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Seo. 0gpproximately 450,000 burn injuries that required, A medical treatment occurred in the United States in 2011, resulting in 3,000 fire- and burn-related deaths (American Burn Association [ABA], 2011). Thermal damage to the skin can be caused by fire, contact with a hot object or hot liquid (scald burn), radiation, chemicals, or electricity. According to statistics from 2001 to 2010, the majority of burns in adults occur in males (70%); the most common cause of burns is fire/flame (44%); and most burns occur in the home, followed by injuries in the workplace (ABA, 2011). These data also show that hot food and liquid spills are the most common source of burns to children. Approximately one-half of patients with burn injuries are admitted co regional burn centers designated by the American Burn Association; the remain- der are treated at local or regional hospitals (ABA, 2011). ‘Therefore, every occupational therapist should under- stand the principles of care and rehabilitation of patients with burn injuries. Treatment of these injuries requires a comprehensive approach by a qualified burn treatment team, including a skilled occupational therapist. This chapter explores the unique role of occupational therapy in treatment of burn patients, from the initial injury to the patient's return to independent function. Topics include various phases of burn rehabilitation, scar management, psychosocial issties, and reconstructive surgery. We hope fo convey the unique and rewarding aspects of working with patients with burn injuries. BURN GLASSIFICATION In the past, burn depth was classified as first, second, or third degree. Today, the preferred classification system more accurately describes the level of cellular injury. The terms in use are superficial, superficial partial-thickness, deep partial-thickness, and full-thickness, Burns typically have mixed depths, which necessitates that the burn team. carefully assess che appearance and progress of each area of the wound site, Disruption of any portion of the skin has the potential to interfere with its normal functions, which include cemperature regulation, excretion, sensa- tion, vitamin D synthesis, and acting as a barrier against infection and dehydration (Falkel, 1994). Occupational therapists may treat patients with all levels of thermal injury. Iris important to differentiace among the classifi- cations to plan appropriate intervention. Superficial Burns Superficial burns damage cells onlyin the epiciormis (Malick & Carr, 1982; Staley, Richard, & Falkel, 1994) (Fig. 40-1), ‘These injuries are painful and red. With a well-nourished, and intact epithelial bed at the base of the hair follicles, these injuries heal spontaneously within approximately 7 days and leave no permanence scar (Malick & Carr, 1982). Chapter 40 Burn ines 12 ‘Superficial Partial-Thickness Burns ‘Superficial partial-thickness burns damage cells in the epi- dermis and the upper level of the dermis (Malick & Carr, 1982; Staley, Richard, & Falkel, 1994). The most common sign of a superficial partial-thickness burn is intact blis- ters over the injured area (Staley, Richard, & Falkel, 1994). Hair follicles remain inact, because these are found in the deeper layers of the dermis. In addition, these injuries are 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 (Staley, Richard, & Falkel, 1994). Deep Partial-Thickness Burns Deep partial-thickness burns cause cell injury in the epider- ‘mis and severe damage to the dermal layer (Malick & Carr, 1982; Staley, Richard, & Falkel, 1994). These injuries appear blotchy, with areas of whitish color interspersed through- ‘out the wound, which is the result of damage to the blood vessels the dermal layer (Malick & Carr, 1982). The injury site is painful. Pressure sensation is intact, but light-rouch sensation is diminished because of the relative locations of receptors for these modalities (Staley, Richard, & Falkel, 1994). Spontaneous healing of deep partial-thickness burns is sluggish (3-S weeks) because vascularity in the dermal layer is impaired. Therefore, the risk of significant scarring is increased (Staley, Richard, & Falkel, 1994). For this reason, deep partial-thickness bums are often grafted to expedite healing and minimize scarring. Full-Thickness Injury Burns Ina full-thickness injury, both the epidermis and the dermal layer are destroyed (Malick & Carr, 1982; Staley, Richard, & Falkel, 1994), These wounds appear white or waxy because of the underlying adipose tissue and are inherently insensate because of the complete destruction of the dermal nerve end- ings (Malick & Carr, 1982). Full-thickness bums require sur- gical intervention, such as skin grafting (Malick & Carr, 1982; Staley, Richard, & Falkel, 1994), because there are no dermal elements to support the regrowth of epithelial tissue. Some ‘burns, such as electrical bums, may damage structures below the dermis, including subcutaneous fat, muscle, or bone. RULE OF NINES The rule of nines is a commonly used technique to deter mine burn size in adults (Fig, 40-2). For example, ifan adult received a bun that included the anterior and posterior sur- faces of his right arm (9%), his anterior head and neck (4.5%), and his anterior chest (18%), then his total body surface area (TBSA) affected would be 31.5%. To determine the TBSA of a bum injury in children and infants, a modification of this technique, the Lund-Browder chart, is used. In addition, inboth cilden and aul, 2 widely wed etimate hat the palmar surface of one hands appreinately 16 TESA. ‘The bum percentage TRSA wed othe lowing ‘+ Calelaing nuttona and Mui eguitements 1 Deering evel of