A well-documented and thorough life care plan plays an important role in the long-term recovery of a burn-injured individual. Serious burns cause a significant interruption of the patient’s life, including physical, social, emotional, and financial stability. Therefore, it is vitally important that the life care plan for the burn patient is holistic and addresses concerns regarding the client’s medical, emotional, social, and financial needs and well-being.
Burn care has evolved dramatically over the past 20 years. Acute burn medical care has improved greatly and has resulted in dramatically higher survival rates (Brusselaers et al., 2005). Persons, especially children, with a large percentage of total body surface area burns (% TBSA) survive routinely (Wolf et al., 1997). While it is encouraging that mortality has declined, an individual’s survival of serious burn injury often results in lifelong challenges and complications for the burn patient and the family. Recovery often necessitates post-acute care rehabilitation, future reconstructive surgeries with accompanying therapies, home health care, as well as the need for assistance with psychological, social, educational, and vocational rehabilitation issues. A well-thought-out and comprehensive life care plan can provide the survivor and the family with a vital road map that will assist them in navigating the long and arduous road to recovery.
Burn care is a highly specialized field of medicine. The burn care team is multidisciplinary and is made up of an extensive array of medical professionals. A burn injury is complex and complicated from both a physical and a psychological standpoint and survivors benefit from a multifaceted team approach to their care (Demling, 1995).
In the acute hospital setting, the patient is cared for by a team of burn care professionals, which includes burn surgeons, physician’s assistants, nurses, burn techs, physical and occupational therapists, nutritionists, respiratory therapists, psychologists, social workers, and case managers. Patients often require additional care from specialists such as plastic/reconstructive surgeons, hand surgeons, cardiologists, neurologists, psychiatrists, and speech therapists. The acute medical care setting for burn patients is labor intensive, and the care is expensive. It takes tremendous effort on the part of the entire burn care team, as well as an immense effort on the part of the patient and the patient’s family for basic survival to occur (Herndon & Blakeney, 2007). Rehabilitation begins in the hospital and is often extended in a specialized rehabilitation facility after discharge from the acute burn care setting for weeks or even months postdischarge.
Life care planners and medical case managers should be familiar with the prevalence, etiology, and pathophysiology of burn injury. Over the past two decades there has been a notable reduction in the total number of burn injuries in the United States; however, every year approximately 700,000 persons in the United States continue to require medical attention for their burn injuries (Brigham, 2005). It is estimated that approximately 40,000 of those injured will be hospitalized and that approximately 3,500 individuals will die from their burns (Pruitt, 2007). Survival is
predicated on a number of factors including age, severity of the burn, comorbid trauma, inhalation injury, and premorbid health conditions. Burn patients between the ages of 5 and 20 years of age are among those most likely to have a favorable outcome. Infants and patients over 70 years of age have marked increased for morbidity and mortality (Saffle, 1995).
The severity of the burn is determined by a number of factors including the size of the burn injury, the need for skin grafting, and the presence or absence of an inhalation injury. The larger the percentage of TBSA (total body surface area) burned, the less favorable the outcome is likely to be. The depth of the burn, including the degree of the burn, also influences the ultimate outcome, with deeper burns resulting in a less favorable prognosis and the need for the patient to receive skin grafts. Inhalation injury is another factor, which often contributes to poorer outcome. Burns may present with other trauma, which can also complicate survival and future care needs. Premorbid medical conditions can also have a negative influence on the patient’s outcome (Hartford, 2007). All of these details are important to consider when developing the life care plan or managing a burn case; therefore, a thorough review of the patient’s medical records and familiarity with the patient’s medical history are imperative.
The risk of being burned, as well as the etiology of the burn, is related to a person’s age, type of employment, economic status, type of recreational activities in which one engages, and location of residence. Although the specific number of burn injuries in the United States is unknown, individuals suffer from far more minor than major burns. It is estimated that only 3% to 4% of burn-injured persons reporting to emergency rooms are admitted or transferred to a burn center/ unit. However, burn injuries are still a significant problem and an expensive injury. In 2003, fire/flame-related burns and inhalation injury continued to rank as the sixth leading cause of unintentional death due to injury in the United States and fires/flames caused the fifth largest number of injury-related deaths in the home (National Safety Council, 2003). The economic cost of burn injury is high with hospital bills for severe burns ranging from many thousands to millions of dollars for one patient. Ongoing reconstruction and rehabilitation are also costly, which is another reason why an accurate life care plan is important.
While burns can be caused in a variety of ways, the most prevalent causes of burn injuries requiring admission to the hospital are fire/flame, scalds (most common in young children and the elderly), and chemical, electrical, and radiation burns. Flame and scald burns account for the vast majority or approximately 79% of all reported cases (Pruitt et al., 2007). The arms and hands, head and neck, and lower extremities are the areas of the body most likely to sustain burns. Of nonfatal burns, 45% involve the hand and arm, 25% involve the neck and head, and 16% result in burns to the leg and foot (Pruitt et al., 2007). The face, limbs, hands, and feet are vital to both physical and social function, and burns to these body parts, especially scarring across the joints, can be disfiguring as well as disabling (Demling & LaLonde, 1989).
