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Rehabilitation Of Burn
Injuries And Burn
Prevention:
A Team
Approach
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor,
professor of academic medicine, and medical
author. He graduated from Ross University
School of Medicine and has completed his
clinical clerkship training in various teaching
hospitals throughout New York, including
King’s County Hospital Center and Brookdale
Medical Center, among others. Dr. Jouria has passed all USMLE medical board
exams, and has served as a test prep tutor and instructor for Kaplan. He has
developed several medical courses and curricula for a variety of educational
institutions. Dr. Jouria has also served on multiple levels in the academic field
including faculty member and Department Chair. Dr. Jouria continues to serves as a
Subject Matter Expert for several continuing education organizations covering
multiple basic medical sciences. He has also developed several continuing medical
education courses covering various topics in clinical medicine. Recently, Dr. Jouria
has been contracted by the University of Miami/Jackson Memorial Hospital’s
Department of Surgery to develop an e-module training series for trauma patient
management. Dr. Jouria is currently authoring an academic textbook on Human
Anatomy & Physiology.
ABSTRACT
There are many different types of burn injuries, including those from
fire, scalds, electricity, friction, contact with chemicals, and others.
The one constant is that people who suffer burns have a desire for
minimal scarring and impact to their lives. Emergency intervention is
vital to help patients heal with minimal scarring and other lasting
effects. This course discusses rehabilitation of the burn patient through
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a multidisciplinary approach to treat the patient’s physical and
psychological needs during initial and long-term recovery.
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Statement of Learning Need
Burn injuries involve acute physiological changes, pain and wound
healing that require interventions from the beginning and long after
the initial treatment. Health clinicians need to be knowledgeable of the
potential and prevention of burn injury complications.
Course Purpose
To provide health clinicians with knowledge about burn conditions and
treatments during the acute emergency setting and throughout a
patient’s treatment.
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Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1.
Wound contracture can develop as:
a.
b.
c.
d.
2.
Approximately ______ percent of patients who undergo
grafting procedures for wound healing develop significant
contractures afterward.
a.
b.
c.
d.
3.
10 percent
50 percent
30 percent
None of the above
An immobilized body part should be taken out of a splint
________________________ to promote circulation and
flexibility.
a.
b.
c.
d.
4.
part of the healing process of burn wounds
as the wound heals and the skin closes
the skin becomes distorted and immobile
all of the above
several times each day
every other day
when circulation is poor
if joint pain is present
True or False: The extensor muscles are typically stronger
than the flexor muscles causing more effort to maintain a
position against contracture.
a. True
b. False
5.
Compression therapy involves the use of garments worn on
the burned areas of the body that have healed to provide
a.
b.
c.
d.
short-term management of scar tissue.
intermittent compression on the burned areas.
continuous compression on the burned areas.
increases in the rate of collagen synthesis.
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Introduction
Therapy may be necessary for months or even years after a burn
injury. It requires a team approach composed of several disciplines,
including medicine, physical therapy, occupational therapy, and social
service and/or psychological therapy. Following a burn injury, the
patient must undergo physical therapy to try to regain their bodily
function and appearance. The treatment and therapies available have
become more advanced than ever before. The goal of therapy is to
return the burn patient to a state of wellbeing, comfort, and to
function independently in everyday life.
Therapy And Rehabilitation
Therapy and rehabilitation after a burn injury is initiated early on
following the injury and continues not only throughout the period of
hospitalization, but as an ongoing effort to improve function and to
reduce complications for the burn victim. The goals of rehabilitation
after a burn injury are to minimize contractures, improve range of
motion, improve overall patient function, and to maximize
psychosocial functioning and independence.
Some have posited that there should not be a delineation of time after
a burn injury considered as the ‘acute phase’ versus the ‘rehabilitation
phase.’ All time after a burn injury can be considered a rehabilitation
phase and there are several activities that should be incorporated into
various stages following the burn injury. Rehabilitation activities should
be incorporated early enough that they become a natural and expected
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part of the patient’s recovery, rather than an additional component
that has been added after the fact. Shortly after injury, exercise and
therapy may require pain medication since the patient’s burn wounds
are still fresh enough that movement and exercise can be significantly
painful. This section reviews potential complications of burn injuries
and treatment to promote healing and prevent poor outcomes.1-4,7,9,10
Minimizing Wound Contracture
Wound contracture is a potential complication that can develop as part
of the healing process of burn wounds. As the wound heals and the
skin closes, it pulls on nearby tissue, potentially causing severe
scarring and disfigurement. The dermal layer of skin is firmly attached
to its underlying structures; as the wound heals the skin remains
tightened and is further fixed into position. The skin becomes distorted
and immobile. Contractures that develop over joints may cause
difficulties with joint movement and flexibility. Furthermore,
contractures lead to such scarring that the patient may suffer from
issues related to cosmetic appearance long after the wounds have
healed.
Contractures may be a complication associated with graft application.
Studies have shown that approximately thirty percent of patients who
undergo grafting procedures for wound healing develop significant
contractures afterward. It is therefore important to implement early
physical and occupational therapy in order to avoid contracture
formation that is debilitating. Range-of-motion exercises are often
implemented to improve circulation and flexibility and to avoid frozen
joints that often occur with contractures.
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Without help for proper positioning, a patient may be more likely to
develop contractures when he or she is allowed to rest in a position of
comfort or flexion. Wound healing starts just after the injury and will
continue into a state of contracture as the edges of the wound come
together to form a scar. The patient should be positioned in a way that
stretches or lengthens the tissue in order to prevent the wound edges
from pulling together, tightening, and causing a contracture. This may
require splinting as needed to keep extremities and other areas in the
appropriate alignment.
Positioning against contracture must start right away as soon as the
wounds are treated and covered. There should not be a delay in proper
positioning in favor of waiting until the wound has healed more, as the
more healing that takes place with the affected area in the wrong
position the greater the likelihood that the wound may heal in an
unnatural position of contracture. The goal of anti-contracture
positioning is to prevent the contracture from forming. Treatment of a
contracture is possible after it has started but it is very difficult to
restore normal range-of-motion after it has developed. It is preferable
to position correctly right away as a prevention measure to better ease
the treatment process.
As mentioned earlier, the normal position of comfort is a flexed
position, not a position of extension. The flexor muscles are typically
stronger than the extensor muscles thereby increasing the effort to
maintain a position against contracture. The clinician should consider
the natural position of flexion and then position in the opposite
direction into extension of the affected area. Examples of preventive
positioning for contractures include:
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
Hands should be positioned with the fingers straight with the
metacarpophalangeal joints flexed and the interphalangeal
joints extended. The thumb should be positioned in abduction
away from the hand to prevent clawing of the fingers.

The neck should be positioned without a pillow under the
head, and, rather, keeping a pillow under the shoulder with
the neck in extension. This prevents a flexion contracture of
the neck by pulling the neck downward.

An extension splint for the elbow may be used to keep it in
the extended position and to prevent it from contracting into
a flexed, fixed position.

The feet should be kept flat on the floor while sitting or
standing; the feet should be protected and positioned with
pillows while in bed to avoid a dorsal contracture in which the
feet become flexed upward.
Splints may be created out of a number of materials, including
thermoplastic, which is moldable and can be contoured to fit parts of
the body that are formed in the correct position. Other materials that
may be used for splints include cardboard, clothing, elastic roll
bandages, foam, or Plaster of Paris. Pillows and blankets are also
commonly used for positioning and can maintain an elevated position
or provide support for certain areas, yet remain soft and comfortable.
Splinting, followed by gentle range-of-motion exercises on a regular
basis, is the most common method of preventing contractures and
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promoting flexibility. Splinting is important because it is gentle and
non-traumatic for the tissues, yet continues to provide the correct
positioning needed in between therapeutic exercises.
Increasing Function
The goal of improving function, and of burn rehabilitation, is to return
the patient to as near a normal level of functioning as possible
compared to his or her abilities before the injury. Increasing function is
only one aspect of rehabilitation, but it is very important because
recovering from a burn wound takes considerable toll on the body and
can significantly impact the level of a patient’s abilities to perform
activities of daily living, as well as to maintain a job or relationships.
Wounds that have healed can develop significant scars, which can be a
considerable complication as part of the outcome. Scarring reduces
elasticity and flexibility of the involved tissue, which can have a
significant impact on function and ability, as well as contribute to an
unwelcome cosmetic appearance. Elastin, the substance that normally
contributes to elasticity of skin tissue, typically does not regenerate
after being damaged from a burn wound. Consequently, the burn scar
can be limited in flexibility and movement, particularly when the scar
is large.
Physical rehabilitation may begin relatively quickly after the burn
injury in order to preserve function and to reduce the negative
consequences of immobility. If a patient has received a graft, physical
rehabilitation can begin within three days after surgery where grafting
has occurred, as long as measures are taken to protect the graft site
from damage. When early rehabilitation has been started through
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range-of-motion techniques and mobilization therapy within 3 to 7
days following graft surgery, there is a greater chance of improved
overall function and faster return to adequate levels of functioning.
