AOTA®’S NBCOT® EXAM PREP: BURNS

Burns

I. Definition of burn: thermal injury that destroys layers of the skin
A. Classifications: size, depth, and mechanism (Pessina & Orroth, 2008; Reeves & Deshaies, 2013)
1. Burn size; estimating total body surface area that has been burned
a. Adults: The rule of nines, which divides the body into 9s or multiples of 9s to calculate total body surface area of burns (%TBSA; Wedro, 2013)
b. Children and infants: Lund-Browder chart, a more accurate method of calculating TBSA, used especially for children, based on age (Lund-Browder Classification, 2003; Pessina & Orroth, 2008, p. 1246)

2. Burn depth (Reeves & Deshaies, 2013, Table 42-1)
a. Superficial (first-degree) burn
i. Involves the superficial epidermis.
ii. Pain is minimal to moderate; no blistering or erythema.
iii. Healing time is 3–7 days.
b. Superficial partial-thickness (superficial second-degree) burn
i. Involves the epidermis and upper dermis layers.
ii. Pain is significant; wet blistering and erythema are present.
iii. Healing time is 1–3 weeks.
c. Deep partial-thickness (deep second-degree) burn
i. Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands.
ii. Pain is severe, even to light touch.
iii. Erythema is present, with or without blisters.
iv. Burn has a high risk of turning into a full-thickness burn because of infection; grafting may be considered to prevent wound infection.
v. Client may have impairment of sensation.
vi. Potential for hypertrophic scar is high.
vii. Healing time varies from 3–5 weeks.
d. Full-thickness (third-degree) burn
i. Involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings.
ii. Burn is pain free, no sensation to light touch.
iii. Burn is pale and nonblanching.
iv. Requires skin graft.
v. Potential for hypertrophic scar is extremely high.

e. Subdermal burn
i. Full-thickness burn with damage to underlying tissue such as fat, muscles, and bone.
ii. Charring is present; may have exposed fat, tendons, or muscles.
iii. If the burn is electrical, destruction of nerve along the pathway is present.
iv. Peripheral nerve damage is significant.
v. Requires surgical intervention for wound closure or amputation.
vi. Potential for hypertrophic scar is extremely high.

3. Mechanism of Burn
a. Thermal: heat, cold, scald, or flame
b. Radiation: sunburn, X rays, radiation therapy for cancer patients
c. Chemical: acid (e.g., sulfuric acid, hydrochloric acid), alkali (e.g., dry lime, potassium hydroxide, sodium hydroxide)
i. Burn results in tissue necrosis rather than direct heat production.
ii. Degree of tissue injury is dependent on the toxicity of the chemical and the exposure time.
iii. Alkali burn is usually more severe than an acid burn.
d. Electrical burn: high voltage versus low voltage
i. High-voltage direct current usually causes a single muscle contraction and throws its victim from the source. Client is more likely to have blunt trauma along with the burn.
ii. Low-voltage alternating current (AC) is more dangerous than direct current (DC) at the same voltage. AC causes greater muscle contraction and, therefore, makes it more difficult for the person to voluntarily control muscles to release the electrified object.
iii. Extensive burned areas, including organs, depending on the electrical current’s path from entry to exit (grounded).

II. Medical Management
A. Emergent phase: 0–72 hours after injury
Medical treatment focuses on sustaining life, controlling infection, and managing pain. It can include intravenous fluids, intubation (if inhalant injury), escharotomy (surgical incision of eschar or burned tissue to relieve pressure on extremities after burns), fasciotomy (a similar incision that extends to the fascia), wound dressings with antimicrobial ointment for infection control, and universal precautions for medical staff and family (Pessina & Orroth, 2008, p. 1247).
1. Sustaining life
a. Risk of dehydration: One of the functions of the skin is that it serves as a moisture barrier. De- pending on the TBSA burned, the client is at risk of dehydration through evaporation.
b. Hypo- or hyperthermia: Skin also serves as an organ for temperature regulation. Without pro- tection from the skin, the client may not be able to perspire to cool the body surface or contain heat.
c. Fluid resuscitation: Rapid leakage of the protein-rich intravascular fluid into the surrounding extra- vascular tissues can result in decreased plasma and blood volume and reduced cardiac output.

