Caring Strategy for Burns
It is at the hospital where you will be your caring strategy for your burn wounds would be implemented. The physician at the hospital may decide you would benefit from being treated at a more specialized facility called a burn center. Therefore, you may be transferred to a different department or to another hospital where the burn centre is located.
The medical team will decide upon one of three different approaches to treating the burn wound:
1. Open method
The wound remains exposed, with only a thin layer (2mm to 4mm) of topical antimicrobial ointment spread on the burn wound surface using a sterile glove or applicator.
2. Closed method
The dressing is left intact for two to seven days.
3. Multiple dressing changes
The dressing is changed once or twice daily, according to an agreed-upon schedule. The frequency of changing depends upon the nature of the dressing and the condition of the wound – more or less frequency may be indicated.
Ointment or cream (topical) coverage of the burn
There are a variety of creams or topical applications that are used on the burn area at different stages of the healing process. At the beginning, it is usual to apply an antimicrobial cream whose chemical name is silver sulphadiazine. This cream protects the burn against developing an infection, which can dramatically slow down the healing process. The cream is applied on a wet dressing and covered with a dry dressing and roller wrap.
When choosing a cream or ointment, the medical team will consider the following:
a. How well it works (clinical efficacy)
b. How many types of bacteria it will kill
c. Ease of use
d. Consideration of any toxic/absorption issues
e. Its proven record in not creating difficult infections, called super-infections
f. Acceptance by patient and staff
Here is a list of some of the names of topical agents commonly used during the healing process: Flamazine, Sulfamylon® (Mafenide acetate), silver nitrate (0.5%), Furacin® (nitrofurazone), Garamycin® (gentamycin sulfate), Bacitracin with Polymyxin B (Polysporin), normal saline (0.9%), acetic acid (0.5%), and hydrogen peroxide (half strength).
Following the burn bath or shower, dressings are usually applied over the burn area, with the exception of the face.
Dressings are a vital part of burn care and the healing process. Their primary role is to keep the wound clean and moist and to quicken the removal of dead skin. There are many innovative and technically advanced dressings now available from manufacturers; individual medical facilities have their own particular strategies and choices.
The following factors are considered when choosing dressings:
a. Ability to promote healing
b. Effectiveness in helping to lessen pain
c. Effectiveness in helping the debriding process
d. The amount of pressure it confers
e. Its function as an immobilizer
f. Whether or not it helps to preserve the wound site
g. Acceptance by the patient
h. The condition of the burn wound
i. The desired clinical results
j. The unique properties of the dressing and its cost
The bottom line when considering all these factors is the ultimate healing of the wound. During the healing process, the medical team can adjust their tactics and strategies according to the progress and needs of the burn, which is the number one priority.
The prevention of infection in the burn wound is very important, and strategies are in place to reduce its occurrence. Everyone is encouraged to take the following precautions:
• extremely thorough hand washing;
• when wounds are exposed, isolation gowns, head covers and masks are worn;
• clean gloves are required for removal of soiled dressings and sterile gloves for cleansing of burn wounds and application of clean dressings or topical agents to a burn area.
Other preventive measures include:
• live plants and flowers are not permitted in the burn unit
• culture swabs are taken from patients periodically and analyzed by the laboratory;
• cubicle isolation techniques are observed in patients’ rooms;
• housekeeping staff keep to specific procedures and cleanliness standards when in the burn unit, and
• plastic liners are used for hydrotherapy equipment and changed for each patient.
Intravenous replacement fluid therapy
A vital part of the body’s response to a burn injury is to direct fluid out of the bloodstream and into the tissues surrounding the burn area, causing swelling around the burn area. This swelling, which decreases over time, is also known as edema; it may be present around the arms, legs and face for several days after the burn injury occurs. It is necessary to replace this lost fluid from the bloodstream with an intravenous (IV) drip. To determine how much IV fluid the patient needs, his urine output is measured and his vital signs are monitored.
Nasogastric (NG) tube
Initially, after a burn injury, the stomach may stop digesting food. Consequently, it may be necessary to insert a nasogastric (NG) tube through the patient’s nose into her stomach. As soon as the stomach resumes functioning, a high calorie, high protein drink will be fed through this tube. This feeding continues until the patient is able to feed herself independently.
If, during the burn accident, there has been inhalation of smoke or the neck has been burned and is now swollen, the patient may have problems breathing. To ensure breathing takes place, a tube can be placed through the patient’s nose or mouth and connected to the lungs. This tube is then attached to a machine called a ventilator, which will help the patient breathe properly.
Proper nutrition is vital for the healing process. Usually a high protein, high calorie intake is prescribed. All the food eaten by a patient is recorded by the nurse on a calorie count sheet. This allows the dietician to know how much food the patient is eating and if it is enough each day to ensure the healing process can take place. Family members are encouraged to bring the patient’s favourite foods into the hospital on a regular basis.
If the burn wound is “full thickness” – all the tissues have been destroyed – then it must be covered with healthy skin from an unburned area of the body. This is called a skin graft. The area from where the healthy skin is removed is called the donor site. After this skin graft has been taken, or harvested, the donor site is covered with a dressing. This area of skin usually heals within seven to ten days.
Before the new skin can be applied, the dead tissue must be removed from the burn area. The removal of this skin or dead tissue is called debridement or excision. This process is carried out in the operating room because strict sterile conditions are needed. The actual skin grafting may be carried performed at the same time, or it may be delayed a day or two. The donor skin can actually be stored safely in a refrigerator and then applied to the patient a few days later in the patient’s room.