Initial care to promote function can start even if the patient is in
critical condition or requires intensive care after an injury. Patient
positioning is important to prevent complications associated with
increased edema during the first 1 to 2 days of the post-burn period. A
patient who is immobile should be turned on a regular basis, at least
every two hours, to prevent further wound development from pressure
ulcers. Raising the head of the bed supports excess drainage and may
reduce some edema development in the face and neck, and it
promotes airway clearance to facilitate easier breathing. Extremities
with edema should be positioned properly and elevated, if possible, to
promote return of venous circulation to the heart. Improperly
positioned extremities or areas with edema, such as by placing an
edematous extremity on a flat surface of a table for a period of time,
may lead to skin breakdown and further tissue damage and should be
avoided.
If a patient is unable to move after a burn injury and is immobile and
bedridden, regular turning and proper positioning can prevent
complications that would later cause difficulties with functioning during
rehabilitation. Bony prominences should be checked regularly to
evaluate for signs of skin breakdown that could occur from being
immobile, particularly on the heels, ankles, greater trochanter, and
sacrum. The patient’s body should be kept in a neutral position,
without turning or extending at the joints that would lead to an
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unnatural angle. For example, the patient’s hips should be aligned to
ensure that the hips are not unnaturally abducted at the hip joint.
A joint or body part is typically splinted in order to prevent
contractures. The immobilized body part should be taken out of the
splint several times each day and moved through gentle range-ofmotion exercises to promote circulation and flexibility. In some cases,
the patient may be able to assist with exercises for active range of
motion. There are other times, depending on the patient’s condition,
that passive range of motion is necessary and the therapist will need
to perform the movements for the patient. The clinician will need to
decide how much and at what level the patient can participate in
stretching exercises based on patient assessment and overall
condition.
Splinting should be continued for most of the day and night until the
patient achieves a level of activity and range of motion that indicates
improved flexibility and function. The splints are removed only for
exercise and mobility practice during the initial period. This may need
to continue for weeks or months, depending on the patient’s progress
of healing and activity development. After this point, the amount of
time spent in splints should be slowly decreased during the day until
the patient only needs to wear the splints at night.
Throughout this process, regular stretching of tissue will also prevent
contracture. Not only are range-of-motion exercises necessary to
improve function and prevent contracture, but also gentle stretching
will elongate the tissue out of a state of flexion and will promote
extension of the muscles around the wound. This is particularly true
when the burn wound is near a joint, as the joint may be more likely
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to shorten into a contracture if the muscles nearby are not stretched
on a regular basis. Joints and burn-affected areas should be stretched
several times every day to elongate the tissues and to better prevent
contracture formation. This is an ongoing process, and even if initial
tissue stretching occurs but is later discontinued, the patient is still at
risk of contractures developing in areas not being used regularly.
Regular massage of scar tissue has been shown to be helpful for
improving function after a wound heals and scar formation develops.
Once a scar has formed, the clinician may apply a moisturizer to the
area (or teach the patient to apply it) and massage the tissue. Scar
tissue may become dry and cause itching, which is helped by applying
moisturizer to the site. Additionally, application of a moisturizer
reduces cracking or skin breakdown that may also occur with scarring.
Studies have also shown that deep massage of scars may align
collagen formation and prevent thickening of scar tissue; it may also
help to desensitize the area if it becomes overly sensitive to touch and
temperature changes.
Continuing to improve function also involves early mobilization as soon
as possible based on the patient’s condition. When ready, the patient
should be assisted to get out of bed and walk; the amount of exercise
required depends on how much the patient is able to tolerate. If a
patient has a significant burn, he or she may tire easily and may need
frequent rest breaks. While it is important to promote therapy and
movement with the patient, it is also important not to push too hard to
the point of exhaustion. The exhaustion point is sooner for a burn
patient who has limited activity tolerance. The clinician should keep
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this in mind when encouraging mobilization and try to find a balance
between exercise and rest.
Practice with activities of daily living is also an important step in
therapy to improve function. Not only will the patient have practice at
using fine motor skills, but also being able to participate in daily selfcare measures may more likely help the patient to build a sense of
purpose and a feeling of contribution toward healing. When the patient
is able, he or she should participate in daily self-care measures such
as helping with bathing, brushing teeth, combing hair, or toileting. As
time passes, an increase in activities of daily living (ADL), as well as
practice at vocational skills, such as writing, will all help to increase
function and coordination skills. With routine practice, these activities
will eventually be worked into a regular, daytime occurrence for the
patient and become a standard part of daily life.
Compression Therapy
Compression therapy involves the use of garments worn on the burned
areas of the body that provide continuous compression at a pressure
of approximately 30 mmHg. Compression therapy is a common form of
long-term management of scar tissue and compression garments are
typically created for use when burn wounds have healed; when the
patient is able to tolerate pressure in the area, he or she may start to
wear compression garments. The garments are specifically made and
sized for the patient’s body and the burned area. The patient wears
the compression garment throughout the process of wound healing,
which in some cases may take over a year. Pressure garments are
typically worn for 23 hours per day, every day during the healing
process. The pressure from the garments can feel very tight for the
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patient, but it is this pressure that is needed to restrict capillary blood
flow, which will reduce scar development and the potential loss of
function with hypertrophic scarring.
Hypertrophic scarring can develop in a patient after a burn injury. If it
occurs, a hypertrophic scar causes a loss of function and movement. It
is normal for a wound to develop a scar, but a hypertrophic scar is an
abnormal process in which too much scar tissue develops as a result of
healing. There is increased blood flow to the site and too much
collagen development under the surface of the skin. The hypertrophic
scar appears red and it is much larger in size that a normal scar;
furthermore, if it develops, it is more likely to contribute to contracture
formation and places the patient at risk of decreased range of motion.
The burn care team should therefore continue to monitor scar
formation to ensure that scar tissue is not resulting in hypertrophy of
tissue. Although there is little to be done to prevent a scar from
hypertrophy, there are a number of interventions that can be
implemented to reduce its impact on function.
Custom pressure garments must be made ahead of time, but there are
often several companies available that can measure and make the
garments for specific patients and the body areas that need covering.
The pressure garments may also be available in different colors, which
is desirable for some patients. They can be difficult for the patient to
put on or take off and a professional who is familiar with the garment
and understands the amount of pressure needed should always fit
them initially.
Although pressure garments provide pressure in the right areas where
there is a wound scar, they must be used carefully so that they do not
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provide too much pressure to areas that do not need it. The end of the
garment should not cover a joint and they should be used carefully
over bony prominences. With the correct compression garment,
pressure is placed on the scar, which can minimize its size by
decreasing blood flow to the site and increasing the rate of scar
maturation. Compression therapy also decreases the rate of collagen
synthesis to reduce hypertrophy that leads to thick scars that inhibit
proper function.
Tubular bandages may be used for compression of scars on the
extremities. They have the capacity to control and limit edema
formation, are relatively easy to put on and remove, and they can be
placed over a dressing if one is still covering a burn wound. Tubular
bandages are most often used only on the arms or the legs because of
their shape, and they are made out of elastic and can be cut to the
appropriate length needed, which makes them easy to use.
Organ And Body System Responses To A Burn Injury
Although burn injuries have obvious and outward responses to the
integumentary and respiratory systems, other organs and body
systems are also significantly affected by burn injuries, which may or
may not be immediately obvious. It is essential that the clinician be
familiar with the physiologic changes that occur throughout the body
and that impact different systems as well as the function of various
organs. These alterations, as discussed below, can have widespread
effects on the body such that virtually all areas are affected in some
manner with a severe burn injury.1-10,15,16,31
Metabolic Response
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A burn injury is a stressful event that can cause significant metabolic
changes in the body. The body responds to this stress by increasing
metabolism until it is in a hypermetabolic state. The metabolic
processes that occur with a stressful event, such as a burn, are broken
down into two different phases: 1) the ebb phase and 2) the flow
phase. The ebb phase occurs first, immediately following the injury,
while the flow phase follows.
During the ebb phase, the body responds to the injury by decreasing
oxygen consumption and lowering overall body temperature. This is
what is also known as the early phase and it is during this time that
the health team must focus on essential body functions that are
needed for survival of the patient, such as by maintaining breathing
and circulation. The body’s metabolic response during the ebb phase
involves decreased cardiac output, decreased oxygen consumption,
and lowered plasma volume, leading to hypovolemia and hypotension.
Insulin levels decrease, which increases the risk of hyperglycemia. The
patient may excrete excess lactate, as well produce increased amounts
of stress hormones, including cortisol and catecholamines.
Following the ebb phase, the flow phase develops within approximately
48 hours following the injury. The flow phase then often lasts
throughout the duration of rehabilitation of the burn injury. During the
flow phase, the body’s demands for oxygen increase once again and
body temperature is corrected or overcompensation may occur,
resulting in hyperthermia. The patient may begin to secrete normal or
even high levels of insulin, which corrects the low levels once created
during the ebb phase but then subsequently increases the risk of
hypoglycemia. There is increased nitrogen excretion and lactate
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production normalizes, and there is continued secretion of stress
hormones.
The flow phase remains throughout the healing process of the patient’s
injuries. Consequently, the patient may enter a hypermetabolic state
and may remain in that state long after release from the hospital or
rehabilitation therapy. For some patients, this state may last for two
years after the initial injury. Long after return to home, work, and
social environments, the patient recovering from a burn injury may
still experience increased rates of metabolism, insulin resistance,
muscle breakdown, and increased risk of infection.
Since discovering the effects of the hypermetabolic response, clinicians
have come up with methods of deterring some of the negative effects
and complications of this state. Early excision and grafting, within
three days after the burn injury, has been shown to diminish some of
the effects of the hypermetabolic response by diminishing muscle
protein catabolism and decreasing the resting energy rate.