d. Cardiopulmonary stability: Achieving this stability is especially important if the respiratory tract has sustained a smoke inhalation injury.
e. Escharotomy and fasciotomy: Circulation can be compromised when burn injuries girdle a body segment. The inelasticity of the eschar (burned tissue) can increase the internal pressure within fascia compartments and lead to compartment syndrome. Symptoms of compartment syndrome include paresthesia, coldness, and decreased or absent pulse in the extremities. Surgical excision of the eschars or incision into the fascia can release the pressure within the fascia compartments.
2. Controlling infection
a. Skin serves as an environmental barrier and protects against bacterial invasion.
b. Open wound area increases chances of bacterial infection and can be a wound bed for bacteria to grow.
c. Wound-dressing products protect the wound against infection, superficially debride the wound, and provide comfort.
d. Types of wound dressing include
i. Topical antibiotics
ii. Biologic dressing
• Xenografts—bovine skin, processed pig skin
• Allograft—human cadaver skin
iii. Nonbiological skin-substitute dressings—biosynthetic products such as Biobrane®
3. Managing pain
a. Pharmacological; likely use of narcotic analgesics
b. Includes pain management for any associated injuries, such as organ injuries or fractures

B. Acute phase: 72 hours after injury or until wound is closed (may be days or months; Pessina & Orroth, 2008, p. 1247)
Treatment focuses on infection control and grafts (removal of dead tissue and replacement of skin or substitute over the wound); biological dressings may also be used to cover the wound. Psychological support and team communication are important.
1. Infection control can be nonsurgical or surgical.
a. Nonsurgical intervention: maintenance of wound care until wound heals
b. Surgical intervention
i. Escharotomy and debridement: removal of burned or dead skin, allowing new vascularized skin to close up the wound
ii. Skin graft
• Autograft: transplantation of the person’s own skin from an unburned donor site to the burned receiving site
• Split-thickness skin graft
– Full epidermal and partial dermal layer are taken from the donor site.
– Chance of graft survival is high.

• Full-thickness skin graft
– Full thickness of the epidermal and dermal layers plus a percentage of fat layers are taken from the donor site.
– Chance of graft survival is less.
– The outcome is functionally and cosmetically better if graft adherence occurs.
• Meshed versus sheet graft
– Meshed graft is when the donor graft is “meshed” and stretched to cover a greater area of the receiving area.
– Sheet graft is when the donor graft is removed and laid down on the receiving area as is.
2. Pain management often includes use of narcotic analgesics.
3. Proper nutrition and hydration must be ensured.
a. A high-protein diet promotes wound healing.
b. Maintain proper hydration.
4. Cardiopulmonary stability is maintained.

C. Rehabilitation phase
Medical treatment continues with skin grafts and reconstruction surgery as needed for movement and function.

III. Occupational Therapy Evaluation and Intervention
A. Emergent Phase
1. Occupational therapy evaluation: clinical observations of joints affected by burns, information gath- ering on prior functional status
2. Occupational therapy intervention: splinting in antideformity positions
a. Intrinsic plus for hands
b. Opposite client’s posture
c. Generally in extension for the neck, elbows, and knees
d. Shoulder in abduction and hip in extension
e. Anti–frog leg and anti–foot drop for lower extremity

B. Acute Phase
1. Occupational therapy evaluation: ADLs, psychosocial aspects, communication, cognition, ROM, muscle strength, and pain 

2. Intervention: splinting and positioning in antideformity positions, edema management, early par- ticipation in ADLs, and client and caregiver education

3. Anticontracture positioning: Positioning is critical because the position of greatest comfort is usu- ally the position of contracture .

