considerably between the two phases. During the first alert stage, the patient initially orients to the burn
injury; a severely burned patient may simply be happy to be alive (Baker et al., 1996). It may not be until later, as the pa- tient enters the rehabilitation phase and approaches the pre-discharge stage, that he or she begins to deal with the limitations in physical function. The patient, however, may also exhibit early signs of depression and withdrawal, and early assessment of the patient’s psychosocial status is es- sential. LeDoux et al. (1996) state that the burn team can foster healthy coping strategies while working with the burn patient by using these techniques:
1. Identifystrengthsthateachpatientcanemphasize,re- minding him or her of the strength already involved in surviving a painful and frightening experience.
2. Validatesadnessandfear.
3. Assistpatienttoachievegoals;thishelpstoshowhope for the future.
4. Instillabeliefthatthepatientcansucceed.

Question 36

Team Communication

Answer 36

Communication with all members of the team, including the patient and the patient’s family and/or support sys- tem, throughout hospitalization is essential. During this acute phase, collaboration between the occupational ther- apist and the burn team is essential for several reasons, including (Pessina & Ellis, 1997):

1. Alerting the team to developing contractures and response to therapeutic intervention
2. Planning for perioperative splinting
3. Clarifying range-of-motion orders based on graft integrity
4. Teachingtheteamaboutenvironmentalmodifications or communication systems
5. Advocating on the patient’s behalf regarding eventual outpatient needs

Question 37

Medical Management

Answer 37

Types of grafts

Autograft
Temporary graft

Question 38

Medical management

Answer 38

Skin grafting, which occurs primarily in the acute phase, is required when the dermal bed is sufficiently destroyed to prevent or significantly impair spontaneous regrowth of the epithelial tissue (Grigsby deLinde & Miles, 1995). If reepithelialization of the burn site has not occurred within 14 days of the injury or is not expected, grafting would be considered (Kagan & Warden, 1994). Skin graft- ing is generally performed for all full-thickness burns and for large, deep partial-thickness burns. Skin grafting entails both excision of necrotic (dead) tissue and the placement of skin or a skin substitute over the wound bed.

Question 39

Types of Grafts

Answer 39

A variety of grafting procedures are available to the burn team. According to the size of the burn and the medical stability of the patient, the team may opt to use one or more of the graft types described next.

Question 40

TEMPORARY GRAFTS

Answer 40

In cases of extensive burn injuries, where there is not suffi- cient donor skin to cover all of the affected area with auto-
graft, the burn team may opt to use temporary grafts until the donor site has healed sufficiently for reharvesting. These temporary dressings aid in wound management by decreasing infection, stimulating healing and preparing the wound bed for autograft skin, decreasing pain, and protecting exposed tendons, nerves, and blood vessels (Duncan & Driscoll, 1991). Examples include xenografts (medically manipulated bovine skin), allografts (cadaver skin), and biological dressings, such as Biobrane.

Question 41

TEMPORARY GRAFTS

Answer 41

In cases of extensive burn injuries, where there is not suffi- cient donor skin to cover all of the affected area with auto-
graft, the burn team may opt to use temporary grafts until the donor site has healed sufficiently for reharvesting. These temporary dressings aid in wound management by decreasing infection, stimulating healing and preparing the wound bed for autograft skin, decreasing pain, and protecting exposed tendons, nerves, and blood vessels (Duncan & Driscoll, 1991). Examples include xenografts (medically manipulated bovine skin), allografts (cadaver skin), and biological dressings, such as Biobrane.

Question 42

TEMPORARY GRAFTS

Answer 42

In cases of extensive burn injuries, where there is not suffi- cient donor skin to cover all of the affected area with auto-
graft, the burn team may opt to use temporary grafts until the donor site has healed sufficiently for reharvesting. These temporary dressings aid in wound management by decreasing infection, stimulating healing and preparing the wound bed for autograft skin, decreasing pain, and protecting exposed tendons, nerves, and blood vessels (Duncan & Driscoll, 1991). Examples include xenografts (medically manipulated bovine skin), allografts (cadaver skin), and biological dressings, such as Biobrane.