acuity oestblish he evo med ical eatment needed (admin co an intensive ‘areunt) 1 Clasifjing patiens fr use of standardized prosoeols PHASES OF BURN MANAGEMENT AND REHABILITATION. ‘ening specif phar of bare managenene alg co describe che rl of occupational therapy for patients with ‘bum injuries These nese he emergent, ace and ha bition pases Each of the phases, long with accompa ying occupational therapy conskeratons are deserted, Emergent Phase “The emergent phase of «bur injury considered to be fost py to appraninately 72 hours afer the bum Grist deine Miles, 1995), Figur 4-2 haem et wn eso MM eA in a nme fn at Pu mane asta Cee ‘achwolomy and Fanltomy. Ctulation can be comm [romcd when burn ijrer ence 2 hay segment {hn die to dhe ineaicy af the son (ourned toe combined with creed intel pene whi ‘Rol comperemcnes. Loa resin Premio the tater fomprencsboed wera and reduc lod fw (Sheran e985), Symptoms of nese come ‘primera pss nce prety, odes, a Arend or abn plein the eure Inthe rn, Inet ecarean acta co, ting hang expan ton and peeing adequate epson Tn both cae finial intention echartomy andlor fanny) it gud eve he pres and pre nat death An exchartoy ra sungal aco hough he tach whereas a asco i deeper iesion extend ‘ig erough the facia Unies exponl tendon preset, the eachaotomy ein cn be mabe daring heap {Gigs detinde ies 1998) Dressings After the nal burn assesses, he nursing ‘Ma applies cresings The uneions of drestngs include [proecting the wound against infection maiming con- {ace beeween the tpieal agent and the wound, super ‘lly cooing the wound and providing comfort forthe paten (Gray deinde file, 198) Debriding ithe ‘Medical Management Ding the emergent phase, the medical team attempts stablize the patent This may include Bid vesucation, ‘tablidhment of adequate tate perfusion by means of ‘mechanical venation, and achievement of cadiopulno- ary stably: Awociated injuries, sc a Frac, are ko evaluated and rated during hte. Inhalation lry. An important consideration in the emer ‘gent phase the pouty of an inhalation injury Das pe w0 the upper away fom inhaling ether smoke or ‘osu gases ess in an inhalation nary. This damages the rpirtry epithelia and can impair gas exchange Inhalation injures can signficandy Increase mortality race (Gof &¢ Roe, 1991). Singsd eyebrows, soot around the nares and fac edema ate ndatons ofan ila tio jury (Gof & Rue, 1991). Dsagnosi is coniemed by analysis of ater Blood gases, chest radiographs and bronchoscopy In addition edema can guckly deep 0 thesiewayandconsrctbreatheg Therefore, patent ‘Spnifcant bum ojre are unl eeuband (placed on ‘mechanical venlaon 9 mainain an open area uel the rik fairway closure caused by eema has minished. Chapter 40, Bun iqures removal of devitalized sue fom the wound site. Types of topical ages vary wide, alchough most are wile ‘pecum antimicrobials Examples include malenide sete eather suladisine (Svadene), and (05% ser aiteate solution (Duncan &e Dracll, 1991) [As are the nursing atl changes che deessngs how ‘er, by perially paripating in desing removal Sed application, the ocupaeinal makes ‘opportunities to view the healing wounds. This allows the therapist to monitor healing and adjust the therapy program accordingly Infection Contra, One ofthe futons ofthe skin sso sctasabamer against infection (Falla, 1994) Therefor, {patent with a burn injury se suscepeble to infection Tete ential that ll taffy, and waits adhere to snfection control procedures Thi nudes frequent hand stashing use of gloves when necessary, and avouding cron ‘oneamination through instruments and equipment {Procedures for Practice 40-1, Procedures Hond Hygiene oper hand tygene, ater by we of Yana! Nae ‘eating wth S009 an ate rh ic Pred rte {ann onsen fe mehr freon fr au ar Your cers. A sty by Kamel and Lote (200 tes {hot noxocema recto alos can be rein at uch ‘tO by proper raed hygere Arosa con ‘Showptscqured ricon When to Pertorm Proper Hand Hygiene 1 Bere arate a ptr cortact 1 Ate vomonng gos wed to pram 9 ask meg ‘ata wit Bod, boy fader tactous rai «+ tarraeing powsty recto deve oF easBent 1 Bere anda prepairg ard otg od ‘General Procedure for Hand Washing, 1 Dapense paer owe Rastupiong sores Wet hana and writs ‘ea arcapc steno 20 1 Uestreton can batwean tnger, unr ras ae arr and boda ofan: etectve sora lat at (tea 20-90 secant wa hrc ow hy “Lume tcet wiry paper tov: ance oso tet eee ae tare 1 Wetton hed cere an be wed thre wasting ‘ache ae mae |@ Section VI_ Rehabilitation to Promote Occupational Function for Selected Diagnostic Categories Contracture Formation Patients with burn injuries are at significant risk for con- ‘tractures. Wound contracture, a normal physiological response to an open wound (Greenhalgh & Staley, 1994; Jordan, Daher, & Wasil, 2000) combined with prolonged immobilization, creates an opportunity for permanent soft tissue contracture. Contractures tend to occur in predictable patterns, usually flexed, shortened positions (eg, elbow flexion, shoulder adduction, or knee flexion) and can considerably limit the patient's ability to perform activities of daily living (ADL). For example, decreased elbow extension may limit che patient’s ability to dress. ‘Occupational Therapy during the Emergent Phase During the emergent phase, the occupational therapist per- forms a screen of the patient's needs. A full evaluation is defered unl fer he emergent pase, when che patie i ‘more medically stable. During the screen, the the dsebution ofthe burn and which joie are involved This allows the occupational therapist co establish an appro- priate splinting and positioning program. Ic is also during this time that the therapist begins collecting information regarding the patient's