Additionally, early excision of eschar followed by grafting diminishes
excess protein loss that is more likely to occur in this population and
may further decrease the incidence of sepsis.
Burn patients are often at risk of hypothermia based on many of the
treatment procedures they receive, the temperature of the rooms they
are in, and the amount of skin exposed during burn wound
management procedures. Alternatively, the metabolic response of the
burn patient may involve a rise in core body temperature following the
injury when the body attempts to compensate for significant fluid and
heat loss from the injury. With excessive daily water loss due to the
injury, the patient’s body often responds by raising core temperature.
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To mediate this elevation in body temperature, studies have shown
that raising ambient temperature to a higher level — between 85 and
90 degrees — can decrease the patient’s resting energy expenditure
levels. With a higher ambient temperature, the body does not need to
use energy to sweat and cool itself; by regulating this process,
metabolic rates may decline, followed by a decrease in protein and
muscle catabolism.
Increased muscle catabolism and increased metabolic rates continue
into the phase in which the patient begins to receive therapy and
physical rehabilitation after the burn injury. In fact, these rates may
last long after hospitalization and outpatient therapy. To offset the
effects of continued muscle breakdown after the injury, the clinician
should help the patient to develop a regular therapeutic exercise
regimen. It may mean starting with short sessions at first but, by the
time of discharge from the hospital, the patient should have an
exercise routine in place that should continue well into outpatient
therapy. Regular exercise increases cardiovascular capacity and
improves flexibility, lean body mass, and overall body strength. By
participating in regular exercise, the patient methodically works
against the hypermetabolic response of the body that otherwise serves
to break down and weaken muscle tissue.
As mentioned earlier, the patient is at risk of hyperglycemia because
of increased glucose production as a result of increased
catecholamines, glucocorticoids, and glucagon in response to the burn.
According to studies published in Clinics in Plastic Surgery, strict
control of blood glucose levels through intensive insulin therapy has
been shown to stimulate muscle protein synthesis, improve bone
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mineral density, increase lean body mass, and decrease length of
hospital stay. Control of glucose levels through insulin administration
can also reduce the effects of continued hyperglycemia, which
increases the risk of infection and is associated with reduced
acceptance of the graft.
The hypermetabolic response may be somewhat offset in pediatric
burn patients with the administration of recombinant human growth
hormone (rhGH). Administration of rhGH may mediate some of the
effects of severe muscle atrophy that occurs with burned pediatric
patients and it has been shown to improve outcomes by reducing the
time of healing for donor graft sites, decreasing levels of C-reactive
protein in the body, stimulating production of T-helper cells, improving
overall weight and height, and increasing amounts of lean body mass.
Not only have these effects been seen during the immediate
hospitalization period, but also positive results with rhGH have
continued for up to three years following the injury. It should be noted
that these results have been shown when rhGH was administered to
pediatric burn patients and not necessarily adults; the results for
adults have been mixed.
The metabolic system affects so many different body processes that
virtually no area remains unaffected after a severe burn injury. Over
time, clinicians have devised many methods of offsetting some of the
negative effects of the hypermetabolic response that occurs with this
type of injury. With continued practice and work, clinicians may come
up with even more ways of controlling this response, which can
otherwise wreak havoc on the body during a time when tissue healing
is necessary for survival.
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Cardiovascular Response
The response of the cardiovascular system significantly impacts body
functions and may cause life-threatening complications in the initial
hours and days following a burn injury. At the cellular level, there is an
increase in membrane permeability, which allows fluids to shift from
the intravascular space into the surrounding tissues. This transfer of
fluid is further potentiated by the body’s inflammatory response and
release of vasoactive mediators, both of which contribute to increased
capillary permeability and increased edema in the intracellular and
interstitial spaces.
This increased permeability results in excessive amounts of fluid
leaking out of the circulatory system. This not only creates massive
edema, but it also contributes to hypovolemia and shock when there is
too little fluid left in the intravascular space. The most significant
amount of fluid loss in this method occurs during the first 48 hours
following the burn injury. The larger the size of body area burned the
greater the potential for significant circulatory compromise and
possible shock. A patient with greater than 20% total body surface
area (TBSA) burned is at great risk of circulatory collapse due to fluid
loss if substantial measures are not taken to replace fluid volume
through fluid resuscitation.
Because a person’s body also undergoes a significant metabolic
response as a result of a burn injury, there is a greater amount of
work placed on the cardiac structures and the heart must often work
harder to keep up with energy demands. The increased rate of
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catecholamine release from the metabolic system results in an
increased resting energy expenditure rate, muscle tissue breakdown,
and difficulties with regulating core body temperature. In response,
the heart often beats faster to offset some of the energy demands,
resulting in a higher heart rate and a greater amount of work for the
heart.
The amount of blood that the heart is able to pump to the tissues can
also be considerably affected by hypovolemia due to fluid loss. The
amount of preload, or the initial stretching of the cardiac muscle tissue
prior to cardiac contraction, will be diminished because of decreased
volume. Cardiac contractility and afterload are both initially diminished
following the burn injury and then increase as the patient is stabilized,
and may remain elevated throughout the course of rehabilitation. The
clinician must take these factors into account when calculating fluid
volume requirements through the initial fluid resuscitation period after
fluid volumes have stabilized and the patient is continuing to recover.
During this period, an increased heart rate or development of
consistent tachycardia may alter the amount of blood flow to the
tissues because the heart is beating too fast for the ventricles to
properly fill between contractions. Blood pressure levels are also
impacted and blood pressure must be continuously monitored through
hemodynamic methods, such as an arterial catheter, with
corresponding interventions as appropriate.
Due to preliminary hypovolemia, hypotension may exist at first,
further requiring the need for fluid resuscitation and volume
replacement in the initial hours after injury. Placement of an arterial
catheter can provide a continuous reading of blood pressure that can
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give more effective results than when attempting to check a peripheral
blood pressure level using a cuff and sphygmomanometer. As fluid
levels are corrected from fluid resuscitation, tachycardia may continue
in response to hypermetabolism that is occurring throughout the body.
This increased heart rate results in lower cardiac output and the
potential for hypotension.
The patient’s physical abilities should be monitored during the postburn period to determine how much activity can be tolerated based on
cardiovascular function. The patient may also become anemic, which
can lead to shortness of breath, dizziness, and fatigue. Anemia may be
more likely to develop in burn patients because of impaired production
and circulation of red blood cells, resulting in inadequate oxygenation
of tissues. The symptomatic burn patient may need to undergo blood
transfusions to correct anemia, especially if the anemia is affecting
activities of daily living. The acceptable hemoglobin level to consider
transfusion is based on the clinician’s preference and whether the
patient is exhibiting symptoms.
Burn patients are also at risk of developing venous thromboembolism
in the bloodstream. Since this is a known risk associated with this type
of injury, clinicians must continually monitor for any signs or
symptoms of embolus development. The risk of thromboembolism is
increased among this population because of various factors, which
includes:

changes in the cardiovascular system as a result of blood loss
and fluid leak into the tissues.

the potential for many transfusions of packed red blood cells in
order to maintain hemodynamic stability.
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
the increased risk of infection.

the presence of central venous access for intravenous fluid
administration.
Among burn patients, there are three main risk factors for
thromboembolism development, some of which actually double the
risk of developing a clot. The risks associated with thromboembolic
events include a burn area of greater than 10% TBSA, admission to
the intensive care unit, and the number of surgical operations needed
for treatment and burn care. Unfortunately, thromboembolism
development is not always noticeable until it may be too late. A
thromboembolism may initially develop as a deep vein thrombosis
(DVT) and may have obscure symptoms that take less priority to the
many other symptoms that a burn patient may already be
experiencing. If the DVT is not recognized, however, it may progress
through the circulatory system and cause further complications,
including a pulmonary embolism, which is when the situation becomes
life threatening.
The patient who develops a pulmonary embolism will develop
difficulties with breathing and may quickly deteriorate. If the DVT had
been noted earlier, the potential for pulmonary embolism could have
been avoided, but as stated, it can often be difficult to detect a DVT
before it is too late. Because of this, chemoprophylaxis is typically
necessary; and, according to the American College of Chest Physicians
chemoprophylaxis should be administered when a patient has
increased risk factors for thromboembolism. Additionally, mechanical
prophylaxis may be implemented as a method of preventing DVT.
Mechanical prophylaxis includes such measures as compression
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stockings, pneumatic compression devices, and foot pumps. Each of
these measures must be considered based on the patient’s condition
and ability to tolerate such methods, including the burned area and
the patient’s response to the therapy.
Cardiovascular complications can quickly cause problems in the burn
victim that are life threatening. The rapid development of burn
complications requires an understanding of the cardiovascular
response to the injury and prophylactic measures to prevent
complications before symptoms develop. The clinician should be well
aware of cardiovascular responses to this type of physical trauma and
consistently take measures to monitor, manage, and treat those
responses as they appear.
Gastrointestinal Response
The metabolic and cellular responses to a burn injury impact overall
circulation and typically produce an inflammatory response. Decreases
in intravascular volume may not only risk hypovolemic shock, but can
significantly reduce the amount of blood flow to major organs,
including the gastrointestinal tract. Despite aggressive fluid
resuscitation, the gastrointestinal tract may still suffer reduced blood
flow, particularly among those patients who suffer from greater TBSA
burns. This results in decreased oxygenation and hypoxia of the
intestinal tract as well as alterations in levels of normal gastrointestinal
flora.
