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Wound Care for Burn Patients in Acute Rehabilitation Settings
Caring for patients who are recovering from severe burns is not common in most inpatient rehabilitation settings. Nursing challenges include patients’ physical and psychological changes and their high care demands. Harborview Medical Center (HMC), a regional Level 1 burn and trauma center in Seattle, WA, accepted these nursing challenges and developed a successful plan of care consistent with current evidence. This article describes HMC’s nursing experiences while caring for patients with burns. Our experiences may assist other rehabilitation units that serve burn patients. Says one burn survivor: “Nurses make a huge difference in recovery, as they are there 24 hours a day. It is their touch, their caring, and their listening that aids the patient in his journey from fire victim to burn survivor.”
Nurses who care for burn patients on inpatient rehabilitation units take on the roles of caregiver, teacher, advocate, confidante, and liaison. In each of these roles, nurses influence the development of a patient’s new self-image (Coull, 2003). In the acute burn unit, wound healing is the primary focus of care. When patients enter the rehabilitation phase of treatment, care priorities shift to maximizing functional status and abilities, coping, and adjusting to major life changes. While wound care remains important, patients assume a more active role in their care, with nurses facilitating as teacher and confidant. In the context of their relationships with nurses, patients are able to share their deepest fears and concerns.
Patients must develop the ability to direct and participate in their care to the greatest extent possible. Family members also are involved as they learn to support patients in recovery posthospitalization, and to perform postdischarge wound care (Helvig, 1983).
Patients’ needs are identified upon their arrival on the rehabilitation unit. The nurse’s roles as liaison and advocate are critical in coordinating care among members of the healthcare team to ensure that needs are met and that the entire team remains connected to the plan of care and patient goals.
Pain is a major issue for burn patients, and effective management is vital (Ulmer, 1998). Patients experience pain related to wound care and their participation in at least 3 hours of daily physical, occupational, and speech therapy. Psychological pain also may interfere with rehabilitation, so advocacy for the involvement of a rehabilitation psychologist may be warranted (Patterson et al., 1993).
Pain control advocacy is important. Common pain control medications include acetaminophen, opiates, and antianxiety agents. Nurses should assess patients’ response to wound care and their anxiety in anticipation of painful procedures and therapy sessions. If anxiety is an issue, an antianxiety medication given approximatley 1 hour before wound care lessens the stress on a patient. If pain is an issue, short-acting opiates given 30 minutes before wound care usually provide adequate pain control throughout the procedure. For patients who experience a great deal of pain during each step of the process, dividing the opiate dose provides relief throughtout the entire process.
Accepting a new self-image is another challenge for burn patients. Here nurses play a major role as they extend an accepting and positive attitude while interacting with patients. Because many patients sustain extreme disfigurement, approaching them with a positive attitude may require deliberate effort from nurses. Helping patients build self-esteem increases self-confidence and gives them strength for the long recovery road ahead (Patterson et al., 1993). When, where, and how does this partnership between the nurse and patient begin? Relationships begin when patients are on the acute burn unit. Rehabilitation nurses visit them here and become familiar with their current wound care. Patients witness the nurses working together and can be comforted by the impression of collaboration and planning. These visits provide patients with a sense of continuity and feeling that their wound care needs are understood by the nurse assuming responsibility for their care. Over time, mutual trust and respect between rehabilitation and burn unit nurses also is established.
Avoiding infection remains a primary goal in wound care (Carrougher, 1998). In the acute burn unit, patients are treated daily in a tank room. On the rehabilitation unit, patients have a private room, bathroom, and shower. This is an important component of care be cause it minimizes the possibility of cross-contamination (Helvig, 2002).
Once in rehabilitation, patient participation in wound care begins with the shower. The occupational therapist participates on the first day to evaluate the need for adaptive equipment. Often, a simple modification to a long-handled sponge allows the patient a degree of independence in the daily shower routine (Jacobs, 1992).