functional status before admission, including interests and social supports. ‘Occupational therapy intervention in the emergent phase Focuses on the prevention of early contracture forma- tion through the use of splines and positioning programs. It isideal co initiate occupational therapy intervention as early as 24-48 hours after burn, because collagen synthesis and contracture formation begin during the initial response to thermal injury (Dewey, Richand, & Parry 2011; Jordan, Da- her, & Wasil, 2000). ‘Splinting. Ideally, splints are fabricared and applied in the initial visit, and a positioning program is established and ‘communicated to the team. Table 40-1 describes common contracture patterns, antideformity positions, and appro- priate splints. Generally, any joint involved in a superfi- ial partial-thickness injury or worse has che potential for contracture and is usually splinted. Splint wearing times are determined by che 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 parient cannot perform active movement and therefore requires splincing at all times except for ther- apy and dressing changes. An alert patient who can use his co 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 dressing and secured with either gauze wrap or Velcro® straps. Although splinting is considered the standard of care in burn creat- ment, there is a paucity of evidence to support its use (Richard & Ward, 2005), Validation of the practice of splint- ing for the prevention of contracture is a research area that maybe addressed by occupational therapists in the fiarure, Positioning. Antideformity 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 GECEZIED Anticontracture Positioning by Location of Burn Location of Burn | Contracture Tendency | Anticontracture Positioning and/or Typical Splint _) “Anterior nock | ‘Neck fasion Remove plows: use hal-mattess to extend the neck: nck extension spint orcolar Axia ‘Adduction 120° abducton with sight external rotation: axila splint or positioning wedges: watch for signs of brachial plans san Antorior elbow Flexion [Ebow extension spint in 5°=10° flexion Dorsal wrist Wrist extansion \Wist suppor in neutral Volar wrist Wrist faxon | ‘Wet cock-up splint in §°=10" extansion Hand dorsal ‘Claw hand deformity Functional hand spin with MP joints 70°-00". IP jonts uty extended, frst web open, thumb in appostion (safe postion: see Chapt 37) Hand volar Palmar contracture aim extension spiint Cupping of han MPs in sight hyperextension Hip-antarior Hip flexion Prone positioning: weights on thigh in supine: knoe immobizers Knee ‘Knee fexion| Knee extension pasttioning and/or spints: prevent extemal rotation, which ‘may cause peroneal nerve compression Foot Foot drop ‘Ankle at 90° with foot board or spin; watch for signs of heel ulcer Reprinted wth parmisson fom Pessina, M.A. & its, & M (1097) Rehabltaton. Nursing Gints of Norh America $2:367tunable to be fitted with a custom wrist extension splint, supporting the hand on a rolled pillow can, ar least temporarily, maintain appropriate joint position. Elevat- ing the upper extremities can also help to minimize upper extremity edema. Elevation can be done with foam wedges, pillows, or specialized arm troughs ateached co the bed. Arisk of upper extremity elevation is the potential for bra- chial plexus strain. Symptoms of brachial plexus strain include ringling, numbness, and cold fingers. Acute Phase ‘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. For example, a patient with a 10% TBSA may have an acute phase of 1 week, during which the patient is mobile and undergoes one excision and grafting procedure, However, a patient with a 70% TBSA burn may be in the acute phase for several weeks, during which the patient is in an intensive care unit and undergoes many ‘grafting procedures to close the wounds. ‘Support and Psychosocial Adjustment in the Acute Phase All patients wich burn injuries, regardless of age, exhibit some of the same psychological responses, including with- drawal, denial, fear of death, regression, anxiety, depres- sion, and grief (Wright, 1984). In addition, various factors can influence 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, adjustment to others’ reactions, and location and depth of the burn injury (Baker et al, 1996; LeDoux et al, 1996). The psychosocial challenges of burn patients vary as the patient moves through each stage of physical recov- ery (Weichman & Patterson, 2004). Patients in the acute stage deal with issues of depression and anxiety and may begin to exhibie signs of both acute and post-traumatic stress disorder. Also at this time, any preinjury psycho- pathology may become more apparent (Weichman & Patterson, 2004). LeDoux et al. (1996) state that the burn team can fos- ter healthy coping strategies while working with the burn patient by using these techniques: 41. Identify strengths that each patient can emphasize, reminding him or her of the strength already involved in surviving a painful and frightening experience. 2. Validate sadness and fear. 8. Assist patient to achieve goals; this helps to show hope for the future. 4, Instill a belief that the patient can succeed. Chapter 40. Burn injuries ‘Team Communication ‘Communication with all members of the team, including the patient and the parient’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 che following (Pessina & Ellis, 1997): 1. Alerting the team to developing contractures and response to therapeutic intervention. 2. Planning for perioperative splinting. 8. Clarifying range-of-motion orders based on graft integrity. 4, Teaching the team about environmental modifica- tions or communication systems. 