Occupational Therapy, Burns & Scarring – Flashcards
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Epidemiology
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-Between 1 - 2 million Americans seek medical attention for burns each year. -Most burns occur at home, at work, or are part of an injury from a motor vehicle accident. -Between 50,000 - 70,000 people are hospitalized for burns every year in the United States -30 - 40% of whom are children younger than 15 years of age -Most burns in children come from scalding liquids (not easy to treat children)
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Skin Anatomy
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-Largest organ in the body -Protection from infection & injury -Prevention of loss of body fluid -Regulation of body temperature -Sensory contact with environment -infections, wound, reg. body temp, dehydration -need IVs
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layers of skin
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1. Epidermis (outer) 2. Dermis (hear, sweat glands) 3. Subcutaneous (fat and muscle) -layer determines degree of burn
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Causes of Burns
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1. Thermal (hot flame, liquids) 2. Electric (wires) 3. Chemical (splashes, sulfuric acid) 4. Inhalation (house fire, inhale smoke..OTs don't deal with it) 5. Radiation (nuc. power plant)
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why are electric burns tricky?
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-they burn from the inside out (internal) -doesn't look bad from outside -compartment syndrome: have to go in surgically if struck by lightning
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what determines burn?
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Depth of burn is dependent on the temperature and duration of the thermal energy applied to the skin
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First Degree
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-Epidermis involvement only -Skin is red and hypersensitive -really bad sunburn -red, blistery, painful -not medical emergency, learn lesson -treat with ointments -steam (OTs don't deal with first)
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Second Degree
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-partial thickness burn -Involves the epidermis and part of the dermis -Skin is red, blistered, edematous, red patchy islands (deep tissue color) -Sensory nerves are partially damaged, thus causing extreme pain
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Third Degree
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-Considered full thickness -Destroys both layers of the skin (epi and dermis) -Sensory nerves are destroyed -Have a whitish appearance with eschar -want this one because its so deep its not painful -creamy texture to skin (could misdiagnose if they have pale skin, hair falls out, rubbery...not pliable like normal skin)
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Fourth Degree Burn
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-Extend through the skin and subcutaneous fat into the underlying muscle and bone. -Fourth degree burns are stiff and charred. -worse, extensive...amputation -electrical burns
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Complications
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#1 problems: Fluid loss & Infections..renal compl. kidneys shut down because of fluid loss -Edema -Burns of face, feet, hands, eyes axilla, perineum require unique management: considered medical emergencies because of functional problems -Child abuse cases: pattern of burn tells a story -Contractures -Pain management -Psychological problems
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Assessment
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-Type and extent of burn (rule of nines) -Secondary injuries (fractures, respiratory) -Joints affected -Pain -Procedures performed (escharotomy, skin grafts, debridement)
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Rule of 9s
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-total burn surface of pt. baby: head is 18%, arms 9%, front and back 18% and legs 14% adult: head is 9%, front and back 18%, arms 9%, groin 1%, legs 18%
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when should assessment be completed?
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-To be completed 1st day of admission -Functional status (past, present) -Wound assessment: Type of injury,size, location, depth -Degree of AROM & PROM -Medical/surgical intervention(s) -General medical conditions -Social history/support/physical environment
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Treatment
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Early intervention is crucial in order to prevent contractures, deformities and maintain function.
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Surgical Treatments
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-Skin grafting (autograft, allograft, xenograft) -Debridement -Flaps
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OT goals
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-maximize function through... splinting to immobilize skin grafts, flaps, and to prevent contractures.
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Anti-deformity positioning
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-ensures they won't be contracted in bad position -neck should be hyperextension, no rotation -shoulders abducted -elbows extended -wrist extension, hands should be intrinsic plus -hip extended and abducted -knees extended -ankles in neutral
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Scar : Contracture
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-Caused by scar tissues that pull the edges of the skin together (contraction). -Can affect the adjacent muscles and joints, thus restricting normal movement. -biggest enemy @ therapy POV -difficult to treat, the key is prevention
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Why do we need to know about scars?