According to Herndon, in Total Burn Care, the effects of circulatory
compromise and reduced blood flow to the gastrointestinal tract are
more likely to cause complications in the burn patient, including such
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conditions as Curling’s ulcer, cholecystitis, and enterocolitis. Increased
insulin resistance develops as a result of tissue catabolism and the
patient may be more likely to develop hyperglycemia, which can result
in further complications while healing, including poor wound healing,
increased risk of infection, and kidney damage.
The mucosal barrier of the intestine may be more prone to breakdown
with decreased oxygenation and tissue perfusion. Consequently, the
normal gut flora, which may have proliferated to much higher levels by
this point, may leak into the surrounding tissues, resulting in an
increased immune response required by the body. However, if the
affected person’s body cannot respond to this influx of bacteria from
the gastrointestinal tract, there is the potential for infection and
widespread sepsis.
Decreased circulation, possible infection, and increased use of narcotic
pain medications may also contribute to slowing of intestinal transit
and subsequent paralytic ileus. The patient may develop abdominal
pain and bloating. If enteral feedings have already been started, there
is typically a decreased tolerance for feedings and increased gastric
residual after feeding administration through a feeding tube.
Treatment involves decompression of the intestinal tract and increased
fluid administration; placement of a nasogastric or nasojejunal feeding
tube with low suction is typically done to decompress the stomach. If
possible, the use of opioid narcotic analgesics should be reduced and
replaced with anti-inflammatory medications, such as COX-2 inhibitors
to manage pain and to increase gut peristalsis.
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Ulceration of the duodenal portion of the gastrointestinal tract, known
as Curling’s ulcer, used to be a common complication in burn patients
before the importance of aggressive fluid resuscitation was recognized.
Today, the incidence of Curling’s ulcer is approximately three percent
among burn patients, but ulcers found in the stomach or other parts of
the gastrointestinal tract beyond the duodenum occur at a rate of
approximately fifteen percent. Ulceration may develop when decreased
perfusion to the gut, combined with the hypermetabolic state after the
injury, result in intestinal mucosal breakdown. This may be further
aggravated by increased stomach acid production and, if feeding tube
placement has occurred, the end of a feeding tube may further irritate
the lining of the gastrointestinal tract, potentially exacerbating
symptoms.
A patient who develops an ulcer of the gastrointestinal tract may
develop pain, hypotension, and blood in the stool or blood noted in the
nasogastric tube output. If the ulcer perforates the intestinal tract,
there is potential for gastric contents to leak into surrounding tissues,
resulting in peritonitis and widespread infection. Fortunately, this is
not a common occurrence.
The recognition of the circulatory effects on the gastrointestinal
system has led to greater prevention measures for gastrointestinal
ulcers among burn patients. Not only is fluid resuscitation calculated to
prevent hypovolemia and to improve circulation to the gastrointestinal
tract, but also many medications are offered prophylactically that can
control gastric secretions and prevent ulcers and tissue breakdown in
the intestinal system. Common medications include proton-pump
inhibitors, which reduce overall stomach acid, and may be included as
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part of enteral feedings. Additionally, the start of early enteral feedings
has been shown to prevent gastrointestinal ulcers despite potential
ischemia.
Ulcer development, particularly that which involves bleeding, requires
prompt intervention to reduce further volume reduction and to prevent
shock, especially if large hemorrhage is present. Intravenous
vasopressin or somatostatin, as well as continued proton-pump
inhibitor administration are standard forms of treatment to regulate
stomach acid, fluid levels, and secretion of various hormones. If
significant bleeding occurs (more than 2.5 liters in adults),
electrocautery or surgical laparotomy of the lesion is necessary to stop
bleeding and prevent further blood loss. However, these procedures
should be carefully considered to outweigh the risks against the
benefits, particularly if the patient has suffered burn wounds to the
abdomen or near the surgical site.
Cholecystitis affects up to 3.5% of burn patients and may develop
because of increased bile stasis, decreased circulation to the
gallbladder, and sepsis. Cholecystitis requires prompt intervention;
without taking measures to control the situation, the gallbladder could
become ischemic and gangrenous or could perforate, leading to
infection of surrounding tissues, peritonitis, and sepsis. There is a
65% mortality rate associated with a gangrenous gallbladder. It is
therefore essential to recognize symptoms and provide rapid
treatment. Symptoms of cholecystitis include right upper quadrant
pain, elevated liver enzymes, leukocytosis, and fever. Confirmation of
the condition is typically performed through an ultrasound test. The
most frequent treatment is a cholescystectomy. If a patient is critically
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ill and cannot otherwise tolerate the surgical procedure, percutaneous
cholecystostomy may be an option in which a drainage tube is inserted
into the gallbladder.
Enteral feedings
Early enteral feedings have been shown to have a positive effect on
the metabolic response of the body following a burn injury. Enteral
feedings are preferable for providing nutrition as compared to
parenteral therapies; parenteral nutrition increases the risk of catheter
infection and gut atrophy. Enteral nutrition has been shown to improve
patient outcome, improve function of the gastrointestinal system, and
to support the immune system. It is a safe alternative that can provide
the added calories and protein that the patient needs during the initial
post-burn period and into the rehabilitation phase.
Many patients who have suffered severe burns are unable to take in
oral feedings, particularly if they require a ventilator or are in a
comatose state. Additionally, the amount of calories and nutrients
required for healing after a burn injury is usually so much that a
patient who can take oral feedings often cannot ingest that much food
and nutrients. It is preferable to place a feeding tube and in some
cases, the patient may be able to take oral feedings with the feeding
tube in place to add more calories and nutrition.
There are various advantages and disadvantages to different types of
feeding tubes, although a number of options are available for
delivering enteral nutrition, including nasogastric, gastric, and jejunal
tubes. A patient who is at risk of aspiration because of immobility and
poor gastric emptying may benefit from placement of a gastric or
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jejunal feeding tube instead of a nasogastric tube, which could
increase the risk of aspiration. However, a nasogastric tube is much
easier to insert and maintain in a patient as compared to surgical
placement of a gastric tube, which could involve another painful
surgical procedure for the burn patient who must already undergo
various other medical and surgical treatments.
Enteral nutrition should be started quickly after the burn injury and
should be maintained on any patient who has suffered from an injury
of more than 20% TBSA burned. Furthermore, any patient who
suffered from malnutrition or who had a medical condition that
impacted digestion or weight prior to becoming burned should also be
considered a candidate for enteral nutrition.
If a patient is able to take food by mouth, foods should be eaten that
are good sources of protein and that contain appropriate vitamins and
minerals. Regular snacks should be included along with meals
throughout the day that the patient can tolerate. In many cases, meal
supplements that contain extra calories and are designed to promote
weight gain among some patient populations may be helpful in
increasing caloric intake on a daily basis. These supplements are not
designed as substitutes for meals; they should be consumed in
addition to meals. Examples of these types of supplements are Ensure
or MightyShakes.
Fortunately for many burn victims, clinicians are more aware of the
potential gastrointestinal responses that occur after an injury and can
take measures to prevent negative outcomes from developing.
Additionally, the advent of including enteral nutrition at an early time
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in recovery, as well as the understanding of the importance of nutrition
for effective recovery have continued to support gastrointestinal needs
of the burn patient when they may have otherwise been overlooked in
favor of other, more pressing symptoms and complications. The
benefits of nutrition and provision of nutrients to the patient can
effectively control and prevent some adverse effects and further
supports growth and healing for the patient recovering from burn(s).
Surgical Intervention For Burn Wounds
Surgical intervention for burn wounds involves excision of tissue and
grafting of skin onto burned areas to promote healing. The procedure
typically requires anesthesia for pain management and is performed in
a surgical operating suite for strict aseptic technique to reduce the risk
of infection and to promote the best chance for healing after graft
placement. Whether or not a burn wound requires surgical intervention
depends on the depth of the burn injury and the tissue involved.
Generally, burn surgery is needed on those burn wounds that would
not spontaneously heal without intervention, including third degree,
full-thickness burns, and second-degree, deep partial-thickness burns;
such burns would take more than 2 to 3 weeks to heal.
Skin grafting is treatment of burn wounds and one of the most
common methods of treating third-degree burn wounds that would not
heal spontaneously. One of the most common methods of skin grafting
involves autografting, in which a sample of healthy skin that includes
the dermis and the epidermis is taken from another area of the
patient’s body and grafted onto the wound. Another skin grafting
procedure that has been used when the patient’s own skin is not
available involves using skin samples from a cadaver, called an
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allograft, or using skin samples from an animal in a process called a
xenograft. These types of grafts are not compatible with permanent
wound closure and healing because of the differences in tissue types
between the sample and the patient, as well as the possibility of the
transfer of infectious pathogens that could occur between the donor
and the recipient. However, these skin grafts may be applied
temporarily to protect the underlying wound and to facilitate healing.
Autografting is a relatively common procedure used among patients
who have skin samples that can be used. It cannot be done on
patients who have such extensive burn injuries that skin in other areas
of the body is not available for harvesting because it has also been
damaged. The grafts are taken from sites where there is healthy skin
available that can be transferred to the burned area. It is removed
using an instrument called a dermatome, in which slices are removed
in pieces that are very thin. Within one to two days, new blood vessels
form in the wound and connect with the donor skin graft, solidifying
the transplant area. Most of the time, burn grafts are successful and
do not develop complications, although there are times when the graft
transplant does not take and must be removed.