a. Neck: neutral to slight extension
b. Chest and abdomen: trunk extension, shoulder retraction
c. Axilla: shoulder abduction to 90°, external rotation
d. Elbow: extension
e. Forearm: neutral to supination
f. Wrist
i. Dorsal wrist: wrist in neutral to 30° extension
ii. Volar wrist: wrist in 30°–45° extension
g. Hand: metacarpal extension, 70° flexion; interphalangeal extension, thumb abducted and extended
h. Hip: 10°–15° abduction, neutral extension
i. Knee: extension; with anterior burn, slight flexion
j. Ankle: Neutral to 5° dorsiflexion

4. Edema management
a. Elevation of extremities
b. AROM exercises, if movement is allowed
c. Wrapping with elastic bandage, unless bulky wound dressing is used

5. Early participation in ADLs
a. Apply adaptive strategies, adaptive equipment, or both, allowing early success in selected par- ticipation in self-care activities. Gradually discontinue use of adaptive equipment to encourage active movement.
b. Implement a ROM program and activity as tolerated. No passive or active ROM with exposed tendons or recent grafts (wait 5–7 days).
i. Active, active-assisted, or passive exercises are used, depending on the client’s condition.
ii. The focus of exercise and activity is to preserve ROM and functional strength, build cardio- pulmonary endurance, and decrease edema.
iii. Pain is often a limiting factor. It is best to coordinate with nursing on scheduled pain medi- cations or short-term breakthrough pain relief. Treat 30 minutes after pain medication is administered.
iv. Use techniques such as visual imagery and relaxation to minimize pain.
v. Respect pain. Stop before the client reaches the limits of pain tolerance.
vi. Explain procedures before starting an exercise or activity and allow the client to control the time limit on painful treatment sessions, if appropriate.
vii. To avoid pooling of fluid and blood in the lower extremities in dependent or standing posi- tion, it is important to apply compression wrapping to provide adequate vascular support to lower extremities before walking, standing, or prolonged sitting with feet in dependent position.
viii. Address fear factor that can exacerbate perceived pain early in the intervention.

6. Client and caregiver education
a. Stages of burn recovery
b. Importance of independent activity and exercise participation
c. Pain management techniques

C. Surgical and postoperative phase

1. Post-operation immobilization period
a. Immobilization is important after skin graft operation to allow for graft adherence.
b. The immobilization period varies; confirm the specific period of time with the surgeon. Gener- ally, it is between 3 and 10 days or until graft adherence is confirmed.
c. Immobilization period of the donor site is usually 2–3 days, if no active bleeding occurs at the donor site.
d. Walking is usually not resumed until 5–7 days after grafting in lower extremities.

2. Positioning
a. May be the same as anticontracture positioning.
b. Surgeon may specify optimal positioning. The goal is to promote the greatest surface area for graft placement.
c. Donor site should be treated similarly to a burn site, involving elevation and wrapping with an elastic bandage.

3. Exercise and activity
a. Exercise and movement of the uninvolved extremities should be continued.
b. After immobilization period, start with gentle AROM to avoid shearing of the new grafts.

D. Rehabilitation phase: Wound is healing, and wound closure is stable.

1. Skin conditioning
a. Skin lubrication should be performed several times a day to prevent dry skin from splitting be- cause of shearing forces or overstretching during movement and exercise.
b. Use skin massage to desensitize the hypersensitive grafted sites or burn scars. Massaging a tight scar band can reduce shearing forces and prevent splitting of immature or problematic scar tissue.
c. Use sunblock or avoid unprotected sun exposure.

