Download - Nursing Care of the Burned Client
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Nursing Care of the Burned Client
Joyce M. Black, PhD, RN
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A “minor” burn happens to someone else.
Anonymous burn victim.
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How serious is the burn problem? 1.4 million people seek care for
burn injuries yearly 54,000 hospitalizations 5,000 deaths annually
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How do burn injuries occur? Thermal Burns
flames, hot liquids, semi-liquids (steam), semi-solids (tar) or hot objects
the most common etiology
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How do burn injuries occur? Chemical Burns
strong acids, alkali, or organic compounds
depth of injury determined by: - concentration - volume - duration of contact - type of chemical
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How do burn injuries occur? Electrical Burns
• lightning• faulty or exposed wiring
- electrical wiring - high-voltage power lines
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How do burn injuries occur? Radiation Burns
least common form of burns exposure to radioactive source
- nuclear radiation accidents
- ionizing radiation exposure - prolonged exposure to ultraviolet
light ( sunburn)
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Who is at risk of burn injury? 75% due to action of the victim Contact with scalding liquids
elderly with mental and /or physical limitations
reduce temperatures on water heaters clothing ignition during meal prep
no flammability standards yet cigarette-related mattress fires playing with matches need for operable smoke detectors
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What are the responses to burn injury? If the burn is greater than 25%
BSA: Systemic and proportional response
If burn is less than 25% BSA:• Localized to injured area
Response characterized by early system hypofunction followed by hyperfunction
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Nervous System Response Neurological problems uncommon
unless injury was associated with: A fall An explosion Impaired brain perfusion Closed-space fire Inhalation injury Ingested drugs
Usually awake and alert on admission
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Fluid and Electrolyte Response Vasoactive substances released from
injured tissues increases capillary permeability
Direct heat injury to vessels further increases permeability
Fluids are shifted throughout entire body, not just in burned area
Leads to hypovolemic shock Low B/P, high Hct,
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Cardiovascular Response Catecholamine release and
hypovolemia increases HR and peripheral vascular resistance (PVR)
Initial decrease in cardiac output ? Myocardial depressant factor May explain unresponsiveness to
fluids in extensive burn injuries
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Pulmonary Response Without inhalation injury,
pulmonary response is minimal Rise in minute rate and tidal volume Slight increase in pulmonary
resistance and a decrease in lung compliance
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Renal System Response Blood shunted from kidneys:
If fluids not replaced, prerenal renal failure can develop
Hemoglobin and myoglobin can become trapped in nephron Can lead to renal failure Presents as
hemoglobinuria/myoglobinuria RX= fluids, tubular diuretics
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Gastrointestinal (GI) Response Decreased blood flow initially:
Ileus Risks of bleeding - Erosions lead to - Ulcerations (called Curlings ulcers
in burn victims)
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Immune Response Depressed immune function:
Decreased lymphocyte activity Decreased immunoglobulin production Suppression of complement Altered neutrophil and phagocyte
function Increases risk of sepsis and
infections
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Psychological Response Influenced by:
Age Personality Cultural and ethnic background Extent and location of injury Impact on body image Cause of injury (self-inflicted vs.
victim of others)
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Four Stages of Psychosocial Response Impact Stage
Shock, disbelief, feelings of being overwhelmed
Family and client need assurance, proximity to the client, information
Retreat Stage repression, withdrawal, denial,
suppression Family needs to know that these
responses are normal and self-protective
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Psychological Response Continued… Acknowledgment Stage
Begins when client accepts the injury Mourns actual or perceived losses Family and client may benefit from meeting
other burned clients Reconstructive Phase
Accepts limitations imposed by injury Begins to plan realistically for the future May benefit from job retraining
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Pain Response Burns hurt!!! Background pain
Pain while at rest or with nonprocedural activities
Continuous and low intensity Procedural pain
Related to therapeutic modalities Debridement especially painful Acute and high intensity
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Can the respiratory tract be burned? Direct heat injury is uncommon Respiratory tract is very efficient at
cooling inspired air Air entering pharynx at 518 degrees is
cooled to 122 degrees by the time it reaches the trachea
Reflex closure of glottis Only live steam can burn
It has 6,000 times the heat carrying capacity
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What substances burn the respiratory tract? By products of combustion
Wood, cotton, paper Acetaldehyde, formaldehyde
Petroleum• Acrolein (tear gas)
Wool, silk• Ammonia, hydrogen cyanide, hydrogen sulfide
Polymer of plastic• Hydrochloric acid, hydrogen cyanide, ammonia
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How does inhalation injury occur? Asphyxiants (most common) From carbon monoxide (CO) produced
when organic material is burned CO poisoning manifestations
5-10% = impaired visual acuity 11-20% = flushing, headache 21-30% = nausea, impaired dexterity 31-40% = vomiting, dizziness, syncope 41-50% = tachypnea, tachycardia > 50% = coma, death
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Inhalation injuries cont… Smoke Poisoning
Inhalation of combustion by-products Noxious chemicals and particulates
Produces edema, epithelial sloughing and ARDS
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Inhalation Injuries Leading cause of death in burn
victims Most inhalation injury victims never
reach the hospital Seen in 30% of victims of residential
fires High risk clients:
Trapped in enclosed, smoke filled spaces
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How can I recognize inhalation injury? Look for:
Facial burns, singed nasal hairs Erythema or edema of oropharnyx or
nasophanyx Stridor, wheezing, dyspnea Hoarse voice or change in voice carbonaceous sputum, cough
Examine by brochoscopy or xenon-133 lung scan
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Management of Inhalation Injuries Frequent ABG’s Continuous oximetry Monitor for respiratory alkalosis,
hypoxia, hypercapnia Monitor carboxyhemoglobin Hyperbaric oxygen therapy (HBO) Mechanical Ventilation with PEEP?