Question 43

TEMPORARY GRAFTS

Answer 43

In cases of extensive burn injuries, where there is not suffi- cient donor skin to cover all of the affected area with auto-
graft, the burn team may opt to use temporary grafts until the donor site has healed sufficiently for reharvesting. These temporary dressings aid in wound management by decreasing infection, stimulating healing and preparing the wound bed for autograft skin, decreasing pain, and protecting exposed tendons, nerves, and blood vessels (Duncan & Driscoll, 1991). Examples include xenografts (medically manipulated bovine skin), allografts (cadaver skin), and biological dressings, such as Biobrane.

Question 44

Occupational Therapy Assessment During the Acute Phase

Answer 44

During the acute phase, the occupational therapist per- forms a detailed initial evaluation. This includes a thor- ough chart review to determine the history of the wound and associated injuries. Previous medical history is also important. Associated diagnoses that may limit occupa- tional performance, such as psychiatric illness, diabetes, or lung disease, are to be noted and accounted for during oc- cupational therapy treatment planning. Areas specifically assessed by the occupational therapist during the initial evaluation include:
• ADL and instrumental activities of daily living (IADL) • Psychosocial status and support systems
• Behavior and communication
• Cognitive-perceptual status
• Neuromuscular status (range of motion, strength, sensation)
• Activity tolerance
Evaluation can consist of observation during task per- formance, interviews with patient and family, and the use of standardized tests such as the Functional Independence Measure (Uniform Data System for Medical Rehabilitation, 1997). The potential for permanent scarring and disfigure- ment may cause significant anxiety and limit the patient’s ability to participate in rehabilitation. Thus, early identifi- cation of the patient’s support systems can improve func- tional outcomes.

Question 45

Occupational Therapy Intervention During the Acute Phase

Answer 45

• Splinting and Positioning
• Exercise and Activity
• Perioperative Care
• Pain Management
• Environmental Adaptation
• Patient and Family Teaching

Question 46

Splinting and Positioning

Answer 46

During the acute phase, the splinting and positioning pro- grams established in the emergent phase are continually monitored and adjusted. Splinting schedules are adjusted according to the individual’s ability to participate in an ex- ercise and positioning program. For example, if a patient consistently uses an affected elbow for self-feeding and ADL during the day, decreasing the wearing time for the elbow splint to nights and rest periods is appropriate. Conversely, a patient who cannot follow through with an exercise and positioning program because of impaired alertness or poor motivation should wear a splint contin- uously except for dressing changes and therapeutic activ- ity. It is imperative to check all splints daily to ensure proper fit and function. In addition, teaching the nursing staff proper fit and application of splints can decrease the potential for complications (Pessina & Ellis, 1997).

Question 47

Exercise and Activity

Answer 47

In the acute phase, splinting and positioning are used in combination with exercise and activity. Exercise is especially important to control edema and prevent muscle atrophy, tendon adherence, joint stiffness, and capsular shortening (Harden & Luster, 1991). Exercise types include passive range of motion, active range of motion, active assistive range of motion, and functional activity. If the patient can- not participate in active exercise or activity because of poor medical status or impaired level of alertness, passive range of motion is indicated. Active exercise is encouraged when- ever possible, however, (Burke Evans et al., 1996; Wright, 1984), and it is the role of the therapist to guide the patient toward function. Within a single treatment session, a pa- tient may participate in all of these forms of exercise. In fact, functional activities may be used to improve active range of motion. Exercise and activity programs are performed up to five times daily (Wright). Contraindications to exercise in- clude exposed tendons, recent autografts (approximately 5–10 days), acute medical complications, and fractures (Duran-Coleman, 1991; Grigsby deLinde & Miles, 1995; Staley, Richard, & Falkel, 1994). In addition, periodic in- spection of the wound by the occupational therapist is es- sential to determine status of wound healing and skin in- tegrity as related to tolerance of the exercise program.

Question 48

Perioperative Care

Answer 48

The 5–10 days after a skin graft procedure is the perioper- ative period. A patient with a large burn injury may make many trips to the operating room for skin grafting. Each surgical procedure begins a new perioperative stage. For example, a patient needing grafting on the trunk, arms, and legs may make three trips to the operating room, with each successive area requiring proper perioperative care. The role of the occupational therapist in the perioperative period is to fabricate custom splints to immobilize the
newly grafted areas in anti-deformity positions. Ideally, splints are fabricated immediately prior to or during surgery and applied at the conclusion of the surgery. These splints usually stay in place, along with the primary dress- ing, for 5–10 days (Duran-Coleman, 1991; Grigsby deLinde & Miles, 1995). During this time, range-of-motion exer- cises are contraindicated to allow for graft adherence. After the primary dressing is removed, the burn team assesses the graft adherence, and a determination is made regarding the appropriateness of resuming exercise.