5. Advocating on the patient's behalf regarding eventual ourpatient needs. Medical Management ‘Skin grafting, which occurs primarily in the acute phase, is required when the dermal bed is sufficiently destroyed to prevent or significantly impair spontaneous 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 graft- ing entails both excision of necrotic (dead) tissue and the placement of skin ora skin substitute over the wound bed. ‘Types of Grafts. A variety of grafting procedures are avail- able 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. ‘Autografts. Skin harvested from an unburned area of the patient is an autograft. Split-thickness autografts, the most frequently used, are taken at the level of the mid- dermis (Institute for Healthcare Quality [IHQ], 1997; Staley, Richard, & Falkel, 1994). Donor sites are ideally selected for the best match of color and texture to the affected area. As donor sites produce mild scarring, their location, when possible, is in an inconspicuous site, such asthe upper thigh. The harvested skin can be left asa solid sheet (sheet graft) or perforated to increase surface area (meshed graft) (Staley, Richard, & Falkel, 1994). Meshing allows the surface area of the harvested skin to cover up to four times the original area. Both sheet and meshed grafts have advantages and disadvantages. A sheet graft hhas the best cosmetic outcome and is thus preferred for the face and hands (Hazani, Whitney, & Wilhelmani, 2012). Infection and the development of hematoma under a sheet graft, however, can cause complete graft loss andSection VI Rehabiltation to Promote Occupational Function for Selected Diagnostic Categories require regrafting. A meshed graft, although less cosmet- ically appealing (the meshed pattern is retained perma- rently), covers large areas when the donor site is limited. In addition, meshed grafts allow drainage of blood and exudate, which prevents hematomas and improves graft adherence (Hazani, Whitney, & Wilhelmani, 2012). Temporary Grafts. In cases of extensive burn injuries, where there is not sufficient donor skin to cover all of the affected area with autograft, the burn team may opt to use temporary grafts until the donor site has healed sufficiently for reharvesting. These temporary dressings are either biologic, such as allografts or xenografts (from cadaver and bovine skin, respectively) or synthetic, such as Biobrane® composed of nylon and silastic. These dress- ings 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 (Halim, Khoo, & Mohd Yussof, 2010). Occupational Therapy during the Acute Phase During the acute phase, the occupational therapist performs a detailed initial evaluation. This includes a thorough chart review to determine the history of the wound and associated injuries. Previous medical history is also important. Associated diagnoses that may limit occupational performance, such as psychiatric illness, diabetes, or lung disease, are to be noted and accounted for during occupational therapy treatment planning. ‘Areas specifically assessed by the occupational therapist during the initial evaluation include client Factors (¢:g, mental functions, cognitive skills, communication and social skills, sensory functions, neuromusculoskelecal and movement-related functions, joint mobility/stabil- ity, and muscle strength/tone/endurance) and ADL and instrumental activities of daily living. Evaluation can consist of observation during task performance and interviews with patient and family. The potential for permanent scarring and disfigurement may cause significant anxiety and limit che patient's ability to participate in rehabilitation. Thus, early assessment of the patient's support systems allows the therapist to identify resources that may aid in early patient motivation and goal sexting, Because of the acute medical nature of many burn injuries, occupational therapy intervention in the acute phase focuses on capacities and abilities such as range of ‘motion and strength. These are addressed through con- tinued splinting, positioning, exercise, and functional activity. Whenever possible, activities in treatment should reflect each patient's interests, For example, using sports analogies to encourage performance in active range of motion may benefit one patient, while using images of nature and music may benefit another. Other potential treatment activities include environmental modifications, pain remediation, environmental adaptation, and patient and family education. In the acute phase, the individual's ability to participate in treatment related to self-care and Functional retraining is often limited by complex medical issues. These areas are addressed in detail during the reha- bilitation phase. Splinting and Positioning. During the acute phase, the splinting and positioning programs established in the ‘emergent phase are continually monitored and adjusted. Splinting schedules are adjusted according to the individ- uual’s ability to participate in an exercise 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 motiva- tion should wear a splint continuously except for dressing changes and therapeutic activity. Ic is imperative to check all splints often to ensure proper fit and function (Dewey, Richard, & Parry, 2011). In addition, reaching the nursing staff proper fit and application of splints can decrease the potential for complications (Pessina & Ellis, 1997). Exercise and Activity. In the acute phase, splinting and positioning are used in combination with exercise and activity (Schneider et al., 2012). Exercise is especially important to control edema and prevent muscle atrophy, tendon adherence, joint stiffness, and capsular short- ening (Dewey, Richard, & Parry 2011; 