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How do I determine burn severity? Burn depth Burn size Burn location Age General health Mechanism of burn injury
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Determining burn depth Superficial partial thickness (aka
first degree) Mild to severe erythema Skin blanches with pressure Painful Pain eased by cooling Desquamation in 3-7 days Heals on its own
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Determining burn depth Partial thickness burn (aka second degree)
Large, thick blisters (wet or shiny if blisters open)
Yellow, red, white eschar Mottled red base Edematous Painful Sensitive to cold air Heals in 14-28 days Healing rate varies with depth and infection
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Determine burn depth Full thickness injury (aka third degree)
Surface is dry and black, brown, red, white Edematous May have exposed sub-q tissue, muscle or
bone Little pain Desquamates in 2-3 weeks Cannot heal on its own unless very small Subject to hypertrophic scar and contractures
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Determine burn size Size of burn (excluding first degree
areas) Percent body surface areas (BSA) Most accurate after debridement Rule of nines
Quick assessment Body parts are nines or multiples of nines
Lund and Browder charts Age-specific More accurate after exposure
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Determine burn location Burns of the head, chest, neck have
pulmonary complications Burns of the eyes have corneal abrasions Burns of the ears subject to tissue loss burns of the hands subject to contracture
and may lead to permanent disability Circumferential burns prone to vascular
compromise
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Determine age and general health Mortality higher for children > 4
yrs and elderly over 65 General health Systemic diseases
Cardiac disease 3.5-4 times mortality rate
Alcoholism 3 times mortality rate
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Determine mechanism of injury Chemical burns
Systemic toxicity from absorption Organ failure
Esp hydrocarbons from petroleum products
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Determine mechanisms of injury Electrical burn
Injuries always worse than they first seem
AC more dangerous than DC Heat is generated as electricity travels
through the body Myoglobin release leads to ARF Fractures Cataracts
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ABA Severity Classification for Burns Minor Burns
< 15% BSA in adults < 10% BSA in children < 10% BSA in adults > 40 years No functional or cosmetic impairment
or disability
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ABA Severity Classification for Burns Moderate Burns
15-25% BSA in adults 10-20% BSA in children < 10 yrs 10-20% BSA in adults > 40 < 10% BSA full thickness burn of the
face, eyes, ears, hands, feet, or perineum
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Phases of Burn Treatment Emergent Period – from the time of
injury until fluid resuscitation is completed
Acute Period – from time of fluid resuscitation until ungrafted BSA < 20%
Rehabilitation Period – from the time of ungrafted BSA < 20% until total rehabilitation
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Management of Minor Burns History of injury, past medical history,
allergies, usual medications Wound Care – cleansing, debridement,
dressing Twice daily with mild antimicrobial ointment
Oral analgesia Tetanus immunization Teach about ROM, elevation
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ABA Severity Classification for Burns Severe Burns
25% BSA in adults 20% BSA in children < 10 yrs Burns of face, eyes, ears, hands, feet,
or perineum High-voltage electrical injury All burns with concomitant inhalation
injury or major trauma
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Burn Care Phases Emergent Phase
From time of injury until capillary integrity restored and diuresis begins
Goals are prevention of hypovolemic shock and preservation of vital organ function
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Prehospital Burn Care Stop the Burning Process!