Question 49

Pain Management

Answer 49

The occupational therapist must address pain issues that arise during treatment. Many patients in intensive care cannot verbalize subjective response to manipulation, such as during dressing changes or exercise. In these cases, the therapist monitors objective responses to pain, such as blood pressure, heart rate, and respiratory rate, and ad- justs the treatment accordingly. If necessary, the time of the treatment may be changed to allow pain medication to be administered. Decreased repetitions and increased rest breaks during exercise sessions may also be appropriate. Other techniques used to manage pain throughout re- covery include distraction techniques, meditation, and vi- sualization. Activity context and emotional state can also affect perception of pain (Dubner & Ren, 1999).

Question 50

Environmental Adaptation

Answer 50

Beginning in the acute phase and throughout recovery, the occupational therapist provides modified call buttons and bed controls, voice-activated telephone systems, and modified utensils (Fig. 45-3) and self-care items. These modifications, combined with patient, staff, and family education, can increase a patient’s sense of control and in- dependence. The development of environmental modifi cations is limited only by the patient’s motivation and the therapist’s creativity.

Question 51

Patient and Family Teaching

Answer 51

The occupational therapist provides members of the pa- tient’s support system with guidance regarding ways to in- teract with and support the patient during recovery. They may be encouraged to make tape recordings and posters or to bring in favorite music or foods. They may need to learn new ways to touch or comfort their loved one. In addition, the family and friends provide a source of information re- garding the patient’s vocational and avocational roles and available community resources if the patient cannot com- municate this information. An educated family and/or support system can be an important asset for ensuring follow-through of exercise and splinting programs and for encouraging participation in functional activities (Duran-Coleman, 1991).

Question 52

Discharge Planning

Answer 52

Since hospital stays are generally short, discharge planning begins as soon as possible after admission (Fletchall & Hickerson, 1995; Rivers & Jordan, 1998). Many patients in the acute phase are discharged directly home or leave a burn center for continued care on a rehabilitation unit. Elements to consider during discharge planning are the availability of community resources for outpatient or follow-up care, sup- port systems available to the patient, and physical demands of the home environment. When patients who have sus- tained major burns cannot return to the hospital where they received acute care, it is important for the inpatient oc- cupational therapist to establish a relationship with a ther- apist in the patient’s community to ensure continuity of care throughout the rehabilitation phase. In accordance with the knowledge and experience of the community ther- apist, the discharging therapist provides appropriate litera- ture and written, photographic, and/or videotaped descrip- tions of the rehabilitation program. This establishes a communication channel for the community therapist so questions and concerns can be addressed in a timely man- ner. Whenever possible, all authorization from third-party payers should be established prior to discharge (Fletchall & Hickerson, 1995) to avoid delays in the initiation of outpa- tient therapy. If a patient cannot be discharged directly to home, transfer to an inpatient rehabilitation facility is ap- propriate; again, early communication with the receiving therapist is necessary to ensure continuity of care. Regardless of the discharge setting, well-briefed patients are best able to advocate for appropriate care.

Question 53

Rehabilitation Phase

Answer 53

The rehabilitation phase follows the acute phase and con- tinues until scar maturation (Rivers & Jordan, 1998). Scar maturation can take 6 months to 2 years (Rivers & Jordan,
1998; Staley, Richard, & Falkel, 1994). It is considered complete when the scar becomes pale and the rate of collagen synthesis levels off (Grigsby deLinde & Miles, 1995). The level of direct involvement of the occupational therapist during this extended time is varied. It may range from daily inpatient treatment to weekly outpatient treat- ment to annual clinic visits.

Question 54

Occupational Therapy Assessment During the Rehabilitation Phase

Answer 54

During the rehabilitation phase, the occupational therapist continues to assess capacities and abilities such as range of motion and strength. In addition, functional assessments specific to self-care and homemaking are valuable in guid- ing treatment planning and preparing for discharge. Standardized tests, such as the Functional Independence Measure (Uniform Data System for Medical Rehabilitation, 1997) and the Valpar Work Samples (Resources 45-1) are im- portant because they provide objective data.