2. Scar management (includes massage and pressure garments)
a. Initiate compression therapy for both edema control and scar compression.
i. Temporary interim pressure bandages or garments
• Elastic bandages
• 3M Coban™ (3M, St. Paul, MN) wrapping of the fingers
• Elasticated tubular support bandages
• Thigh-high or knee-high thromboembolism-deterrent hose

• Spandex bicycle pants
• Isotonic gloves with impression silicone (Otoform®), elastomer, closed-cell foam, or sili- cone pad inserts; Pessina & Orroth, 2008, pp. 1254–1255)
ii. Measurement for custom-made compression garment
• Use of compression garments is indicated for all donor sites, grafted sites, and burn wounds that take more than 2 WEEKS to heal spontaneously.
iii. Custom-made pressure garment and insert
• Custom-made pressure garments are constructed to provide gradient pressure, starting at 35 mm Hg distally.
• The garment should be worn 24 hours a day except during bathing, massage, and other skin care activity.
• A minimum of two sets of garments should be ordered for changing and laundering.
• To conform to body contours and prominences, additional flexible inserts or conformers are often added under the garments to distribute the pressure more evenly.
3. Therapeutic exercise and activity
a. Exercise and activity should be progressively graded to regain strength and activity tolerance.
b. Client needs to be taught to perform skin lubrication and massage as pretreatment skin care before exercise and activity program.
c. Includes daily stretching, resistive exercise, activity to tolerance, and coordination activities
4. Splinting
a. Continue anticontracture positioning to prevent contracture formation.
b. Use dynamic splint or serial casting to reverse disabling or disfiguring contracture formation. For the hands, attend to extensor tendon injury and web space contracture management.
5. ADLs
a. Apply adaptive strategies or adaptive equipment to promote independence in ADLs and a return to a normal daily routine.
b. Identify abnormal movement pattern early; client needs to relearn normal movement patterns.
6. Client education to aid transition from hospital to home
a. Independent skin care protocol
b. Understanding of wound-healing process
c. Compression therapy and positioning with practice opportunity to apply garment and splint
d. Preservation of independence in ADLs and IADLs with continuing exercise and activity program

E. Outpatient and community reintegration phase
1. Scar management
a. Continue compression therapy, skin conditioning, splinting and positioning, and exercise pro- gram till the scar is mature.
b. Maturation may take from 1 to 2 years to occur.

2. Community reentry
a. Improve skin tolerance for friction and shear from the compression garments and inserts during activities with skin-conditioning activities and exercises.
b. Promote ROM and strength tolerance to activity with activity tolerance training.
c. Adapt activity demands and environment if any limitations in movement result from tight scar band or contracture.
3. Psychosocial adjustment
a. Client may experience symptoms of posttraumatic stress disorder.
b. An adjustment period may be needed, especially if disfigurement or contracture has occurred.
c. Client may require counseling, a support group, training in pain management, relaxation, and stress management.

IV. Burn-Related Complications and Management
A. Contracture
1. Results from tight scar band, hypertrophic scar, or prolonged immobilization.
2. Addressed with early implementation of anticontracture positioning, continuous exercise and activ- ity programs, and serial splinting programs to prevent or reverse deformity.

B. Hypertrophic scar
1. Scar is most apparent 6–8 weeks after wound closure.
2. It is most active in the initial 4–6 months.
3. Because of increased vascularity, the scar becomes firmer and thicker and rises above the original surface level of the skin.
4. It can happen at the donor site, at the original burn area, or with a wound that does not close spon- taneously after 2 WEEKS.
5. Apply compression therapy early, and continue it until the scar matures in 1–2 years.

C. Heterotopic ossification
1. Heterotopic ossification is the formation of bones in abnormal areas. It typically occurs in soft tis- sue around the joint or joint capsule.
2. Common areas in which it occurs are the elbow, knee, hip, and shoulder.
3. Loss of ROM is rapid, and pain is localized and severe.
4. Hard end feel during PROM activity.
5. Once diagnosis is confirmed, discontinue passive stretching (including use of dynamic splint) and begin AROM exercise within the pain-free range to preserve as much joint movement as possible.
6. Heterotopic ossification usually requires surgical intervention if functional activity is limited.