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-can cause difficulties for patients socially -changes in cosmetic appearance (psychosocial) -self-esteem -function -pain -A/PROM
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Histological appearance of hypertrophic scar in early stage
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-Dense collagen fibers in a tight uneven pattern. -During remodeling phase, the weave of these fibers is changed into a more organized pattern. This pattern can be influenced by applying physical forces -pumping out collagen so no organization
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what is the dermis held together by?
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-The dermis is held together by a protein called collagen, made by fibroblasts (skin cells that give the skin its strength). -Exaggeration of the inflammatory phase which produces an increase in fibrosis growth factors causes increased fibroblast numbers and thus excess amounts of collagen.
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Phases of Wound Healing
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1. Inflammation Stage 2. Reparative Stage 3. Maturation & Remodeling
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1st stage of wound healing
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Inflammation Stage - Onset is immediate and peaks at 12 hrs. Duration is 24-48 hrs. Bleeding, edema, leucocytes and macrophages. Rx - rest, elevation, ice.
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2nd stage of wound healing
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Reparative Sage - Onset at 12 hrs, can last up to 10 days. -Fibroblasts proliferate and begin process of collagen synthesis. Min. strength -tissue starting to heal, wound closes, scab..fibroblasts kick in
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3rd stage of wound healing
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Maturation & Remodeling - Onset is at 1 month up to 2 years. Fibroblasts contract and there is vascular and wound shrinkage. -OT -wounds closed but not healed functionally
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healing time of scars
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Scar tissue takes approximately a year to mature and is approximately 80% as strong as non-altered skin. Since scar tissue is not as strong as the normal structure it replaces; scar strength is directly proportional to scar volume When there is a heavy scar- especially one that traverses gliding planes- scar volume is inversely proportional to motion.
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Keloid scar
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- thick, and grow beyond the edges of the wound or incision. -stubborn, don't stop growing, can come back -earlobe, sternum, shoulder blade -round, bulbous, itchy
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Hypertrophic scar
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- raised above the surface of the wound and remain within the boundaries of the original incision or wound. -eventually stop growing by 2 years
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Who's at Risk?
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-Dark skin -Children-young adults - scars stay harder & redder longer. -Prolonged opened wounds (being exposed) -Would infections - increased formation of thicker connective tissue = increase scar formation.
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Unresolved edema
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- causes increased fibrosis
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Hematoma
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- decreases perfusion & increases workload of phagocytes. Medium for bacteria. Increases inflammation.
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Scar Assessment
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-Assess risk factors - predictors -History of scarring -Height of scar, Size, shape, length, width -Elasticity/pliability -Color - can be difficult to assess since determined by skin color, texture, vascularity & light & Pigmentation -Pain -Vancouver Scar Scale (pliability, height, vascularity, pigmentation) -Photography -Involved joints -Types of injury - cutting & slicing, crushing, degloving & avulsion, tidy & untidy -A/PROM -Scar age -Itchiness
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Psychosocial Function
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-Perception - the manner in which the patient assesses their scar will influence that patient's quality of life & outcome (Powers, et al, 1999). -Psychosocial function -Body image/self-esteem -Past psychiatric history
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Scar: Maturation
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-Scar takes eighteen months or more to mature -Over the months scars: ---Increase in thickness ---Become more rigid ---Become contracted ---Lose their intense red inflammatory response.
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Scar management
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-Scar massage (stable skin grafts) -Conformer -Silicone gel sheet -Splinting -Pressure Garments
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Scar management : Pressure therapy
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-Provide constant and equal pressure over healed and stable skin grafts -To prevent hypertrophic and keloid scarring -Control edema -Provide protection
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Occupational Therapy Goals for burns
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#1: encourage active ROM exs on unaffected and affected joints -edema control -gentle stretching exs -ADL retraining (leisure participation) -education to patient and family -Scar management imperative for form and function
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key points for burns
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For maximum results early intervention is crucial. Highly individualized therapy program. Patient's compliance is of utmost importance to gain maximal results.