Question 55

Range of Motion

Answer 55

In the rehabilitation stage, the patient continues to bene- fit from daily stretching routines established in the acute phase of care. In the early part of this phase, the rate of collagen synthesis is increased (Staley, Richard, & Falkel, 1994), requiring the patient to stretch frequently through- out the day. As the scar matures and collagen synthesis slows, decreased frequency of stretching is required. At all times, skin integrity must be monitored during stretching to prevent tearing. Massage using a non–water-based cream should precede stretching to help prevent dry skin from rupturing (Rivers & Jordan, 1998). An appropriate stretch consists of bringing the tissue to the point of blanching, or becoming pale, and holding it in that posi- tion for several seconds. The patient should report tension but not pain. Overzealous stretching can result in tissue tears and edema, which increase joint stiffness. Stretching is initially performed by the occupational therapist. With training, however, the patient and/or caregiver can also complete stretching routines.

Question 56

Strength

Answer 56

Resistive exercise and graded functional activities can im- prove strength. For example, a patient may be taught an independent exercise program with resistive rubber rib- bon or tubing, such as Theraband, to increase proximal upper body strength. Patients also gain strength as they perform self-care activities, such as progressing from sit- ting to standing for hygiene activities.

Question 57

Activity Tolerance

Answer 57

A key feature of rehabilitation is mobilizing the patient as much as possible, thereby increasing the patient’s activity tolerance. For an inpatient, this includes increased time spent out of bed and trips to the gym and off the nursing unit. For an outpatient, this may mean resuming leisure activities and going on community outings.

Question 58

Sensation

Answer 58

Newly healed skin and grafted skin may be hypersensitive. Hypersensitivity can be addressed effectively by systematic desensitization. This can be achieved by asking the patient to manipulate objects with varying textures in the envi- ronment. Initially, the patient practices holding soft tex- tures, such as cotton balls or lambswool, and then pro- gresses to manipulating objects with rougher textures, such as Velcro or burlap. Sometimes a formal system such as the Downey desensitization program (Barber, 1990) is used (see Chapter 27).

Question 59

Coordination

Answer 59

Coordination can be impaired by a variety of factors, in- cluding limited range of motion, strength, or sensation. Coordination can be improved through the use of selected progressive tasks designed to challenge the patient’s skills. For example, a patient may be asked first to tak

Question 60

Scar Management

Answer 60

Scar tissue formation is a natural response to wound heal- ing (Grisby deLinde & Miles, 1995). It begins in the emer- gent phase and may take up to 2 years (Poh-Fitzpatrick, 1992). A hypertrophic scar is an aberration of the normal healing process and presents as a red, raised, and inelastic scar (Abston, 1987) (Fig. 45-5). A hypertrophic scar con- tains an increased number of fibroblasts as compared to normal skin, and the collagen fibers are arranged in a nodular as opposed to parallel fashion (Abston, 1987). There is thought to be a disruption in the balance between collagen synthesis and lysis (Grigsby deLinde & Miles, 1995). The tendency for hypertrophic scarring is unique to each individual. In general, patients with large amounts of pigment in the skin and young patients are most prone to hypertrophic scarring. Hypertrophic scarring is also in- versely related to the depth of the initial burn wound (Staley, Richard, & Falkel, 1994). In addition to being cosmetically unappealing, hypertrophic scars can limit functional skills by restricting joint range of motion.

Question 61

OCCUPATIONAL THERAPY ASSESSMENT OF SCARS

Answer 61

The Burn Scar Index (Vancouver Scar Scale) is the most widely used standardized scar assessment tool and is used to rate the pliability, vascularity, height, and pigmentation of scars (Sullivan et al., 1990). Used periodically, the Burn Scar Index can help guide the occupational therapist in de- termining effective scar management and evaluating the stage of scar maturation. Other assessments include the Patient and Observer Scar Assessment Scale (Draaijers et al., 2004) and the Matching Assessment of Scars and Photographs (Masters, McMahon, & Svens, 2005).