Extinguish burning clothes Remove saturated clothing
(chemicals/scalds) Cool the tar burn Copiously irrigate the chemical burn Do not attempt to neutralize Brush dry chemicals off, do not activate with
water Shut off power or remove source of
electricity using a dry, nonconductive object
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Prehospital Burn Care Assess the ABCs
Establish airway Ensure adequate breathing (100% oxygen
via non rebreather mask for suspected inhalation injury
Assess circulation Assess for associated trauma Conserve body heat Start a large bore IV in unburned skin Transport
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Initial Care of the Burn Victim Reevaluate ABCs and associated trauma
100% oxygen or HBO when high COHb levels Obtain IV Access
Large bore IV in unburned skin, proximal to burn or central access
Estimate BSA size of burn Begin fluid resuscitation
Goal is to provide adequate circulating volume without fluid overload
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Principles of Fluid Resuscitation Purpose is to prevent hypovolemic shock
while capillaries are highly permeable Time zero is the time of injury, not the time
fluid resuscitation began Fluid formulas are only guidelines Fluids titrated to maintain urine output Colloids and dextrose given after 24 hours
to prevent increased edema and diuresis
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Fluid Resuscitation Guidelines-Brooke First 24 hours
LR 1.5 ml/kg/%burn Colloid 0.5mg/kg/%burn
Second 24 hours LR 1/2 to ¾ of first 24 hr volume Colloid ½ to ¾ first 24 hr volume
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Fluid ResuscitationGuidelines-Evans Evans formula
First 24 hours NS 1ml/kg/% burn Colloids 1ml/kg/% burn Dextrose in water 2000ml
Second 24 hours ½ volume of NS, ½ volume of colloid,
2000 ml Dextrose
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Fluid ResuscitationGuidelines-Parkland First 24 hours
LR 4ml/kg/% burn No colloids or dextrose
Second 24 hours Colloid 0.3 – 0.5 ml/kg/ % burn Titrate Dextrose solution to maintain
urine output
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How much fluid does this burn victim need? Using Parkland formula calculate
fluid needs for 70 kg man with 50% BSA burn
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Initial Care of the Burn Victim Insert NG tube Baseline Vital Signs Assess Urine Output
Indwelling catheter Assess for
hemoglobinuria/myoglobinuria Can lead to renal failure (ATN) Increase fluids to maintain 75-100ml output
if present
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Initial Care of Burn Victim Baseline Lab studies
Glucose, BUN, Creatinine, Electrolytes, Hematocrit, ABGs and COHb
Pain assessment and Management IV morphine No oral meds or injections (no
digestion or absorption) Tetanus Immunization
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Initial Care of Burn Victim Date Collection
Time of injury Loss of consciousness Burned in enclosed space Associated trauma History of past medical problems
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Initial Care of Burn Victim Date Collection, cont
If chemical burn Specific chemical Concentration Duration of exposure Use of irrigation
If electrical burn Source, voltage Type of current
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Initial Wound Care Irrigate contaminants from wound Debride broken blisters Leave intact blisters alone Cover with antimicrobial and dressings
Open method for face, neck, perineum Closed method for remainder of body
Wrap distal to proximal Elevate extremities Monitor pulses and respirations
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Principles of a Releasing Escharotomy
1. Relieve Respiratory Distress
2. Prevent Circulatory Occlusion
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Periods of Burn Treatment Emergent Period – from the time of
injury until fluid resuscitation is complete
Acute Period – from fluid resuscitation until ungrafted BSA less than 20%
Rehabilitation Period – from less than 20%BSA ungrafted until total rehabilitation
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The Acute Phase of Burn Management Acute phase from fluid resuscitation to
wound closure Care focuses on:
Infection control Wound care nutritional support Pain management Psychosocial support Physical therapy Control of scarring
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Why is a burn wound so likely to become infected? Optimal conditions for bacterial
growth Warm environment Dark environment Moisture Food present in eschar and body fluids pH is alkaline Anaerobic/aerobic environment
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How can the risk of infection be reduced? Use antimicrobials Support immune functions Provide adequate nutrition Eliminate reservoirs of infection Reduce risk of contamination
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Infection control Prevent transmission of micro
organisms Common sources are oropharnyx, fecal
flora, unburned skin, cross contamination
Vigilant monitoring for infection, sepsis Use of additional isolation techniques Use of aseptic technique Use of antimicrobials
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Wound Infection – Septicemia
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Wound Care Debridement
Hydrotherapy Mechanical debridement
Dressings Scissors, forceps
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Wound Care –Debridement Enzymatic Debridement
Proteolytic and fibrinolytic topical enzymes to eschar
Digest necrotic tissues Require a moist environment Usually confined to small area and qd Pain and bleeding can result Do not use on wounds adjacent to major
body cavities, or with exposed nerves or tendons
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Wound Debridement –Surgical Excision of devitalized tissues
Tangential excision Very thin layers of eschar removed until
viable tissue reached Facilitates healing and grafting
Fascial excision For deep burn wounds