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 cannot 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 whenever possi- ble, 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 patient may participate in all of these forms of exercise. In fact, func- tional activities may be used to improve active range of motion. For example, ring toss games are entertaining and easily adapted by changing height and distance co meet upper extremity range of motion goals. Exercise and activ- ity programs are performed up to five times daily (Wright, 1984), Contraindications to exercise include exposed ten- dons, recent autografts (approximately 5- 10 days), acute medical complications, and fractures (Dewey, Richard, & Parry, 2011; Grigsby deLinde & Miles, 1995; Staley, Richard, & Falkel, 1994). In addition, periodic inspection of the wound by the occupational therapist is essential to determine status of wound healing and skin integrity as related to tolerance of the exercise program.Perioperative Care. The 5-10 days after a skin graft pro- cedure is the perioperative 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 antideformity posi- tions. 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 dressing, for 5-10 days (Dewey, Richard, & Parry, 2011; Grigsby deLindle & Miles, 1995). During this time, range- of-motion exercises 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. Pain Management. The occupational therapist must address pain issues that arise during treatment. Many patients in intensive care cannot verbalize a subjective re- sponse 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 adjusts the treatment accordingly. If necessary, the time of the treatment may be changed to allow pain medication to be administered. Decreased rep- etitions and increased rest breaks during exercise sessions may also be appropriate. Other techniques used to man- age pain throughout recovery include distraction strate- gies, relaxation techniques, and preparatory information (informing/preparing the client regarding procedures to be performed) (Connor-Ballard, 2009). Activity context and emotional state can also affect perception of pain (Dubner & Ren, 1999). Recently, the effectiveness of vir- tual reality distraction for reducing pain associated with burn injuries has been reported (Hoffman et al., 2011). Environmental Adaptation. Beginning in the acute phase and throughout recovery, the occupational therapist pro- vides modified call buttons and bed controls, voice-acti- vated telephone systems, and modified utensils (Fig. 40-3) and self-care items. These modifications, combined with patient, staff, and family education, can increase a patient's sense of control and independence. The development of environmental modifications is limited only by the patient’s motivation and the therapist’s creativity. Patient and Family Teaching The occupational therapist provides members of the patient's support system with guidance regarding ways to interact with and support the patient during recovery. They may be encouraged to make tape recordings and posters orto bringin favorite music oF Chapter 40 Buninjies 1% Figure 40-3 Modified utensis can increase independence in the acute phase. foods. They may need to learn new ways to touch or com- fort their loved one. In addition, the family and friends provide a source of information regarding the patient's vocational and avocational roles and available community resources if the patient cannot communicate this infor- mation. An educated family and/or support system can be an important asset for ensuring follow-through of exer- cise and splinting programs and for encouraging partic ipation in functional activities (Duran-Coleman, 1991). Discharge Planning Because hospital stays are generally short, discharge plan- ning 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 aburn center for continued care ona rehabilitation unit. Elements to consider during discharge planning are the availability of community resources for outpatient or follow-up care, ‘SUpport systems available to the patient, and physical de- mands of the home environment. When patients who have sustained major burns cannot return to the hospital where they received acute care, it is important for the inpatient ‘occupational therapist to establish a relationship with a therapist in the patient’s community to ensure continuity of care throughout the rehabilitation phase. In accordance with the knowledge and experience of the community therapist, the discharging therapist provides appropriate liserature and written, photographic, and/or videotaped descriptions of the rehabilitation program. This establishes a communication channel for the community therapist so questions and concems 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 out- patient therapy. If a patient cannot be discharged directly to home, transfer to an inpatient rehabilitation facility isSection VI_ Rehabilitation to Promote Occupational Function for Selected Diagnostic Categories appropriate; again, early communication with the receiving, therapist is necessary to ensure continuity of care. Regard- less of the discharge setting, well-briefed patients are best able to advocate for appropriate care. Rehabilitation Phase ‘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 col- lagen synthesis stabilizes (Grigsby deLinde & Miles, 1995). ‘The level of direct involvement of the occupational thera- pist during this extended time is varied. It may range from. daily inpatient treatment to weekly outpatient treatment to annual clinic visits. ‘Occupational Therapy during the Rehabilitation Phase During the rehabilitation phase, the occupational ther- apist 