Question 62

OCCUPATIONAL THERAPY INTERVENTION AND SCAR MANAGEMENT

Answer 62

Massage
Pressure Dressings and Garments

Self-Care and Home Management Skills

Question 63

Massage

Answer 63

Massage may be useful in reducing scar contracture (Sta- ley, Richard, & Falkel, 1994). Scar massage is initiated when it is determined that the injured area can withstand slight friction. In addition, scar massage maintains suppleness,
Figure45-6 GentlepressureisappliedusingCobanand Tubigrip.
as normal sweat and oil gland function is often disrupted. Scar massage also aids in desensitization. Scar massage is performed several times daily with deep pressure (enough to blanch the scar temporarily) in either a circular pattern or perpendicular to the long axis of the scar. Lotion is used during massage to reduce friction. Perfume-free lotions are preferred to decrease potential irritation to newly healed skin. Initially, scar massage is the responsibility of the oc- cupational therapist so that skin integrity and tolerance can be monitored. Once an established routine has been developed, the therapist teaches the patient and/or care- givers to assume responsibility for daily scar massage.

Question 64

Pressure Dressings and Garments

Answer 64

Pressure dressings and garments are another form of scar management that has been advocated in the literature (Chang et al., 1995; Ward, 1991). The flattened, smooth, supple appearance of the scar after application of pressure has been reported clinically, but objective support has been inconclusive (Grigsby deLinde & Miles, 1995; Ward, 1991). The occupational therapist initiates the application of gentle pressure via Tubigrip, elastic bandage wraps, Coban, or Isotoner gloves (Fig. 45-6). Initially pressure dressings are applied for 2-hour intervals. Wearing time is gradually increased by 2-hour increments until 24-hour wear is tolerated. Tolerance is determined by lack of blis- ters or open areas. At this point, increased pressure using customized products such as Jobst or Bioconcepts gar- ments is indicated (Fig. 45-7). Staley, Richard, and Falkel (1994) suggest that the application of 25 mm Hg of pres sure is ideal to aid in collagen organization, which ul- timately helps decrease scar tissue formation. Custom garments cause notable shearing during application and removal and thus should be used only when the skin is healed sufficiently to withstand these forces. Wearing of custom garments continues until the scar is inactive, or mature, as described earlier. The therapist’s role is to initi- ate the ordering of custom garments and oversee their use. Most providers of custom garments send trained person- nel to measure the patient for custom fitting. For facial burns, the patient may use a transparent facial orthosis se- cured by elastic straps to provide even pressure distribu- tion. These orthoses are usually fabricated by a specially trained orthotist at the request of the therapist.
Inserts are often used in conjunction with pressure gar- ments. They may be constructed from products such as Otoform, Elastomere, or closed cell foam. Their purpose is to increase pressure in concave areas, such as the web spaces and the sternoclavicular depression. Silicone inserts have also been demonstrated to be effective in improving some characteristics of hypertrophic scars
(Ahn, Monafo, & Mustoe, 1989), although the mechanism of action remains to be determined. The design of a scar management program is determined by the available re- sources, careful clinical observation, and the patient’s abil- ity to comply with the program (Evans & McAuliffe, 1995). Periodic outpatient visits to occupational therapy or an established burn clinic throughout the rehabilitation phase allow for monitoring and adjustments of the scar management program.

Question 65

Self-Care and Home Management Skills

Answer 65

If neuromuscular limitations impede the patient’s per- formance of functional tasks, the therapist may provide adaptive equipment, such as built-up handles for im- paired grasp or long-handled utensils for decreased elbow flexion. Teaching adaptive techniques, such as performing certain activities using two hands for extra support, may also improve function.

Question 66

Patient and Family Teaching

Answer 66

Patients should understand the rationale for each of the splints and techniques used in their care. They participate in the development of goals, so that they are invested in achieving them. Skin care is an important element in dis- charge teaching. Patients practice monitoring their skin for breakdown and caring for their skin, including the daily use of a moisturizer. They learn to use a sunscreen with an SPF of at least 15 (reapplied frequently) if they an- ticipate exposure to the sun (Staley, Richard, & Falkel, 1994). In addition, patients should have a basic under- standing of wound healing and tissue response to exercise and scar management techniques.