Assess for bleeding and manage pain
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Topical Antimicrobials Ideal agent would:
Promote eschar separation Not destroy granulation or epithelial tissue Be broad spectrum Stay on the wound for 24 hours Produce no pain during application Have limited allergies Be of reasonable cost Have no serious side effects
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What are my choices for topical antimicrobials? Silver sulfadiazine
Broad spectrum, including yeast and fungi Apply bid, apply to dressing first Separates when stored at warm temps Does not produce pain upon application Transient leukopenia is a SE Costs about $12.00 per 50 gm jar The most common agent used
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What are my choices for topical antimicrobials? Mafenide acetate (Sulfamylon)
Broad spectrum, little fungal activity Is applied twice daily in thin layers on
dressings Can inhibit carbonic anhydrase leading
to metabolic acidosis Produces pain and burning on
application Use with caution in clients with renal
failure
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What are my choices for topical antimcirobials? Silver nitrate solution
Broad spectrum, including Candida Penetrates eschar poorly Stains everything black-brown Needs multiple layers of dressings Dressings need to be remoistened
every 2 hrs SEs include: decreased Na, Cl, K, Ca
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What are the advantages of biologic dressings? Decrease evaporative water loss Decrease protein loss Decrease bacterial proliferation Decrease pain Maintain body temperature Protect granulation tissue Protect exposed vessels, tendons,
nerves
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What temporary wound covers can be used? Temporary Wound Covers
Rejection slow due to natural immune suppression after burn injury
Decrease fluid loss, pain, and risk of infection
Improve survival Options
Amnionic membrane Dressing changed every 2 days
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What temporary wound covers can be used? Allograft (cadaveric)
Harvested within 24 hrs of death Used to debride exudative wounds Used to cover and protect wounds
ready for grafting Used to cover and protect meshed
autografts
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What temporary wound covers can be used? Xenograft (heterograft)
Harvested after slaughter, then preserved for storage
Used to promote healing of clean, superficial burns
Changed every 2-5 days
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How is the burn wound permanently covered? Autograft ( Split-thickness skin
graft/STSG) Surgical removal of client’s own
unburned or healed burned skin Only permanent means to heal wound Are not “rejected” but can fail to take
or become infected Sheet grafts or meshed grafts Can be harvested for application later
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What does the graft site need? Immobilization Elevation Assessment of fluids beneath graft
that prevent adherence to wound bed Blood, fluid
Assessment of infection
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What care does the donor site need? Realize that donor sites increase
the size of the wound May increase caloric needs, fluid
needs Donor site is covered to facilitate
healing Moist dressings preferred
Usually heals in 10-14 days
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What nutritional needs do burn clients have? Basal metabolic rate increased by
40-100% Metabolic rates slow as wound closes Aggressive nutritional support
needed Common formula is:
(25 kcal x Kg) + 40 kcal x % burn) How many calories does a 70 Kg man
with a 50% burn wound need to eat?
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How can nutritional needs be supported? Monitor weights, labs Six feedings a day Supplements within foods Tube feedings hs Hyperalimentation
For prolonged ileus Sepsis reported
Difficult to get clients to eat, then difficult to get them to stop eating
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How can pain be managed? Influenced by many factors: depth of
burn, extent stage of healing Also influenced by psychological factors:
anxiety, fear, past experiences with pain, separation from home/family, personality
Medications include: narcotics, nitrous oxide, NSAIDS (ulcerative)
Nonpharmcologic interventions: hypnosis, guided imagery, art and play, relaxation, biofeedback and music
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Periods of Burn Treatment Emergent Period – from the time of
injury until fluid resuscitation is complete
Acute Period – from fluid resuscitation until ungrafted BSA less than 20%
Rehabilitation Period – from less than 20%BSA ungrafted until total rehabilitation
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The Rehabilitation Phase Begins as wounds are being closed and
ends when client reaches full potential Focuses on:
Wound healing, scar revision at 1 year Preventing or minimizing deformities Increasing strength and function Providing emotional support and community
reintegration Providing education
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How can functional outcome be maximized? Splinting
Static and dynamic splints To prevent contractures
Positioning Elevation NOT the position of maximum comfort
Exercise (AROM/PROM)
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How can functional outcome be maximized? Control of scarring
Keloids vs hypertrophic scars Need for continuous pressure
Elastic wraps early Pressure garments later
Worn 23 hrs a day for 18-24 months
Scar revision after a year
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Burn Prevention Educate the public
Smoke detectors Fire escape plans Safety in the home
Influence Legislation Flame retardant clothing
Promote Industrial Fire Safety
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Never forget, there is a person in every
burned body.
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