A consistent daily time frame for wound care is best established immediately upon admission to rehabilitation. A consistent schedule gives patients a sense of security and control that they know what to expect and when on a daily basis. Initially, 2 hours is generally required to complete wound care. Physical and occupational therapists visit during this time to assess the skin and joints they will focus on during therapy. During the shower and wound care, nurses and therapists brainstorm new ideas for adaptive equipment and splinting. As wounds begin to heal and the amount of time needed for wound care decreases, the nursing focus shifts to teaching patients and families about posthospitalization care and support. With a regular schedule and a significant block of time set aside, caregiver training can be effective and thorough. Upon discharge, patients and their families will be confident about their knowledge of ongoing needs of the patient.
Training caregivers can be a lengthy and involved process. Initially, caregivers are encouraged to observe wound care procedures and ask questions. As they become more comfortable during the procedure, the nurse gradually solicits more assistance in preparing the dressing materials and performing skin checks; later, the hands-on application of lotion or ointments and applying the dressing over the wounds is incorporated into the caregivers’ routine. Because it often takes two people to apply a compression garment, caregivers are a ready set of hands.
As wounds heal and wound care changes, it is important to update the plan of care continually and keep a copy in the patient’s room for reference. When the discharge date arrives, the discharge instructions should include a detailed breakdown of wound care needs, as well as information on possible problems that may arise and suggestions for managing these problems. Patients and caregivers also are sent home with the names and telephone numbers of burn clinic and rehabilitation staff for urgent questions. It recently has become our policy for the patient’s primary nurse to call the patient a few days after discharge to evaluate the patient’s transition home and intervene if issues can be managed quickly or major problems averted.
Dressings and Wound Care
The goal of maximizing functional status plays an important part in determining which dressings, splints, and adaptive devices are needed. Typical dressings on the acute burn unit consist of fine-mesh petroleum gauze impregnated with an antimicrobial agent (Carrougher, 1998). This type of dressing is appropriate for new graft/donor sites and when infection is present. By the time patients arrive on the rehabilitation unit, however, their wounds should be healed sufficiently to warrant a change from antibacterial dressings to plain fine mesh gauze (FMG) (Figure 1).
The FMG is moistened with saline and laid flat over the wounds. As it dries, it applies pressure to the new granulation tissue to prevent hypertrophy, and helps to approximate the wound by maintaining the integrity of the wound edges. It is important to distinguish that this is not a wet-to-dry, but a wet-to-dry-to-wet dressing. Current research-based recommendations for best practice do not support wet-to-dry dressings (Ovington, 2001; Coyne, 2003). The dried FMG dressings are removed the next day during the patient’s shower (Heimbach, Engrav, & Gibran, 2003) (Figure 2).
Fine mesh gauze dressings are not flexible; when applied to open areas over joints, they can cause painful therapy sessions when these joints are exercised. It is essential to ensure adequate pain control prior to therapy, or return to petroleum gauze dressings that allow more flexibility until the patient’s skin healing has progressed (Helvig, 2002).
By the time of discharge from the rehabilitation unit, the goal is to design the simplest possible wound care. This may include a daily shower for cleansing and the application of lotion and adhesive strips. Nurses must bear in mind that the person performing wound care (the patient or somebody else) has limited knowledge, skill, and time to attend to this daily commitment.
Preventing Damage to Graft and Donor Sites
Evaluating graft and donor sites daily is the first step toward preventing or minimizing tissue damage to these fragile areas (Walter, 1993). Layers of skin usually are held together and stabilized with fingerlike, interfacing projections called rete ridges and pegs (Wysocki, 1999). New grafts and donor sites lack these projections, and, until they regenerate, the grafts rest unattached on the bed of granulation tissue of which they will eventually become a part (Heimbach et al., 2003).
Shearing is a threat to the integrity of the skin during this period of fragile skin growth. Grafted skin has lost its elasticity, so the application of lotion is an important part of wound care. Water-based lotion is preferred. Lotions that contain alcohol tend to dry skin, and oil-based lotions may build up and clog pores, leading to the formation of inclusion cysts (Merz, 2003). Application of lotion generally is well tolerated and best performed after the daily shower (Helvig, 2002).
