Burn patient rehabilitation is both a philosophy and an attitude which needs to start from the day in which the burn injury was inflicted.
Adequate nutrition is one of the most important aspects required for burn patient rehabilitation. Burn patients have increased caloric intake requirements. Lack of caloric intake leads the patient’s body to start metabolising protein, subsequently causing muscle wasting.
The Role of Nutrition in Burn Patient Rehabilitation
In patients with a burn injury, feeding should be established as early as possible, and ideally should be administered enterally. The patient’s weight should be monitored, especially since a 10% or more decrease in weight is considered to be a failure. However, it is important to note that while the catabolic state of large burn injuries result in a rapidly falling albumin level causing a decrease in dry weight, this decrease is masked due to the large fluid resuscitation volume administered in the first few days following the injury.
NOTE: patients requiring starvation for anaesthesia should be kept starved for the least time possible, starting from 6hrs pre-anaesthesia administration.
Basal Metabolic Rate – BMR
The Basal Metabolic Rate is the body’s resting rate of energy expenditure. The BMR doubles in cases where the patient has experienced more than 50% TBSA (Total Body Surface Area) burn. The larger the TBSA burned, the higher the hypercatabolism degree (excessive metabolic breakdown of complex substances including protein, within the body). The patient typically also experiences hyperglycaemia resulting as another endocrine response.
Typically, the patient’s BMR continues to increase and the core temperature resets to 1-2°C higher than normal, until the burn wound heals. During this healing process, the ambient temperature should be kept around 26-30°C to reduce the body’s energy demands.
NOTE: TBSA does not take into consideration superficial burns where only the epidermis is involved.
Nutritional Intake During Admission Stage
- the patient is weighed so that dry weight measurement is established and recorded
- a nasogastric tube is inserted, and feeding is started at low volume
- feed volume is gradually increased if the nurse determines that the feed is actually being absorbed
Caloric requirements are calculated by a dietician based on the TBSA burned. In burn patients the Curreri formula is used to determine nutritional intake requirement:
The Curreri Formula
(25 x weight in kg) + (40 x TBSA percentage)
Enteral Feeding
- studies show that patients receiving enteral feeding have a decreased mortality and morbidity rate
- enteral feeding is relatively easy to establish early on, and this helps decrease caloric deficit
- in patients with extensive burns obviously requiring a longer hospital stay, a PEG or nasojejunal tube is recommended, since this helps avoid repeated periods of starvation, and can also be passed at the bedside; since by using this way of feeding, nutritional intake bypasses the stomach and goes directly into the intestines, the patient would not require starvation pre-anaesthesia
- PEG feeding is used less in burn patients, especially if the abdomen has suffered from a burn injury, or if the abdominal skin may be required as donor skin
- Total Parenteral Nutrition TPN is only indicated if enteral feeding cannot be established, since studies have shown an increase in burn mortality with IV supplemental feeding in severely burned patients; additionally, due to an increase in burn patients’ core temperature, phlebo-fix used to hold in place a central line tends to keep coming off, thus, a central line is ideally avoided
Burn Patient Co-morbidities
A burn patient may have other primary diseases such as diabetes, high cholesterol, and obesity. Such diseases are referred to as co-morbidities. For this reason, every burn patient needs to be managed in a holistic way, where all pre-existing medical conditions, any related social circumstances, and obviously the patient’s age, are taken into consideration when drawing a burn patient rehabilitation plan.
Diabetes
- diabetes affects the healing process of the burn injury due to poor circulation leading to less oxygen perfusion
- burn wounds, like any other wound, is likely to become infected in a patient with diabetes, thus, patients with diabetes are frequently checked for microbe presence by wound swabbing
- careful monitoring and control of blood glucose levels in patients with diabetes promote better clinical outcomes, therefore this should be monitored right from admission stage
- antibiotic administration is likely to help improve graft take as well as healing period in patients with diabetes
- upon admission of a diabetic patient with a burn injury, the diabetic liaison nurse should be informed
Obesity
- obesity limits burn injury outcome in various ways
- typically, the force of abdominal viscera on the diaphragm limits lung tidal volumes
Age
- young burn injury patients are quite resilient especially since their skin is relatively thin but the ratio of their skin surface area to blood volume is relatively high
- elderly patients have very thin skin, and so, burn injuries endured by patients over 65 years of age are typically classified as full thickness burns; superficial burns in the elderly tend to progress to full thickness burns due to lack of nutrition, lack of self care, and sluggish circulation
Burn Reconstructive Procedures
Reconstructive procedures are performed following burns as well as cancer tumour removal. Plastic surgery uses the Aucher classification to classify burn reconstructive procedures according to their urgency. Burn reconstruction involves scar release or excision. Closure is done either by using a normal flap or by recruiting local skin.