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 guiding erearment planning and preparing, for discharge, The overall goal of occupational therapy intervention during this phase is to facilitate the patient's return to his or her previous level of occupational per- formance. Patients are encouraged to take increasing responsibility for their care, including helping to estab- lish meaningful goals. In addition to range of motion and strength, occupational therapy also focuses on activity tolerance, sensation, coordination, scar management, and self-care and home management skills. Range of Motion. In the rehabilitation stage, the patient con- ‘tinues to benefit from daily stretching routines established in the acute phase of care. Inthe early part ofthis phase, the rate of collagen syrithesis is increased (Staley, Richard, & Falkel, 1994), requiring the patient to stretch frequently throughout the day. As the scar matures and collagen synthesis slows, frequency of stretching should be reduced. At all times, skin integrity must be monitored during stretching to prevent tearing. Massage using a non-waterbased 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 itin that position for several seconds, The patient should report tension but not pain. Overzealous stretching can result in tissue tearsand edema, which increase joint stiffness. Stretching is initially performed by the occu- pational therapist, With training, however, the patient and/ Or caregiver can also complete stretching routines. Strength. Resistive exercise and graded functional acti- vities can improve strength. Patients may be taught an independent exercise program with resistive rubber rib- bon or tubing, such as Theraband@, to increase proximal upper body strength. Functional activities can also be graded to increase strength. For example, patients may gain strength as they perform self-care activities with increasing demands, as when progressing from sitting to standing for hygiene activities. Activity Tolerance. A key feature of rehabilitation is mobi- lizing the patient as much as possible, thereby increasing his or her activity tolerance. For an inpatient, chis includes increased time spent out of bed and trips to the gym and off the nursing unit. Activity time can be increased by 15 minutes every 2 days, if there is no evidence of fatigue. Fatigue can be monitored by patient self-report and clini- cian observation. For an outpatient, this may mean resum- ing leisure activities and going on community outings. Sensation. Newly healed skin and grafted skin may be hypersensitive, which can significantly limit functional performance. Hypersensitivity can be addressed effec- tively by systematic desensitization. This can be achieved ‘by asking the patient to manipulate objects with varying textures in the environment. Initially, the patient practices holding soft textures, such as cotton balls or lambswool, and then progresses to manipulating objects with rougher textures, such as Velcro® or burlap. A formal system such as the Downey desensitization program (Barber, 1990) can be used (see Chapter 22). Coordination. Coordination can be impaired by a variety of factors, including limited range of motion, strength, or sen- sation. Coordination can be improved through the use of selected progressive asks designed to challenge the patient's skills. For example, a patient may be asked first to take lids off large jars and then smaller containers (Fig, 40-4) Figure 40-4 Coordination can be addressed with the use of simulated or ‘actual functonal tasks.‘The patient may also trace lange letters or patterns before attempting fine motor writing tasks such as working a crossword puzzle from the newspaper. ‘Scar Management. Scar tissue formation is a natural re- sponse to wound healing (Grisby deLinde & Miles, 1995), Ic begins in the emergent phase and may take up to 2 years to mature (Jordan, Daher, & Wasil, 2000). A hypertro- phic scar is an aberration of the normal healing process and presents as a red, raised, and inelastic scar (Dewey, Richard, & Parry, 2011) (Fig. 40-5). A hypertrophic scar contains 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) The cause 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 scar- ring is also inversely 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. Occupational Therapy Assessment of Scars. The Bum Scar Index (Vancouver Scar Scale) is the most widely used stan- dardized scar assessment tool and is used to rate the pliabil- ity, vascularity, height, and pigmentation of sears (Sullivan et al,, 1990). Used periodically, che Burn Scar Index can help guide the occupational therapist in determining FFigure 40-5 A. Hypertrophic scars on neck B. Hypertrophic scars on hand. The hypertrophic sear on the dorsum of the hand causes claw hand deformity Chapter 40 Bum Injuries 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). ‘Occupational Therapy Intervention for Scar Management. ‘The occupational therapist attempts to prevent or limit the development of hypertrophic scars. Treatment methods include a combination of techniques, includ- ing massage, pressure therapy, and the use of special- ized inserts. Massage. Massage may be useful in reducing scar con- tracture (Roh, Seo, & Jang, 2010; Staley, Richard, & Falkel, 1994). Scar massage is initiated when it is deter- mined thar the injured area can withstand slight fric- tion, In addition, scar massage maintains suppleness, often at risk as normal sweat and oil gland function is disrupted. Scar massage also aids in desensitization. Scar massage is performed several times daily with deep pres- sure (enough to blanch the scar temporarily) in either a circular partern 