Moving across bed sheets or putting on a pair of pants, a shirt, or pressure garments all can cause shearing. The constant stretching and exercising performed in therapy is another potential cause of shearing. New skin tears, open areas, and blisters will occur as patients work toward maximizing their functional status and abilities. Daily evaluation of skin integrity allow early identification of problems. During these daily assessments, nurses carefully examine skin for inclusion cysts, blisters, and signs of surface infection. Expressing the exudate from cysts and fluid from blisters prevents serious problems and potential threats to the newly healed graft (Heimbach et al., 2003) (Figure 3).
Another potential problem for patients recovering from burns is surface infection (Cutting, 1994). Symptoms of infection include increased or new pain at a graft or donor site, a change in the appearance of a site, and increased drainage or a change in the type of drainage from a wound. A phenomenon known as “melting” may occur, in which the site appears as though it were disintegrating (Heimbach et al., 2003). Surface infection can occur at any stage in the healing process. Common causes include gram-positive and gram-negative bacteria. Although surface infection is a setback, it often is easily treated, and responds well to topical antimicrobial, bacteriostatic, and/or bactericidal therapies, including those that contain silver (Carrougher, 1998; Heimbach et al., 2003) (Figure 4). It is extremely important to prevent surface infection; daily cleansing of the patient’s skin with a solution of any mild, perfume-free soap and water is acceptable for daily showering and cleansing. Removing sloughing skin cells, dried ointments, and/or drainage helps prevent bacteria from invading fragile sites. It is essential to wear gloves during wound care and any time there is contact with open skin. Hand washing is essential for caregivers, patients, family, and visitors. Open skin areas are likely to have serous exudates that soil clothes and linen. Patients are encouraged to wear clean clothes and to change bed linens at least daily, because these items present a ready medium for bacterial growth and can become aesthetically unpleasant.
Proper nutrition, an important aspect of wound healing and resistance to infection, will continue to be important throughout rehabilitation. Dietary supplements, vitamins, and minerals are all essential in proper doses for the patient’s maximum recovery. Vitamin C in doses of 1,000–3,000 mg per day is not unusual, and should be considered essential in the patient’s treatment plan (Mazzotta, 1994). Needed minerals include calcium, iron, magnesium, potassium, sodium, and zinc.
Contractures and Edema
Contractures are a common problem for patients with burns. By the time patients arrive on the rehabilitation unit, range of motion is impaired. Factors that contribute to contractures include tissue damage around joints, the nonelastic nature of grafted skin, and little or no mobilization during prolonged bed rest during the acute hospital stay (Richard, Miller, Staley, & Johnson, 2002).
Nurses work closely with therapists to design and apply splints, when needed. Therapists form and fit patients with splints, and nurses ensure patients adhere to splinting schedules. In addition, nurses must routinely perform skin checks beneath splints, and patients must be educated about what to look for and report. Because most splints are worn during the evening and night hours when patients do not participate in therapy, nurses’ communication regarding splint schedules is important to ensure continuity in care.
Burn patients are prone to edema, which can interfere with wound healing. Compression garments are important treatments that decrease edema, improve circulation, and help prevent hypertrophic scarring (Richard et al., 2002) (Figure 5). Compression garments also are used to keep wound dressings in place. An elasticized, tubular, cloth dressing works well until the patient’s skin has healed well enough to be fitted for a burn compression garment, which is worn for up to 1 year after injury (Carrougher, 1998; Heimbach et al., 2003). Compression garments must be applied carefully to avoid shearing. During the first few weeks of use, additional staff members may be needed during garment application to hold the garment away from the skin and carefully unfold it into place. Compression garments should be worn at all times except during daily wound care (Carrougher; Heimbach et al.).