- Primary Intention Burn Injury Healing – done through surgery; surgery however doesn’t restore sensory functioning
- Secondary Intention Burn Injury Healing – done through normal wound healing, with dressing changes as required and antibiotics to avoid infection; normal wound care without plastic surgery tends to lead to contractures that limit the patient’s functionality
An injury in which part of the body is lost eg. dog bites, human bites, woodwork injuries, butchers etc, is ideally subjected to secondary intention healing, since unintentionally closing the wound with microbes inside may lead to infection and subsequent surgical reconstruction or possibly amputation.
Skin Grafts
A skin graft is a surgical intervention in which tissue is moved from one area (donor site) to another (recipient area). The donor area can be either from the same body or from another.
FULL THICKNESS SKIN GRAFTS
- include the epidermis and dermis
- full thickness grafts can be harvested from only a few body sites
- may be used to cover bone exposure
- donor sites require direct closure or split thickness graft closure
- uptake rate is higher than that by split thickness grafts since the dermal layer is involved
- antibiotics are administered as prophylaxis to avoid infection of skin grafts
SPLIT THICKNESS GRAFTS
- include the epidermis and less than the whole thickness of the dermis
- is commonly done for acute burn wound closure
- healing is done through secondary intention
- uptake rate is less than full thickness skin grafts since only the epidermis is involved, and this is mashed, causing fenestrations in the graft area, and is also quite stretched
Care of Grafts
- foam is usually sutured or stapled over the graft to increase pressure
- foam is removed after 5 days so that the graft is reviewed
- graft is covered with antibacterial dressings
- alternate removal of staples from graft is carried out after 2 days
Care of Donor Site
- following harvesting of the skin, the donor site is covered with an alginate dressing (kaltostat) to control bleeding and protect the wound from becoming infected through contamination
- donor site is exposed after 15 days so as to minimise bleeding; DO NOT REMOVE, even if bleeding is noted – remove ONLY if the wound becomes very smelly, signalling infection
Flaps – Local and Distant
- flaps refer to the transferring of tissue that contains its own blood supply since vascularity is moved along with the flap during surgery
- local flaps have some continuity with the defect they cover
- distant flaps are separated by distance through the use of micro-surgery
- flaps need to be kept warm at all times
The difference between grafts and skin flaps is in the fact that grafts do not bring their own blood supply, however, skin flaps carry their own blood supply to the recipient area.
Care of Flaps
- flaps are held in place by staples or sutures
- removal of staples or sutures is done based on the surgeon’s advice
NOTE: NEVER apply pressure over the flap since this impedes circulation to the area, causing flap necrosis.
Burn Patient Rehabilitation Into Society
Burn injuries have comprehensive needs which are best treated with adequate resources. This is why a multidisciplinary team, commonly managed by a lead consultant, is involved in the burn patient rehabilitation process.
Physiotherapy
- physiotherapy is focused on the anatomical and physiological factors related to patient rehabilitation, helping in preventing or treating impairments or disabilities
- physiotherapy promotes exercises aimed at regaining strength, range of motion, and stretching of the scar area
- physiotherapy may also include chest physio which helps during the healing process, especially in patients who were exposed to smoke inhalation
occupational therapy
- occupational therapy focuses on the functional aspect of the patient’s ability to participate in the daily activities of life, providing functional training to promote improvement
- occupational therapy helps prepare the patient for discharge in relation to required support and services, including necessary equipment and environmental adaptations, assessment and provision
Burn Patient Challenges Prevention
Burn patients may experience various challenges during their healing process, some of which may result in disabling and disfiguring contractures. Challenges may include:
- pain
- scarring
- acute and/or chronic oedema
- muscle wasting (caused by immobilisation and long periods of reduced functionality)
- psychological pain caused by trauma and body image changes
- physical, mental and social limitations when compared to pre-injury
There are things we can do or promote as nurses so as to decrease or ideally prevent such challenges. These include:
- educating, motivating, and empowering the patient through promoting understanding of the healing process
- positioning the patient in a way as to protect the joints, reduce pressure, immobilise, and decrease oedema
- splinting to protect, immobilise, prevent contractures and regain range of movement
- chest physiotherapy helps in secretion removal whilst increasing tidal lung volume
- promoting passive, active, and active assisted exercises to prevent loss of range whilst strengthening the muscles
- scar massage, silicone, and pressure garments
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