When areas of skin are not large enough to cover burn wounds, a skin
sample can be taken from a healthy area and then meshed, in which a
machine makes tiny, parallel cuts in the skin that are a specific
distance apart. This allows the skin graft to stretch larger than normal,
where it can be placed on a bigger area and thereby extended to more
than its original form. This form of grafting may be beneficial in that
the small slits cut in the skin sample tend to allow the graft to remain
more secure when excess fluid can drain through the openings;
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however, the appearance of the graft is less than desirable, as the
meshed appearance remains after healing and the scar has the same
appearance.
There are several different types of skin grafts that may be used for
healing of burn wounds. The type of skin graft chosen depends on the
size and depth of the wound as well as the tissue available to
transplant.
Split-Thickness Graft
Split-thickness grafts are typically placed in areas where the body
would not bear weight, such as on the torso or back. A split-thickness
graft involves taking a piece of donor skin from a healthy area on the
body and placing it on the wound. The skin sample is up to 12 inches
long and may be up to 4 inches wide. Some of the skin consists of
superficial epidermal tissue, while other portions of the graft are
deeper tissue. A split-thickness graft may consist of a sheet of skin
that has been harvested; this type of graft may also more likely be
meshed for a graft.
Full-Thickness Graft
Full-thickness grafts are so named because they are a full thickness of
the layers of skin that are transplanted, including the subcutaneous
tissue and blood vessels. Full-thickness grafts are more commonly
used to cover wounds over joints and in those areas that may be
weight bearing, such as the feet. They are most commonly used for
very deep burns but they also tend to produce better cosmetic results
and may be used for grafts on the face or neck.
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Pedicle Graft
The pedicle graft, also called a flap graft, involves keeping part of the
skin from the donor site attached to the skin at the recipient site. In
this way, the wound site receives blood from the tissue at the donor
site because they are still connected. The flap connecting the two sites
is cut once the transplanted skin is fully attached to the recipient site
and it has developed its own blood supply.
Pinch Graft
The pinch graft involves using very small pieces of skin, the size of a
quarter or postage stamp, to fill in small holes or burned areas. These
sites tend to fill in quickly and develop a new blood supply when
healing.
Stages of Adherence
Once a graft is placed onto the wound bed, it undergoes stages of
adhering to the wound where it will hopefully remain permanently. The
first stage of adherence is called plasmatic imbibition, which may last
between 24 and 48 hours. During this stage, nutrients in the wound
bed are absorbed by the graft through the process of diffusion, which
allows the graft to survive after being removed from its initial location
and being transplanted into a new area. If a wound bed does not have
good circulation and is poorly vascularized, a graft may still take when
it is applied, although the graft will undergo a period of ischemia
immediately after placement. Studies have shown that full-thickness
grafts may tolerate 3 days of ischemia when placed on a wound bed
with poor circulation, while partial-thickness grafts can tolerate even
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longer ischemic periods — up to 5 days, and still take to a poorly
vascularized wound.
The second phase of graft adherence is known as inosculation. It is
during this time that new blood vessel growth begins between the
wound bed and the graft site. New capillaries form channels between
the two sites and small amounts of blood are able to flow between
them. The new graft site becomes pink because it is receiving blood
circulation. This typically occurs within three days of graft placement.
It is also during this time that the graft becomes further adhered to
the wound bed by the development of new deposits of collagen, which
is found in normal, healthy skin, and that secures the graft further to
the wound bed by providing strength to the bond between the two
structures.
Within five to six days post-grafting, revascularization has occurred
between the wound bed and the new graft site. New blood vessels
have developed and the graft site receives an adequate blood supply.
The graft remains a normal, pink color and continues to solidify its
adherence to the wound bed, taking on the permanent role of skin in
place of the wound.
It is important to remember that donor sites can be very painful and
can bleed profusely following the period of harvesting the graft. Some
form of clotting agent, such as epinephrine, should be kept on hand if
bleeding is prominent after the skin is taken for the graft.
Furthermore, the donor site should be covered after blood flow has
been controlled, with the site maintained while it has a chance to heal.
The donor site typically heals within about two weeks.
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Preparing Wounds for Skin Grafting
If possible, the patient should be prepared for surgery through
excision of the burn tissue and skin grafting within several days
following the injury. This depends on the patient’s condition and ability
to tolerate the procedure, but early excision is preferred in order to
best prevent infection and to support a faster process of healing when
compared to waiting longer to graft. Early excision has been shown to
minimize inflammation in the wound area, and is associated with
decreased morbidity and mortality in the burn patient.
Waiting to excise skin tissue may lead to further complications,
including greater risk of bleeding at the site. The body’s inflammatory
response reaches its highest point at 7 to 10 days following the burn
injury. It is during this period that circulation to the burn wound is at
its greatest. If the time of excision is postponed until this period, there
may be greater risk of bleeding from the wound site and complications
of blood loss. If the patient is receiving an autograft, or the skin graft
will be harvested from another area on his body, the patient must first
undergo excision of the skin. The skin excision involves either
tangential or fascial excisions, depending on the depth of tissue
needed for the graft. A tangential excision involves excising a thin
layer of skin using a dermatome to cut away a strip of skin. This type
of incision takes longer than a fascial incision and has a higher risk of
bleeding, but the outcome produces more positive cosmetic results
and improved function at the graft site.
Alternatively, the fascial excision cuts down into the subcutaneous
tissue including the muscle fascia. This type of excision is much faster
than a tangential incision and much larger pieces of tissue may be
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used, but it does not have as good cosmetic results and there are
greater risks of injury to underlying tissues, such as the nerves. In
either case, the surgeon does not take more than 25% TBSA during
the first period of harvest and no more than 18% TBSA at any
subsequent periods of tissue harvesting. As with other procedures,
careful monitoring of the patient’s body for excess exposure is crucial
to prevent too much skin exposure, a drop in body temperature, and
hypothermia.
Prior to placement of the graft, the burn wound site is prepared by
excising any eschar that is covering the wound. The eschar is removed
in thin strips to a level deep enough that only pinpoints of blood
appear after removal. Because removal of the eschar has the potential
for bleeding, backup materials such as electrocautery or topical
thrombin should be on hand to stop bleeding. If possible, blood should
be available for transfusion to be administered right away if excessive
bleeding occurs. Once the area of the burn has been exposed and is
ready, the graft is then immediately placed on the wound bed.
Prior to harvesting and placement of the graft, both the donor and
recipient site must be carefully managed to ensure they are clean and
free from infection. An infected wound bed will not be able to accept a
skin transplant and an infected skin sample will only transfer
microorganisms into the vulnerable burn wound. It is important to
determine the area from which the graft will be taken and work to
keep the site as clean as possible, as well as to continue to manage
the burn wound until it is ready to receive the graft.
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Complications Following Surgery
Profuse bleeding is a potential complication associated with both
wound bed preparation before surgery and during the grafting process.
The clinician should be aware of the potential for bleeding
complications during the grafting process by having clotting therapy,
for example topical thrombin spray, available immediately to stop
blood flow if bleeding develops during the process. The patient should
have had laboratory work to check a blood type and crossmatch
relatively early during the hospitalization period. When preparing for
surgery, it may be necessary to have blood products on hand in case
significant bleeding develops as a result of the procedure and the
patient needs a transfusion.
Following graft placement, the site must be inspected and monitored
carefully to assess for bleeding. If excess bleeding develops, the graft
may become detached from the wound base and may not take. Often,
the area is covered and immobilized for up to a week after surgery to
reduce bleeding and to allow the formation of new blood vessels under
the graft site, thereby enhancing the chance that the graft will remain
firmly attached.
Infection is another potential complication that may develop following
surgical procedures for burn grafting. While topical antibiotic creams
and ointments are typically used on burn wounds, if an infection
develops in a localized area, such as where the graft has been placed,
a systemic antibiotic may be prescribed along with burn antimicrobial
ointment and cream infused into burn dressings.
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With regular monitoring and immobilization of the recipient site, the
there is an improved chance of the skin transplant taking and the body
accepting the graft. Typically, it takes approximately 72 hours to
determine if a graft will be successful. If the site does not bleed
excessively and there is no infection, there is a good chance that the
graft will be successful.
Graft Loss
Following placement of the graft onto the wound bed, the graft is
secured in place using staples or clips. These are removed later, after
several days of allowing the site to heal. A wound VAC (vacuum
assisted closure) may then be placed over the site for the first several
days in order to prevent the graft from shifting and to keep it in place,
and to promote healing.
It should be noted that when a graft is placed that does not have an
outlet for fluid drainage, the graft might be at higher risk of separating
from the wound bed. In the example of the meshed graft, the small
incisions in the sheet of skin allow fluid to drain from under the graft
site and the graft may be more likely to stay in place permanently.
Alternatively, if a graft does not have any holes or incisions for which
excess fluid may seep through, the fluid may instead collect under the
graft site, causing the graft to separate from the wound. It is very
important that the graft site be monitored carefully; this is true with
any graft, but a sheet graft that is not meshed must be kept
hemodynamically stable with adequate control of bleeding and fluid
monitoring to reduce the chance of graft separation.