Question 67

Support and Psychosocial Adjustment During the Rehabilitation Phase

Answer 67

Although the patient and family typically focus on sur- vival immediately after injury, many other issues arise dur- ing rehabilitation. For example, guilt or embarrassment regarding the injury may lead the patient to withdraw. The patient may also begin questioning his or her ability to re- turn to the role of a parent or provider, which creates anx- iety. Patients may have fear about their ability to maintain relationships and be concerned regarding sexual function- ing. The increase in activity in the rehabilitation phase not only assists physical rehabilitation but also assists patients to discover how their injury affects their daily lives. Emotional reactions to the realization of loss may produce a wide range of behaviors, such as crying and expression of anger. Patients may also have responses related to post- traumatic stress disorder, such as flashbacks.
One of the most difficult challenges for the burn thera- pist is caring for patients as they grieve for a functional lim- itation or alteration in body image (Pessina & Ellis, 1997). The occupational therapist supports the patient by encour aging questions and verbalization of feelings about the burn injury (Pessina & Ellis, 1997). The occupational thera- pist also chooses treatment activities to restore confidence and self-esteem. Group activities provide opportunities for socialization and sharing of concerns in a safe environment (Summers, 1991). Given the extensive contact with the pa- tient throughout all phases of recovery, the occupational therapist is in a unique position to identify and address psy- chosocial issues, but consultation with other specialists on the burn team (e.g., nursing staff, family members, social workers, and psychologists) is essential.

Question 68

Potential Complications

Answer 68

Pruritus
Microstomia
Heterotopic Ossification
Heat Intolerance

Question 69

Pruritus

Answer 69

Pruritus (persistent itching) is a common complication (IHQ, 1997; Staley, Richard, & Falkel, 1994), presumably due to nerve regeneration. It usually resolves within 2 years of the initial injury (Poh-Fitzpatrick, 1992). The use of compression garments, skin moisturizers, cold packs, and medications such as antihistamines may alleviate itching (IHQ, 1997).

Question 70

Microstomia

Answer 70

Patients with facial burns in the area of the mouth are at risk for oral commissure contracture (microstomia) (Rivers & Jordan, 1998), which is tightening of the muscu- lature around the lip area that limits mouth opening. In extreme cases, urgent surgical revision is required. This risk is exaggerated if the patient has undergone prolonged periods without eating or speaking because of intubation or respiratory compromise. In addition to daily scar mas- sage, the therapist can teach the patient facial stretching exercises, such as yawning or grinning widely and pursing lips together. The exercises can be combined with the wearing of a microstomia splint to stretch the oral com- missure. The splint may be worn as tolerated, usually starting with 10 minutes and gradually increasing to 60 minutes twice a day. These devices can be purchased or constructed by the occupational therapist. The cognitive level of the patient is an extremely important factor in use of a microstomia device because of the risk of an unex- pected airway emergency. For example, a heavily sedated or confused patient may attempt to swallow the device.

Question 71

Support and Psychosocial Adjustment During the Rehabilitation Phase

Answer 71

Although the patient and family typically focus on sur- vival immediately after injury, many other issues arise dur- ing rehabilitation. For example, guilt or embarrassment regarding the injury may lead the patient to withdraw. The patient may also begin questioning his or her ability to re- turn to the role of a parent or provider, which creates anx- iety. Patients may have fear about their ability to maintain relationships and be concerned regarding sexual function- ing. The increase in activity in the rehabilitation phase not only assists physical rehabilitation but also assists patients to discover how their injury affects their daily lives. Emotional reactions to the realization of loss may produce a wide range of behaviors, such as crying and expression of anger. Patients may also have responses related to post- traumatic stress disorder, such as flashbacks.
One of the most difficult challenges for the burn thera- pist is caring for patients as they grieve for a functional lim- itation or alteration in body image (Pessina & Ellis, 1997). The occupational therapist supports the patient by encour aging questions and verbalization of feelings about the burn injury (Pessina & Ellis, 1997). The occupational thera- pist also chooses treatment activities to restore confidence and self-esteem. Group activities provide opportunities for socialization and sharing of concerns in a safe environment (Summers, 1991). Given the extensive contact with the pa- tient throughout all phases of recovery, the occupational therapist is in a unique position to identify and address psy- chosocial issues, but consultation with other specialists on the burn team (e.g., nursing staff, family members, social workers, and psychologists) is essential.