A variety of adaptive equipment is available for burn patients, and nurses serve as the liaison between patients and therapists when it comes to acquiring the equipment that will help patients gain as much independence as possible (Reg, 2001) (Figure 6). Nurses reinforce the proper use of adaptive devices and encourage patients to become maximally independent with these aids.
Addressing Psychological Needs
A critical recovery step is the patient’s transition from burn victim to burn survivor. Patients with burns learn that attitude matters. If a patient exhibits persistent lack of appetite, sadness, lack of motivation, or sleeping difficulties for more than 2 weeks, clinical depression may be a problem that requires treatment (Patterson et al., 1993). Patients who continue to view themselves as victims are less likely to participate in wound care or therapies; this behavior could extend their length of stay and interfere with wound healing. Burn support groups often are an appropriate and necessary adjunct to treatment while the patient is in the rehabilitation setting. Participation in such a support group can significantly influence a patient’s self-esteem, self-confidence, and a general sense of hope for the future (Heimbach et al., 2003). At Harborview Medical Center (HMC) in Seattle, WA, patient and family attendance at the institution’s burn support group has become a standard part of care during rehabilitation. Patients consistently report these group sessions help them to acknowledge their progress, cope with recovery, and tolerate setbacks. The value of support groups for burn patients at all recovery stages should not be underestimated.
Patient Priorities and Goals
To adequately support patients and their goals, nurses and the rest of the multidisciplinary team must understand patient priorities during rehabilitation. Consider each individual when deciding on a treatment plan. Culture, level of education, social status, job experience, social support, and family dynamics play an important part in the patient’s ability to recover and return to a productive life following rehabilitation. For example, some patients may be more concerned about physical appearance than function. Another patient may resist a prosthesis following hand amputation if the prosthesis cannot be adapted to operate a vehicle or other equipment. Each of these perspectives and requests must be honored and addressed during rehabilitation.
The nurse’s role is multidimensional and requires a holistic approach throughout the rehabilitation period. The patient’s mind, body, and spirit require healing that must continue long after discharge from the rehabilitation setting.
Percy is a 26-year-old native of Alaska who sustained severe burns over 60% of his body when he fell into a bed of hot coals in a bath hut after experiencing a seizure. Kipnic—Percy’s village—is remotely located near the Bering Strait, does not have running water and is far from the nearest hospital. Life in the small town revolves around survival and tradition.
Percy was taken by snowmobile to an area military base by his father, flown to a hospital in Anchorage, and airlifted to HMC. His family joined him in Seattle. As a result of his burns, he lost a hand and part of an arm.
Percy was in the hospital for more than 9 months, 3 of which were spent on the rehabilitation unit. Percy’s unique culture, traditions, and native language were significant challenges to the rehabilitation team. Initially, wound care took 2–3 hours a day. Although it was difficult for her, Percy’s mother learned how to provide wound care by working with the nurses every day.
Percy persevered during his lengthy rehabilitation and several painful regrafting procedures. He did not lose sight of his goal to return to Kipnic with his family as soon as possible. Once home, his mother continued his daily wound care, which included carrying in water from an outside source. Percy slowly regained the strength and stamina to resume the daily chores that are required for survival in Kipnic. Picking berries, fishing, and using a snowmobile became part of his normal routine. A full year after his injury, and just before his return to HMC for a checkup, Percy was able to hunt seal, a mainstay for the people in his village. Percy’s visit to the rehabilitation unit was joyful; the staff was happy to see him thriving and smiling. Living successfully within his culture and traditions, Percy is likely to have a fulfilling life. His is a true success story, and an inspiration for both burn patients and those who care for them (Figure 7).
About the Author
Beth Hall, BS RN, is a staff nurse at the Harborview Medical Center trauma rehabilitation unit in Seattle, WA. Direct correspondence to her at Harborview Medical Center, Trauma Rehabilitation Unit, Box 359-818e, 315 9th Avenue, Seattle, WA 98104, or e-mail email@example.com.
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