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Although early rehabilitation is important to preserve function and to
promote mobility in the patient, it is important to avoid shear forces
that could injure the graft and ultimately cause it to separate from the
wound bed. As stated, a new graft is typically secured in place by
staples or stitches initially after surgery. In some cases, a splint may
need to be applied to maintain the graft position and to prevent it from
shifting, particularly when the graft has been applied over a joint. A
splint protects the graft site when movement of the affected area is
required during rehabilitation exercises such as range of motion or
ambulation.
Another method of promoting graft adherence and preventing loss is
through the use of a wound VAC, applied to the site after the graft
surgery. The system involves placing a dressing over a new graft site,
and the dressing is connected to the wound VAC system. The system
uses negative pressure to keep the site sealed and to remove
infectious materials from the wound. Negative-pressure wound therapy
has been shown to support graft adherence by removing excess
exudate from the wound bed, reducing edema, promoting circulation
and tissue perfusion to the site, and keeping the wound bed moist.
Use of a wound VAC system depends on the clinician’s preference, but
it is a viable treatment option that may be applied after graft surgery
to prevent the risk of losing the graft from non-adherence.
Psychosocial Support
While at one time burn care focused on keeping affected patients alive
and helping them to survive a traumatic burn, the goals of therapy
today are to integrate the recovered burn patient into the community
and to provide ongoing support. Because burn wounds can cause
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significant scarring and the injury that occurs with a burn is a
traumatic event, the burn patient will most likely need to have
strategies in place that will help him or her to function and thrive at
home, work, and in daily relationships.
Burn care health teams may witness patients go through a variety of
emotional responses to their injuries. Each person who has been
injured may respond in a different way, depending on the injury, preexisting level of support from family and friends, and psychosocial
status before being injured. The clinician caring for a burn patient may
witness responses such as fear, sadness, anger, anxiety, and grief
from the burned patient, all of which are normal responses to the
injury. Furthermore, some people overcome the difficulties associated
with their injury rather quickly, while others may need more time to
process their feelings surrounding the event. It is important for the
burn team to remember that emotional responses are normal and
expected parts of recovery and to be aware of available resources that
can be used for support.
Support Networks
Burn survivors have unique needs for support because of everything
they have gone through to heal and return to life outside the health
facility environment. It is often necessary for the burn survivor to get
involved with a support network in order to connect with others and to
receive appropriate support from people beyond immediate family,
close friends, and health clinicians.
A support network for burn survivors can be a dynamic method of
meeting new people who have gone through similar situations because
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of their injuries and who are adjusting to life after rehabilitation.
Because burn injuries can cause lifelong changes in the patient, such
as through mobility or scarring, many people who have also been
through a burn injury can attest to their hard work as well as how their
lives have changed after their injuries. By meeting together, burn
survivors can see firsthand how burn injuries have affected the lives of
others and know that they are not alone. Through support networks,
burn survivors can share their stories, participate in social activities,
and talk about virtually anything, whether it is discussion of therapy
and medications or everyday life activities, such as work or
relationships. Burn support groups may meet in person or may be
available online. In some places, families may also be involved, as
many groups recognize the importance of bringing in family members
for help and in understanding that a major burn injury can have
negative consequences for family members as well.
Burn support networks also often have opportunities for fundraising
and awareness campaigns so that others will be informed of the
significance of burn injuries, the work of rehabilitation and treatment,
and that many burn injuries can be prevented. Some of these
awareness campaigns teach the public about how to prevent injuries
from occurring by making changes in their homes and in how they
work around some substances that could cause burns. Campaigns may
also focus on activities that get people together for fun events to
meet, talk, share, or play games as part of raising support and
awareness. It is beneficial for the burn survivor to participate in a
support network when possible. These types of groups can provide
much encouragement and help when a burned patient is transitioning
back into their normal life. Group participation can give burn survivors
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the opportunity to not only receive support about their own healing
process, but also to reach out and help other burn survivors who may
need help and assistance as well.
Individual Therapy
In some cases, a patient may deal with feelings about having a burn
injury while in the hospital and may come to resolution when ready to
be discharged. Alternatively, some patients may experience a variety
of stages of grief throughout the healing process. Feelings of grief,
anger, and frustration may be overwhelming at some moments during
rehabilitation, while at other times these feelings may be more
manageable. Often, when changes are introduced into a patient’s life,
difficulties coping with new expectations and activities associated with
the change may be experienced. For instance, a patient may become
comfortable with therapy and treatments while still in the hospital, but
may have more difficulties when discharged to home. A patient may
function well at home but may have problems after returning to work
and need to continue with outpatient rehabilitation.
Individual therapy is an option that can address the psychosocial
aspects of care for a patient who is recovering from a burn wound. The
patient meets with a counselor or clinician skilled in working through
psychological issues, typically on a one-to-one basis. The patient may
meet with a therapist on a regular basis to discuss feelings about their
situation and to work through some of the feelings associated with the
injury. Together, the patient and the therapist can come up with
methods of managing grief, anxiety, depression, or other feelings that
are involved.
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Individual therapy is also beneficial for the patient by providing
someone to talk to who understands the complexity of the situation.
The therapist can be someone who will listen to the patient’s concerns
and feelings, but will also be someone who has ideas and possible
solutions for the situation. This may be in the form of cognitivebehavioral therapy, in which the patient learns to recognize inner
feelings and responses to them. Together with the therapist, the
patient may be able to come up with alternative activities that will
have a positive outcome when feelings are encountered.
While every caring person who encounters the burn patient can have
an impact on the patient’s psychosocial needs, if the patient seeks
individual therapy, it is important that the person providing therapy be
a licensed experienced professional working with survivors of trauma.
The therapist should also be someone who is empathic to the patient’s
psychological needs and who shows compassion for his or her
situation. While extensive education can provide the therapist with
much information about the psychosocial needs of trauma victims such
as burn patients, a compassionate therapist with understanding of the
situation is just as beneficial with or without an advanced educational
background. The goal of individual therapy is for the therapist and the
patient to journey together through difficult moments the patient
experiences and to evolve through those experiences with a measure
of hope and healing.
Communication With the Patient and Family
Psychosocial care of the patient begins while he or she is still receiving
acute care in the hospital or burn care facility. The clinician should not
wait to assess the patient’s psychosocial state and levels of support
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and should instead determine how the patient is coping, and to
provide support and communication with the patient and the patient’s
family on a continuous basis.
Often, a patient who has been burned may have significant fear
initially when considering the impact of the wounds and the potential
for possibly life-threatening complications. A burn injury is a traumatic
experience, which is multiplied if the patient suffered from a burn as a
result of a shocking or distressing event, such as an explosion, house
fire, or car accident. The patient may have a variety of emotions,
ranging from fear, to anger and stress about the event. Flashbacks
might be experienced about what happened or the patient may suffer
from anxiety when remembering the events preceding the injury. The
clinician should be prepared to witness a range of emotions from the
patient and should understand that each person’s experience is
unique. The patient may not respond to his or her injury in a method
that the clinician would consider “normal” but whatever emotions are
surfacing should be managed appropriately with support and help from
all members of the health team. The clinician should take time to talk
with the patient about concerns felt regarding the situation, fears
about what could happen, feelings about the injury, and any other
issues that could come up.
Regular communication is important when discussing the situation with
the patient and family members. The patient should be informed
ahead of time what to expect about treatments and therapy, such as
upcoming dressing changes or therapeutic exercises. Giving the
patient plenty of time to know what is on the schedule can better help
him or her to prepare, since many of the processes can be distressing
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and painful. Honest communication is also essential, although it may
be difficult to talk about. For instance, it may not be pleasant to talk
about the pain of cleaning and dressing a burn wound, but it is
necessary to discuss it so that the patient will be aware of what will
happen and not be surprised.
It is also necessary to communicate with the patient’s family on a
regular basis when they are involved with the patient’s care; to keep
them informed and to educate them about the process of treatment
and rehabilitation. This is necessary so that the family can provide
support to the patient while he or she is healing, and during transitions
to levels of care. For example, after a patient is discharged from acute
care in the hospital, outpatient therapy on a regular basis may still be
needed. Family members involved with the patient’s care may be
responsible for helping the patient get to and from therapy
appointments or help them practice therapy exercises at home.
It may be very difficult for some family members of the burn patient,
especially if they feel guilt, pain, and loss themselves over what
happened to their loved one. Some family members may become
overprotective of the patient, feeling that they may be able to keep
the patient safe in the future even though they weren’t able to prevent
the original injury. While it can be helpful to have family support, the
patient needs to learn to perform their own activities and not let a
family member finish tasks or do the work for them. It may be helpful
if the family members associated with the injury have a source of
personal counseling or therapy themselves, in which they can work
through their own feelings in order to best care for the injured patient
in a healthy manner.
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Historically, many burn patients were not expected to survive the
treatments needed to help them recover from burn injuries, as the risk
for life-threatening complications was simply too great. Today, burn
care teams must keep the long-term outlook of burn patients in mind
while providing care from the beginning, as overall mortality has
decreased and there is greater potential for survival following severe
burn injury. Recognizing long-term needs of the burn patient must
include an understanding of the psychosocial impact such injuries will
have on the patient’s quality of life. Despite extensive burn injuries
and traumatic experiences that some burn patients may endure,
studies have shown that with appropriate care and support, most
patients who recover from their physical injuries go on to lead healthy
and well-adjusted lives.