Question 72

Potential Complications

Answer 72

Pruritus
Microstomia
Heterotopic Ossification
Heat Intolerance

Question 73

Pruritus

Answer 73

Pruritus (persistent itching) is a common complication (IHQ, 1997; Staley, Richard, & Falkel, 1994), presumably due to nerve regeneration. It usually resolves within 2 years of the initial injury (Poh-Fitzpatrick, 1992). The use of compression garments, skin moisturizers, cold packs, and medications such as antihistamines may alleviate itching (IHQ, 1997).

Question 74

Microstomia

Answer 74

Patients with facial burns in the area of the mouth are at risk for oral commissure contracture (microstomia) (Rivers & Jordan, 1998), which is tightening of the muscu- lature around the lip area that limits mouth opening. In extreme cases, urgent surgical revision is required. This risk is exaggerated if the patient has undergone prolonged periods without eating or speaking because of intubation or respiratory compromise. In addition to daily scar mas- sage, the therapist can teach the patient facial stretching exercises, such as yawning or grinning widely and pursing lips together. The exercises can be combined with the wearing of a microstomia splint to stretch the oral com- missure. The splint may be worn as tolerated, usually starting with 10 minutes and gradually increasing to 60 minutes twice a day. These devices can be purchased or constructed by the occupational therapist. The cognitive level of the patient is an extremely important factor in use of a microstomia device because of the risk of an unex- pected airway emergency. For example, a heavily sedated or confused patient may attempt to swallow the device.

Question 75

Support and Psychosocial Adjustment During the Rehabilitation Phase

Answer 75

Although the patient and family typically focus on sur- vival immediately after injury, many other issues arise dur- ing rehabilitation. For example, guilt or embarrassment regarding the injury may lead the patient to withdraw. The patient may also begin questioning his or her ability to re- turn to the role of a parent or provider, which creates anx- iety. Patients may have fear about their ability to maintain relationships and be concerned regarding sexual function- ing. The increase in activity in the rehabilitation phase not only assists physical rehabilitation but also assists patients to discover how their injury affects their daily lives. Emotional reactions to the realization of loss may produce a wide range of behaviors, such as crying and expression of anger. Patients may also have responses related to post- traumatic stress disorder, such as flashbacks.
One of the most difficult challenges for the burn thera- pist is caring for patients as they grieve for a functional lim- itation or alteration in body image (Pessina & Ellis, 1997). The occupational therapist supports the patient by encour aging questions and verbalization of feelings about the burn injury (Pessina & Ellis, 1997). The occupational thera- pist also chooses treatment activities to restore confidence and self-esteem. Group activities provide opportunities for socialization and sharing of concerns in a safe environment (Summers, 1991). Given the extensive contact with the pa- tient throughout all phases of recovery, the occupational therapist is in a unique position to identify and address psy- chosocial issues, but consultation with other specialists on the burn team (e.g., nursing staff, family members, social workers, and psychologists) is essential.

Question 76

Potential Complications

Answer 76

Pruritus
Microstomia
Heterotopic Ossification
Heat Intolerance

Question 77

Pruritus

Answer 77

Pruritus (persistent itching) is a common complication (IHQ, 1997; Staley, Richard, & Falkel, 1994), presumably due to nerve regeneration. It usually resolves within 2 years of the initial injury (Poh-Fitzpatrick, 1992). The use of compression garments, skin moisturizers, cold packs, and medications such as antihistamines may alleviate itching (IHQ, 1997).

Question 78

Microstomia

Answer 78

Patients with facial burns in the area of the mouth are at risk for oral commissure contracture (microstomia) (Rivers & Jordan, 1998), which is tightening of the muscu- lature around the lip area that limits mouth opening. In extreme cases, urgent surgical revision is required. This risk is exaggerated if the patient has undergone prolonged periods without eating or speaking because of intubation or respiratory compromise. In addition to daily scar mas- sage, the therapist can teach the patient facial stretching exercises, such as yawning or grinning widely and pursing lips together. The exercises can be combined with the wearing of a microstomia splint to stretch the oral com- missure. The splint may be worn as tolerated, usually starting with 10 minutes and gradually increasing to 60 minutes twice a day. These devices can be purchased or constructed by the occupational therapist. The cognitive level of the patient is an extremely important factor in use of a microstomia device because of the risk of an unex- pected airway emergency. For example, a heavily sedated or confused patient may attempt to swallow the device.