Most donor skin is “meshed” so that it can expand to cover a larger surface area. When healed, the grafted skin may have a sort of checkered appearance, which will gradually fade over time.
Once a skin graft is applied, the dressing will not be changed for five days. This is because it is vital not to disturb the new skin area. In fact, grafted arms and legs are often kept still by being put into a cast, splint, pins or traction. The process is so delicate that even with these precautions, re-grafting may be necessary. Healing times vary from one individual to the next, so the medical team constantly evaluates progress at each dressing change.
Burn care and pain are normally synonymous and both the burn team and the patient should maintain an open dialogue for monitoring this critical aspect of treatment. As a patient, you should never be afraid or reluctant to communicate about any pain you may be feeling. In addition, the burn team should regularly ask how you are feeling with regard to pain. Alleviation of pain and how it contributes to a positive mental attitude in coping with the healing process is a critical factor that deserves priority status.
Medication is very effective in controlling pain and additional doses should be given before dressing changes and physiotherapy sessions.
Once you are ready to be discharged from the hospital, the most intensive and critical part of your treatment is over. However, this is just one battle won – the war is not over yet. Through education, training and communication, the burn team has empowered you to care for your skin and participate in treatment programs in order for you to have the best possible outcome after your burn injury.
You may be required to visit the hospital on an out-patient basis, depending on the nature of your injury. You may even have your dressings changed at the hospital. Conversely, you may visit your family physician in your community and see the burn team periodically.
Continuing pain management
One area which you should consider as you leave the hospital is the issue of controlling pain as you recover from your burn injury. In fact, you may experience some discomfort over the next year or two as your burn scars mature. This can be frustrating but, over time, it will improve.
While there is no absolute way to remove the discomfort, you can discuss with your physician the best approach to taking pain medications and whether or not stronger medication is needed. Here are some suggestions that may help you cope with the discomfort:
Try relaxation techniques such as deep breathing, muscle relaxation, yoga, massage therapy, meditation and so on. We are all unique in terms of what makes us relax and distracts us from feelings of discomfort. Read up on these techniques and experiment until you find what works best for you.
Walking and getting out into the fresh air can be invigorating.
Follow all skin care instructions deliberately and thoroughly; this will help quicken your recovery.
Do things you enjoy – hobbies, social events and so on. Try to get back to your previous routines. This will make you feel good and distract you from feelings of discomfort.
The ABC’s of when to seek medical attention
A. Pain increases
B. Redness or red streaking appears around the wound
C. Fever of 38.9° (102° F) develops and persists for more than 18 hours.
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Managing burn care after leaving the hospital
Every burn survivor leaving a hospital has a unique set of needs, follow-up procedures and post-hospital care activities to ensure complete healing. Be sure to study all the instructions, ask all pertinent questions to your burn team, and be sure you know the name of the contact person at the hospital and the names and phone numbers of the support professionals you’ll be dealing with.
As previously highlighted, support staff could be the physical therapist, the social worker, or the occupational therapist, to name a few. There is another key health care professional who may play an important role in your rehabilitation, and that is the home care nurse. These nurses come to your home, change your dressing and ensure your recovery is proceeding well at home.
You will probably be given an appointment to return to the burn clinic in a week or two to see the team. These appointments are extremely important to your overall recovery; if you are unable to attend, you should quickly reschedule. You should also see your family physician in order to keep him or her informed of your progress.
In many communities, there are support groups of people who have experienced the same sort of burn injury as you and can provide assistance to help you on the road to recovery. Speak to the burn team about this aspect of care.
It is completely normal to experience a wide range of emotions after leaving the hospital. You have experienced a traumatic event. You have probably felt some insecurity and anxiety about possible disfigurement and may be concerned about your physical appearance. Whether or not you have had skin grafts, a burn injury is physically debilitating. You will find yourself lacking in energy and will experience frustration at your possible loss of mobility.
All these factors can lead to anger and depression; this can affect your willingness to cooperate with your health care team, which in turn can affect your achievement of a full recovery.
Remind yourself that the worst is over – you have survived, and you owe it to yourself to resume as many of your pre-burn activities as you can. Feel free to speak to the burn team as it is quite common to feel a little depressed or sad. Help is available – you are not alone in this journey.
Be kind to yourself, give yourself time to adjust, set reasonable goals and try not to have high expectations in the short term: patience is the order of the day in this sort of rehabilitation. Think two years for full recovery; if you feel better sooner than that, then that is a bonus.
One major concern you may experience upon your return home is the reaction of family and friends to your accident. You can be sure they want to help and they probably feel as much or more anxiety as you do. The key here is communication. Take a proactive approach – discuss with them your concerns about what they may be feeling and what you’re feeling as well. Once dialogue is begun, you will be amazed at how quickly a constructive and supportive climate of cooperation and love is created. Feel free to talk to the burn team about this – they can help.
One critical factor in the short term is getting enough sleep. Your regular sleep patterns will have been dramatically disrupted due to the burn injury and it may take some time to adapt. Here are some suggestions that may help:
• Avoid long naps during the day.
• Try walking outside in the fresh air with some light exercise.
• Try a relaxing activity which suits you before going to bed.
• Make sure you follow your skin care instructions to reduce itchiness.
• Keep on top of your comfort levels by optimum usage of pain medication.
Finally, remember that the burn team understands the emotional challenges that can occur after leaving the hospital and are always available to help. If you are having flashbacks or nightmares, speak to the burn team. Ask for advice on relaxation techniques and know that these flashbacks usually decrease in frequency fairly quickly and are very normal, however unsettling they might be.
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