Burn Injury Prevention
Burn injury prevention involves education of the public to provide
information about the most common types of burns and how best to
prevent injuries from occurring. Health clinicians are in a position to
offer education to patients about behaviors that may more likely result
in burn injuries, and to give information about alternative lifestyle
practices that may best avoid injuries and severe burn wounds.1,32
Health clinicians can teach their patients and families about how to
best prevent fire and other situations that could lead to thermal burns
in the home, as well as conditions that could cause electrical or
chemical burns. For example, to reduce the risk of thermal burns from
fire, information about cooking practices may be necessary, as a
majority of thermal burns are caused by cooking fires or scalding
water. The health team may give the patient information or direct
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him/her to resources on how best to practice cooking with the least
risk of fire, such as by monitoring the stove carefully and covering
grease fires if they do develop.
Other measures that can also be taken in the home to prevent fires
and other sources of injuries include careful use of space heaters and
electrical equipment. Safety measures include ensuring that heating
systems and electrical outlets are in good condition and are working
appropriately; additionally, setting water heater temperatures to less
than 120 degrees, and keeping matches and flammable materials out
of reach of children. The public should be taught about the appropriate
use and maintenance of smoke detectors and fire extinguishers in the
home, such as how to use them, how to check if they are working, and
when to replace them.
Although accidents at home are typically the most common causes of
thermal burns, there are many other situations where precautionary
measures should be taken to reduce the risk of burn injuries, including
work in the garage, in industrial facilities, or while camping and using
fires. Additionally, people must be educated about how best to manage
a situation if a burn does occur and they are waiting for help. Many
well-meaning people try to treat burn injuries inappropriately and
could potentially end up making the skin condition worse.
Part of the health team’s role in education about burn prevention is to
teach the public about what to do when someone nearby becomes
burned, as well as which practices to avoid. People should be taught
how best to keep a burn victim safe as the first measure, without
becoming injured in the process of helping. The burn victim should be
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removed from the source of the burn, whether it is a fire or electrical
source. If chemicals burn the victim, removing the chemical as much
as possible - typically by flushing with copious amounts of water - is
necessary to stop the burning process. The public must also be taught
that while irrigating a burn with cool water is important, putting ice on
burned skin is damaging and may only cause further harm. It is also
important to emphasize not to put household substances on a burn
injury as this will need to be removed to assess the burn when the
patient arrives at the healthcare facility.
While the public as a whole cannot be expected to understand the
components of triage and stabilization of a burn-injured patient,
clinicians can educate the public to help change incorrect information
or practices that may not be helpful to a burn victim or may make the
situation worse. Health professionals can also provide education about
how important it is to practice fire safety and burn prevention.
Educating the public how severe burns can be avoided to prevent life
threatening consequences and permanent life changing outcomes is an
important role of the burn health team. By providing as much
information as possible about the prevention of burn injuries, burn
centers and healthcare facilities may see fewer patients who need
treatment for severe injuries caused by burns.
Summary
Burn injury rehabilitation begins from the initial injury and continues
through all phases of recovery. Treatment focuses on improving the
patient’s physical function and ability to return to daily activities.
Physical therapy to prevent loss of range-of-motion and contractures
requires the dedicated commitment of all members of the health team,
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the patient and family members. Rehabilitation is often a difficult time
for the patient and family members, which can continue for a long
time following initial care and discharge from a burn treatment center.
Physical and psychosocial care of the patient begins in the acute care
phase of treatment. Understanding the type and degree of injury as
well as how each patient is coping following the trauma of a burn
injury is important to a multidisciplinary treatment plan; to support the
patient to progress through all required levels of treatment and to be
reintegrated into everyday life. The ability of many burn patients to
survive and to surmount the risk of life-threatening complications has
improved due to new advances in burn care treatment and
rehabilitation to support the needs of the burn patient to achieve
quality of life.
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1.
Wound contracture can develop as:
a.
b.
c.
d.
2.
Approximately ____ % of patients with grafts develop
significant contractures afterward.
a.
b.
c.
d.
3.
10 percent
50 percent
30 percent
None of the above
An immobilized body part should be taken out of a splint
________________________ to promote circulation and
flexibility.
a.
b.
c.
d.
4.
part of the healing process of burn wounds
as the wound heals and the skin closes
the skin becomes distorted and immobile
All of the above
several times each day
every other day
when circulation is poor
if joint pain is present
True or False: The extensor muscles are typically stronger
than the flexor muscles causing more effort to maintain a
position against contracture.
a. True
b. False
5.
Compression therapy involves the use of garments worn on
the burned areas of the body that have healed to provide
a.
b.
c.
d.
short-term management of scar tissue.
intermittent compression on the burned areas.
continuous compression on the burned areas.
increases in the rate of collagen synthesis.
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6.
True or False: Risk of hyperglycemia in a burn injury
results from increased glucose due to increased
catecholamines, glucocorticoids, and glucagon in response
to the burn.
a. True
b. False
7.
_____________ is a skin grafting procedure used to treat
third-degree burn wounds that would not heal
spontaneously, which uses skin samples from a cadaver.
a.
b.
c.
d.
8.
Skin autografting
Allograft
Porcine graft
Xenograft
True or False: Psychosocial care of a burn patient begins
after acute care and in an outpatient treatment center.
a. True
b. False
9.
Following placement of the graft onto the wound bed, the
graft is secured in place using
a.
b.
c.
d.
a compression garment.
a wound VAC (vacuum assisted closure).
a wet dressing.
staples or clips.
10. Increased insulin resistance develops as a result of tissue
______________ and the patient may be more likely to
develop hyperglycemia.
a.
b.
c.
d.
anabolism
rejection
catabolism
grafting
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11. A burn patient who develops abdominal pain and bloating,
due to paralytic ileus, may be treated with decompression
of the stomach using
a.
b.
c.
d.
a compression garment.
a wound VAC.
a nasojejunal feeding tube.
pressure to the abdomen.
12. Ulceration of the duodenal portion of the gastrointestinal
tract, known as
a.
b.
c.
d.
peritonitis.
cholecystitis.
cholecystitis.
Curling’s ulcer.
13. A nasogastric tube has the following advantages over a
jejunal feeding tube:
a.
b.
c.
d.
It
It
It
It
is
is
is
is
preferred for a patient with risk of aspiration.
much easier to insert and maintain.
recommended in cases of more than 20% TBSA burned.
preferred by most patients.
14. True or False: Early excision of burn tissue has been shown
to minimize inflammation in the wound area, and is
associated with decreased morbidity and mortality in the
burn patient.
a. True
b. False
15. Enteral nutrition should be started quickly after the burn
injury and should be maintained on any patient who has
suffered from an injury of more than ____ TBSA burned.
a.
b.
c.
d.
20%
50%
10%
60%
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16. Split-thickness grafts are typically placed in what areas of
the body?
a.
b.
c.
d.
The areas over the joints
Areas that do not bear weight
Limited to small burn areas
Areas that bear weight
17. Once a graft is placed onto the wound bed, it undergoes
stages of adhering: The second stage of adherence is called
____________, in which new blood vessel growth begins
between the wound bed and the graft site.
a.
b.
c.
d.
revascularization
closure
inosculation
plasmatic imbibition
18. A skin excision involves either tangential or fascial
excisions, depending on the depth of tissue needed for the
graft: Which of the following describes a fascial excision?
a.
b.
c.
d.
It
It
It
It
involves excising a thin layer of skin
has a higher risk of bleeding
provides better cosmetic results
allows for larger pieces of tissue to be used
19. With regular monitoring and ____________________ the
recipient site, the there is an improved chance of the skin
transplant taking and the body accepting the graft.
a.
b.
c.
d.
use of a compression garment on
immobilization of
massaging of
wound contracture of
20. Which of the following is used to promote graft adherence
and prevent loss of the graft?
a.
b.
c.
d.
Positive-pressure wound therapy
A compression garment
A wound VAC
Flushing wound site with copious amounts of water
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21. True or False: A patient who suffers from extensive TBSA
burns will not suffer reduced blood flow to organs, such as
the gastrointestinal tract, if the patient is treated with
aggressive fluid resuscitation.
a. True
b. False
CORRECT ANSWERS:
1.
Wound contracture can develop as:
a.
b.
c.
d.
part of the healing process of burn wounds
as the wound heals and the skin closes
the skin becomes distorted and immobile
All of the above
“Wound contracture is a potential complication that can
develop as part of the healing process of burn wounds. As the
wound heals and the skin closes, it pulls on nearby tissue,
potentially causing severe scarring and disfigurement.... The
skin becomes distorted and immobile.”
2.
Approximately ____ % of patients with grafts develop
significant contractures afterward.
c. 30 percent
“Studies have shown that approximately thirty percent of
patients who undergo grafting procedures for wound healing
develop significant contractures afterward.”
3.
An immobilized body part should be taken out of a splint
________________________ to promote circulation and
flexibility.
a. several times each day
“The immobilized body part should be taken out of the splint
several times each day and moved through gentle range-ofmotion exercises to promote circulation and flexibility.”
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4.
True or False: The extensor muscles are typically stronger
than the flexor muscles causing more effort to maintain a
position against contracture.
b. False
“The flexor muscles are typically stronger than the extensor
muscles thereby increasing the effort to maintain a position
against contracture.”
5.
Compression therapy involves the use of garments worn on
the burned areas of the body that have healed to provide
c. continuous compression on the burned areas.
“Compression therapy involves the use of garments worn on
the burned areas of the body that provide continuous
compression at a pressure of approximately 30 mmHg.