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 ro newly healed skin. Initially, scar massage is the responsibility of the occupational therapist so that skin integrity and tolerance can be monitored. Once an established routine has been developed, the therapist teaches the patient and/or caregivers to assume respon- sibility for daily scar massageSection Vi Figure 40-6 Gente pressure is applied using Coban" and Tubigip™ Pressure Dressings and Garments. Pressure dressings and garments are another Form of scar management that has been advocated in the literature (Chang et al., 1995; Li-Tsang, Zheng, & Lau, 2010; Ward, 1991). The flattened, smooth, supple appearance of the scar after application of pressure has been reported clinically, but objective sup- port has been inconclusive (Bloemen et al, 2009; Grigsby deLinde & Miles, 1995). The occupational therapistinitiates Figure 40-7 Custom pressure garments can be wom while performing simulated functional activity. Rehabilitation to Promote Occupational Function for Selected Diagnostic Categories the application of gentle pressure via Tubigrip™, elastic bandage wraps, Coban™, or Isoroner® gloves (Fig, 40-6) 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 blisters or open areas. At this point, increased pres- sure using customized products such as Jobst® or Biocon- cepts™ garments is indicated (Fig, 40-7). Staley, Richard, and Falkel (1994) suggest that the application of 25 mm Hg of pressure is ideal to aid in collagen organization, which ultimately helps decrease scar tissue formation. Custom garments cause norable 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 isto ini tiate the ordering of custom garments and oversee their use. Most providers of custom garments send trained per sonnel to measure the patient for custom fitting. For facial burns, the patient may use a transparent facial orthosis secured 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 garments. They may be constructed from products such as Otoform®, or closed cell foam (Fig. 40-8, A & B). Their purpose is to increase pressure in concave areas, such as the web spaces and the sternoclavicular depression. Sil cone inserts have also been demonstrated to be effective in improving some characteristics of hypertrophic scars Figure 40-8 A. Use of Otolom® insert. 8. Without insert.(Aho, Monafo, & Mustoe, 1989), although the mecha: ‘im of ston remaine ro be determined. The design of a scar management progeam is determined by the aalable resources, careful lnical observation, and the paints big co comply wich the program (Evans & McAulie, 1995), Periodic oucpatient visits co occupational therapy ‘oan exablshed burn cnc throughouc the rehab tion phat allow for monitoring aed adjustment of the scar management program, ‘Sel-care and Home Management Sis 1 acuromus ‘lar Umitaions inopede the patients performance of Fanesional casks, che therapist. may provide adaptive ‘equipment, such sa butup handle for inpaired grasp oF Jong handled utensils for deceased elbow flexion. Teach: ing edaptve techniques auch a performing certain acti sings hinds rer sport ma aa imprne Patient and Famdy Teaching. Paces and thee family members should undertand the rttnale foreach af the lint and eechniques wed in their cae, They participate {the development of goals 0 that they ae vested in Achieving them Skincare fe an importan clement nie charge teaching, Patients practice monitoring thee skin for Breakdown and earing for their skin, inelading the daly use ofa movscurier Tey lear 10 use a sunscreen ‘vith an SPF ofa least 1S (eapplied Frequent) they anicpate exposure co the sun (Staley, Richard, & Fall, 1994) In addition, patients should have abasic under standing of wound healing and ae esponte to exece and sear management echnsgues ‘Suppor and Paychorocal Adhstment during the Rehab tation Phase. Although the patent and family eypialy focus on aural immediacy after injury, many other issuesarise during ehaation. According Weichman a Paterson (2004) patent the rehabilitation phase Face chalengesin three areas physical (suchas deceasesin aneton), soca (sch as boy image and changing roles), and phological (nich as aniety and depression) The increate in activi in the rehabilitation phase not only asses physical reabitation but also aut patients icover how thee iogryaffcs their daily Hives Emo. tional reactions fo the realzation of los may produce a vie rage of behaviors, such as crying oF expression of Anges In adition, uit or embarassment regarding the Injry may len the patient co withdraw, Patients may also Ihave responses related to post-raumaie sess disorder, sch au ashback, ‘One ofthe mos dificult challenges for the burn chee. apie caring for patients a they gneve fora Functional limitation or alteration in body image (Pesins & Elis, 1997) The ocuptionaltherapas: suppor the patient by encouraging questions and vebalzation of fecingrabout ‘the burn injury (Pessina & Elis, 1997). The occupational ‘herpise also chooser treatment activites 10 restore ‘confience and sefestem. Group acthiten provide ‘opportunities for socialisation and sharing of concerns it 2 Safe entonment Summers, 1991). Given the exensive contact with the patient throughout all phases of recor fy, the occupational therapist a unique position © ‘lenfy and addres psychosocial issues, but cllabor. tion with other specialists on the burn ream (eg, nursing {all family members, social workers, and psyehologss) ‘semen, —— In addon so the potent for sof tue concaccaes nd Tos of joint ange of movin, ether completions ‘may occur ia any phase of burn recovery. Prunus Prustus (persistent itching) is common complication (QHQ, 1997; tale, Richard, & Falkel, 194), presumably ‘aused by nerve regeneration, We usually rescires within 2 years ofthe inital ijury (Pol Fzpatrick, 1992). The ‘ue of comprestion garments, skin mcltorzers, cold packs, and medications sich as anthistamines may alle ‘ate stching HQ, 1997) Microstomia Pacients with fail burns i the area of the mouth are At ak for oral commusure contracture (mirostoma) (Rivers Jordan, 1998), which is ightening ofthe mus ‘lature around the lip are that mits mouth opening Imencteme cases, urgent surgical revision i required This tik in exaggerated if the pains has undergone prolonged Pevods without eating oF speaking because of intubation ‘Se reapcatory compromise Un addin vo daily scat eas ‘ig, the cheraps cn teach the paint facial stretching ‘erciss, such as yawning or grinning widely and pur: ing lips together. The exercises can be combined with the wearing of micromomia spline to setch the oral commissure. The splint may be worn as tolerated, us Ally atarcng with 10 minutes and gradvaly increasing (60 nutes orice a day. These devices can be purchased onstrcted by the occupational therapist. The cognitive lev the paien isan extremely factor in use ‘of 4 micromomia device because of the rik ofan unex: pected airway emergency For example, heal sedated ‘Sr confused patent may attempt o wallow the device Hoterotopic Ossitication Heterotopic ossification, oF myositis onsifcans, is the evelopment of new bone in tnsuer that normaly do not ‘nny Taccursin upto 13% of patente wth major burns ‘Section Vi_ehabitao o Frrete Oceupatnal Function fr Slated Diagnose Categries (Dutcher Johnson, 1994). The most common lation in che burninjured population ache elbow although the shoulder, knead hip ean aso be affected (Duteher & Johnson, 1999), Hetercopie esficacion causes pain, ‘uelling and rapid fou of range of motion. The thers. pst muse beatae of the sympoms and alert che ream Sotteatment options, including medications and surgery, ‘Heat intolerance Heat intolerance is cause by loss of sweating, because splieshickness skin graft do noe contain swest glance (Grigsby deLinde & Miles, 1995, Rivers de Jordan, 1998) "To compeasate for this, paiens may sweat excessively in remaining unburned areas, Patent in extremely hot climates may requie additonal air conditones in che ‘home to maintain comfort (Rivers & Jordan, 1998). The lack of eat glands ako makes healed grafts euscepeible twextreme dryness (Grigsby detinde Niles, 1995, Stale, Richard, & Falkl, 1994), and patent are encouraged © ‘ae racial nan ian ech on lp Presure therapy over the newly grafted area mininzes scarring. This cludes the use Of pressure garment tnd am inset fabricated to match the contour of the ew ra RETURN TO WORK Recurning to work before fina car maturation fanetionand improves the patent's se Fes. dy hence these bs fore nn meta ove bums > em eo els They ae prota by moist eae ot ued ea, (©) Chemica bans ‘Acid rata case er ‘Tey alo tendo be very Seep he dp econ nly when he slow He. © (@ Becca bums “They occur at poi fey a eit of he Coen th eon ate pol ox bing ‘nore weve (only ee) “The brs ae sul very deep and he dpi i core ony wh te slogh spats "Fuerst developing we owt heal (Raison bs They ae cuted by a ot i a om rete ih han, Teemponed Seanned by CamSeanne! 2 Fro hte Cases ypomania vesicle formation pra chess necosis of in 2 Frome Canues rons of entre skin and ‘cn oa worile depee into enderiying sbi ous 44 Frotbte > Full hicks necrosis of skin, Sub tanoos tan al srctresuadeyng eluding muscle & boneody sre into areas or mules of 8 wih the perineum ea 2) To determine the eve fae establish the level of retisrestment needed (2) To produc length af ute ospalization “The Re of 9s ilferen for als and cae bien The rule of or adits aiety ‘ot applicable oft ar neck of chien dy surface aes of Pea and neck of cite ‘tigficamly lager han | For example: In oe sir old child the surface sen uote with he is about 17% as compared toon Pisin adults. a conta. each lower ‘catomel represents oly 13 ofthe al body e ‘fae aea im these poses as) es) \ e Body Sufice Arca Percentage Extenal genitalia 1 igh Upper Extremity 45% 15.5% Leh Upper Exteity “Aste 4st igh Lower Extremity 6.5% 65% Left Lower Ext erento’ ‘Anceror Chest ll is Posterior Yunk is Head Anterior Este Heed Posterior Asse Toul" ‘With blanching changes in (Gesideration) 2 capillary temperatures, Refill exposure to air CCurens2tght ‘ouch The Lund And Brwader Chart Seamned by CamSeanne rr (b) The Lund and Brower chast This chart provides a more estimate ofthe Total body surface area andi is usd ‘bum centers : ‘This chart assigns a percent of surface area to body segments with adjusted calculations of different age groups. Far smaller % Total body surface area injuries the Therapist can get a quick to, estimate using the size of patients palm to equal . Approximate | % of individuals total body surface area.Scanned by CamScann To method is applicable for those cases where the doy and recipient areas can be approximated to each ‘ther. Operation requires only 2 stages i> APproximatig : lis Division of pedicle : (0) Indirect pedicle graft (tube graft) . Donor site and recipient site cannot be approximated, Flap has to get an attachment to an intermediate career site; (3) Musele and Myocutanteous flap ‘A muscle mass toget can be rotated as one unit on narrow pedicle containing blood vessels. Commonly used are pectoralis major, Lattisimus dorsi, TFL. ther with the overlying fat and (4) Micro vascular free flaps Ifthe vessels have more than 0.8 mm internal di they can be anastomosed microscopically with the vessels at the recipient site for immediate vascularisation of flap such flaps can be totally detached from donor site taken as free grafts to distant sits.