D. Pain
1. Pain interferes most with the rehabilitation process.

2. Respect pain.
3. Coordinate with nursing on scheduled pain management; breakthrough pain relief can improve compliance with therapy program.
4. Educate the client and family on the importance of ROM exercise and activity in spite of pain to prevent deformity formation.
5. Teach the client proper skin care and lubrication to avoid maceration of skin because of friction and shear during exercise and activity.
6. Reinforce pain management and stress reduction management techniques throughout the whole continuum of care.

E. Heat intolerance
1. Loss of the ability to sweat may occur as a result of loss of sweat glands with split-thickness skin graft.
2. Client may sweat excessively in the unburned areas.
3. Special accommodations and modifications (air conditioning) may be required at home or in the work or school area.

F. Sun exposure
1. The risk for sunburn is higher.
2. Extra care should be taken to use sunscreen and avoid prolonged sun exposure, especially without protection.
3. May affect returning to outdoor work or, for children, playground activity.

G. Pruritis (persistent itching)
1. May lead to skin maceration and reopening of the wound as a result of scratching.
2. Use of a compression garment, maintenance of skin lubrication, and use of cold packs and antihista- mine medications may alleviate itching.

H. Psychosocial adjustment
1. Contracture, disfigurement, and pain are the primary stressors after burn.
2. Depression, anxiety, posttraumatic stress disorder, and withdrawal reactions are some of the com- mon psychological reactions postburn.
3. Parents may feel guilty when a child sustains a burn. Parents may feel incompetent and may resist taking over the scar management program at home. A balance between scar management, exercise, and reestablishing the parent–child relationship should be attained through careful intervention and high vigilance on the scar condition.
4. Children may have a more difficult time reintegrating into student and playmate roles. Predischarge plan should include a community-based therapist working in the school system to help with adjust- ment issues.

V. Special Considerations
1. With the exception of the post–graft operation immobilization period, gentle AROM and PROM to the client’s tolerance should be implemented as early as possible.
2. After post–graft operation immobilization, begin with AROM initially, and resume PROM after graft adherence has been confirmed.
3. Close monitoring of scar contracture and deformity development through the continuum of care and making changes to splinting and positioning as often as needed are of utmost importance.
4. Avoid applying a splint on the surface of the burned area (e.g., volar hand splint for burns to dorsum of hand and dorsal hand splint for burns to volar surface of hand). Unless burns are circumferential, apply standard splinting positioning (e.g., volar hand splint).
5. With dorsal hand burns, take care to maintain Boutonniére precaution and avoid having the cli- ent form active or passive composite flexion of the fingers during evaluation and intervention. The integrity of the extensor hood should be confirmed before composite flexion is allowed.
6. With any burn deeper than a deep partial-thickness burn, sensory impairment may occur. Sensory testing for peripheral nerve damage should be performed as soon as the wounds are closed.
7. For electrical burns, a gross sensory screening should be performed on the involved limb to identify the extent of the peripheral sensory nerve involvement.
8. For edema measurement in the hand, use of a volumeter should be avoided until all wounds are closed or permission is obtained from the medical doctor to submerge the hand with open wounds into water.

References
Lund-Browder classification. (2003). Retrieved from http://medical-dictionary.thefreedictionary.com/ Lund-Browder+classification
Pessina, M., & Orroth, A. (2008). Burn injuries. In M. V. Radomski & M. C. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 1245–1263). Baltimore: Lippincott Williams & Wilkins.
Reeves, S. U., & Deshaies, L. (2013). Burns and burn rehabilitation. In H. M. Pendleton & W. Schultz- Krohn (Eds.), Pedretti’s occupational therapy: Practice skills for physical dysfunction (7th ed., pp. 1110–1148). St. Louis, MO: Elsevier.
Wedro, B. C. (2013). Burn percentage in adults: Rule of nines. Retrieved from http://www. emedicinehealth.com/burn_percentage_in_adults_rule_of_nines/article_em.htm