Compression therapy is a common form of long-term
management of scar tissue and compression garments are
typically created for use when burn wounds have healed;…”
6.
True or False: Risk of hyperglycemia in a burn injury
results from increased glucose due to increased
catecholamines, glucocorticoids, and glucagon in response
to the burn.
a. True
“As mentioned earlier, the patient is at risk of hyperglycemia
because of increased glucose production as a result of
increased catecholamines, glucocorticoids, and glucagon in
response to the burn.”
7.
_____________ is a skin grafting procedure used to treat
third-degree burn wounds that would not heal
spontaneously, which uses skin samples from a cadaver.
b. Allograft
“Another skin grafting procedure that has been used when the
patient’s skin is not available involves using skin samples from
a cadaver, called an allograft, ...”
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8.
True or False: Psychosocial care of a burn patient begins
after acute care and in an outpatient treatment center.
b. False
“Psychosocial care of the patient begins while he or she is still
receiving acute care and in the hospital or burn care facility.
The provider should not wait to assess the patient’s
psychosocial state and levels of support and should instead
determine how the patient is coping, and to provide support
and communication with the patient and the patient’s family
on a continuous basis.”
9.
Following placement of the graft onto the wound bed, the
graft is secured in place using
d. staples or clips.
“Following placement of the graft onto the wound bed, the
graft is secured in place using staples or clips.”
10. Increased insulin resistance develops as a result of tissue
______________ and the patient may be more likely to
develop hyperglycemia.
c. catabolism
“Increased insulin resistance develops as a result of tissue
catabolism and the patient may be more likely to develop
hyperglycemia, which can result in further complications while
healing, including poor wound healing, increased risk of
infection, and kidney damage.”
11. A burn patient who develops abdominal pain and bloating,
due to paralytic ileus, may be treated with decompression
of the stomach using
c. a nasojejunal feeding tube.
“The patient may develop abdominal pain and bloating. If
enteral feedings have already been started, there is typically
a decreased tolerance for feedings and increased gastric
residual after feeding administration through a feeding tube.
Treatment involves decompression of the intestinal tract and
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increased fluid administration; placement of a nasogastric or
nasojejunal feeding tube with low suction is typically done to
decompress the stomach.”
12. Ulceration of the duodenal portion of the gastrointestinal
tract, known as
d. Curling’s ulcer.
“Ulceration of the duodenal portion of the gastrointestinal
tract, known as Curling’s ulcer.”
13. A nasogastric tube has the following advantages over a
jejunal feeding tube:
b. It is much easier to insert and maintain.
“… a nasogastric tube is much easier to insert and maintain in
a patient as compared to surgical placement of a gastric tube,
which could involve another painful surgical procedure for the
burn patient who must already undergo various other medical
and surgical treatments.”
14. True or False: Early excision of burn tissue has been shown
to minimize inflammation in the wound area, and is
associated with decreased morbidity and mortality in the
burn patient.
a. True
“Early excision of the burn tissue has been shown to minimize
inflammation in the wound area, and is associated with
decreased morbidity and mortality in the burn patient.”
15. Enteral nutrition should be started quickly after the burn
injury and should be maintained on any patient who has
suffered from an injury of more than ____ TBSA burned.
a. 20%
“Enteral nutrition should be started quickly after the burn
injury and should be maintained on any patient who has
suffered from an injury of more than 20% TBSA burned.”
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16. Split-thickness grafts are typically placed in what areas of
the body?
b. Areas that do not bear weight
“Split-thickness grafts are typically placed in areas where the
body would not bear weight,…”
17. Once a graft is placed onto the wound bed, it undergoes
stages of adhering: The second stage of adherence is called
____________, in which new blood vessel growth begins
between the wound bed and the graft site.
c. inosculation
“The second phase of graft adherence is known as
inosculation. It is during this time that new blood vessel
growth begins between the wound bed and the graft site…”
18. A skin excision involves either tangential or fascial
excisions, depending on the depth of tissue needed for the
graft: Which of the following describes a fascial excision?
d. It allows for larger pieces of tissue to be used
“… the fascial excision cuts down into the subcutaneous tissue
including the muscle fascia. This type of excision is much
faster than a tangential incision and much larger pieces of
tissue may be used...”
19. With regular monitoring and ____________________ the
recipient site, the there is an improved chance of the skin
transplant taking and the body accepting the graft.
b. immobilization of
“With regular monitoring and immobilization of the recipient
site, the there is an improved chance of the skin transplant
taking and the body accepting the graft.”
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20. Which of the following is used to promote graft adherence
and prevent loss of the graft?
c. A wound VAC
“Another method of promoting graft adherence and
preventing loss is through the use of a wound VAC, applied to
the site after the graft surgery.”
21. True or False: A patient who suffers from extensive TBSA
burns will not suffer reduced blood flow to organs, such as
the gastrointestinal tract, if the patient is treated with
aggressive fluid resuscitation.
b. False
“Decreases in intravascular volume may not only risk
hypovolemic shock, but can significantly reduce the amount
of blood flow to major organs, including the gastrointestinal
tract. Despite aggressive fluid resuscitation, the
gastrointestinal tract may still suffer reduced blood flow,
particularly among those patients who suffer from greater
TBSA burns. This results in decreased oxygenation and
hypoxia of the intestinal tract as well as alterations in levels
of normal gastrointestinal flora.”
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References Section
The References below include published works and in-text citations of
published works that are intended as helpful material for your further
reading.
1.
Herndon, D. N. (2012). Total burn care: Expert consult.
Philadelphia, PA: Elsevier Saunders
2. Baldwin-Rodriguez, B. (n.d.). Burn trauma injuries. Retrieved
from
http://dynamicnursingeducation.com/class_more.php?class_id=1
26&more=91
3. Rice, P. L., Orgill, D. P. (2014, Apr). Emergency care of moderate
and severe thermal burns in adults. Retrieved from
http://www.uptodate.com/contents/emergency-care-ofmoderate-and-severe-thermal-burns-in-adults
4. Bacomo, F. K., Chung, K. K. (2011). A primer on burn
resuscitation. Journal of Emergencies, Trauma and Shock 4(1):
109-113. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3097558/#!po=36
.6667
5. University of Michigan Trauma Burn Center. (2014). Fluid
resuscitation. Retrieved from
http://www.traumaburn.org/referring/fluid.shtml
6. University of Wisconsin (2016). Assessing Burns and Planning
Resuscitation: Rule of Nines. Emergency Medicine. Retrieved
online at http://www.uwhealth.org/emergency-room/assessingburns-and-planning-resuscitation-the-rule-of-nines/12698.
7. Nurse Labs. (2012, Mar.). Burn injury. Retrieved from
http://nurseslabs.com/burn-injury-nursing-management/
8. Kirchheimer, S. (2013, Dec.). Electrical burns. Retrieved from
http://www.med.nyu.edu/content?ChunkIID=163347
9. Rice, P., et al. (2016). Classification of burns. Up To Date.
Retrieved online at
http://www.uptodate.com/contents/classification-of-burns.
10. Gauglitz, G. and Williams, F. (2016). Overview of the
management of the severely burned patient. Up To Date.
Retrieved from https://www.uptodate.com/contents/overview-ofthe-management-of-the-severely-burnedpatient?source=search_result&search=burn%20injuries&selected
Title=3~150.
11. Hamel, J. (2011, Feb.). A review of acute cyanide poisoning with
a treatment update. Critical Care Nurse 31(1): 72-81.
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12. Fazal, N. (2012). T-cell suppression in burn and septic injuries.
Retrieved from http://cdn.intechopen.com/pdfs-wm/29072.pdf
13. Wiktor, A. and Richards, D. (2016). Treatment of Minor Thermal
Burns. Up To Date. Retrieved online at
https://www.uptodate.com/contents/treatment-of-minor-thermalburns?source=search_result&search=silvadene&selectedTitle=6~
34.
14. American Burn Association. (n.d.). Burn center referral criteria.
Retrieved from
http://www.ameriburn.org/BurnCenterReferralCriteria.pdf
15. Hall, K. L., Shahrohki, S., Jeschke, M. G. (2012, Nov.). Enteral
nutrition support in burn care: A review of current
recommendations as instituted in the Ross Tilley Burn Centre.
Nutrients 4(1): 1554-1565. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509506/
16. Parrillo, J. E., Dellinger, R. P. (2014). Critical care medicine:
Principles of diagnosis and management in the adult (4th ed.).
Philadelphia, PA: Elsevier Saunders
17. Aguayo-Becerra, O. A., Torres-Garibay, C., González-Ojeda, A.
(2013, Jul.). Serum albumin level as a risk factor for mortality in
burn patients. Clinics (Sao Paulo) 68(7): 940-945. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714858/
18. Davita.com. (2014). What is creatinine? Retrieved from
http://www.davita.com/kidney-disease/overview/symptoms-anddiagnosis/what-is-creatinine?/e/4726
19. Mecott, G. A., Al-Mousawi, A. M., Gauglitz, G. G., Herndon, D. N.,
Jeschke, M. G. (2010, Jan.). The role of hyperglycemia in burned
patients: Evidence-based studies. Shock 33(1): 5-13. Retrieved
from
http://journals.lww.com/shockjournal/Fulltext/2010/01000/The_R
ole_of_Hyperglycemia_in_Burned_Patients_.3.aspx
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