The treatment of burns is often determined by the classification of the injury. Burn injuries are typically classified by etiology, depth of the burn (layers), location of the burn, and the percentage of total body surface area burned (% TBSA). Burn depth, which refers to the layers that have been damaged, is classified as superficial (first degree), superficial partial thickness (second degree), deep
partial thickness (second degree), full thickness (third degree), and deep full thickness (fourth degree). Physicians will often defer the classification of a burn injury for several days, in order to correctly determine the true depth of the burn.
¦ Superficial (first-degree) burns involve only the superficial epidermis and usually require 3 to
7 days for healing with no scarring.
¦ Superficial partial-thickness (second-degree) burns involve the epidermis and the dermis excluding hair follicles, sweat glands, and sebaceous glands and should heal in less than 21 days with minimal scarring.
¦ Deep partial-thickness (also second-degree) burns involve the epidermis and most of the dermis, requiring more than 21 days for healing, and may develop severe hypertrophic scarring.
¦ Full-thickness (third-degree) burns result in total destruction of the skin, both epidermis and dermis and hypodermis, and may involve additional tissue. Full-thickness burns of any significant size require skin grafting.
¦ Deep full-thickness (fourth-degree) burns involve fat, nerve endings, muscle, and/or bone and are usually a result of prolonged contact with heat or an electrical injury and may require flap coverage or amputation (Fisher & Helm, 1984).
Burns are also categorized by the percentage of TBSA involved. It is customary to establish the percentage of partial- and full-thickness burns separately. The American Burn Association (ABA) classifies burn injuries as mild, moderate, and major. Moderate and major burns require hospitalization.
¦ Minor burns are those that involve less than 15% TBSA and are partial thickness. In the elderly and pediatric populations 10% or 2% full thickness is considered minor unless the eyes, ears, face, hands, or perineum are burned.
¦ Moderate burns include a total body surface area of 15% to 25% (10% to 20% for pediatric patients less than age 10 or adults over age 40) without regard to the depth and 2% to 10% full-thickness burns unless the eyes, ears, face, or perineum are burned.
¦ Major burns include those partial-thickness burns that cover more than 25% of the body (20% for children and adults less than the age of 40); or those full-thickness burns that cover more than 10% of the total body surface area as well as all burns to the face, eyes, ears, feet, and perineum. Burns sustained from electricity or lightning or those involving inhalation injury are also considered major. Burns with comorbid trauma and all burns that present with premorbid illness or are in the very young or the elderly are also labeled as major burns (Hartford, 2007).
The skin plays a major role in sustaining life since it makes up the largest organ system of the body. The main functions of the skin follow:
¦ Protective barrier
¦ Regulates body temperature
¦ Fluid conservation
¦ Receives environmental stimuli
¦ Excretory gland
¦ Absorbs Vitamin D
¦ Determines identity
Human skin is made up of several layers: the epidermis (10%), which is the outer layer, and the dermis (90%), which is the inner layer. The average thickness of adult skin is 1 to 2 millimeters. The top layer contains cells that determine skin color and make up the protective layer of skin. The dermis is found beneath the epidermis. The dermis contains connective tissue, capillaries, collagen, and elastic fibers. This layer supplies structure and nutrition to the epidermis, provides elasticity of the skin, and contains the hair follicles and excretory glands including the sweat and sebaceous glands. There are sensory nerve endings found throughout the skin; therefore, deeper burns may cause permanent changes in a person’s capacity to sense pain, touch, and temperature (Cromes & Helm, 1993).
When both layers of the skin, the epidermis and dermis, are destroyed, the patient loses hair follicles, sweat and sebaceous glands. A layer of fat and connective tissue is found under the dermis, and muscle, bone, and tendons are beneath this layer. Sensory nerve endings are distributed throughout the skin and subcutaneous layer. Therefore, burn injury, depending on the depth, may result in a permanent change in the burn victim’s capacity to sense pain, touch, and temperature (Fisher & Helm, 1984).
Wound care is a key component of acute and rehabilitative burn care. Wounds must be maintained in a manner that facilitates and at the very least does not impede re-epithelialization of the skin. This includes care designed to minimize infection, remove dead tissue, reduce heat loss, and prevent further tissue loss. A typical approach to wound care involves cleaning the wound and debriding it twice daily. Donor site dressings must also be changed once or twice a day. Wound care is extremely painful for the patient. If reconstructive surgery is a future recommendation for a patient, a provision for home health care will likely be necessary.
There are a number of common surgical procedures in burn care. If the burn injury is circumferential, the skin can become very tight and stiff and stop the blood flow to the areas below the burn. An escharotomy, a cut made down through the burned skin (the eschar), may be performed. A faciotomy, which is a deeper cut into the tissue below the skin (facia), may also be performed, in order to expose the muscle. Medical records will document these procedures.
Grafting is a surgical procedure that involves the transplantation of skin. Grafting becomes necessary when the patient has burns that will not heal spontaneously. There are several types of skin grafts. The first is an autograft, which is created when the individual’s own skin is taken from an unharmed part of the body (donor site) and placed over the burned area.
If the burned area is not ready for an autograft, a temporary skin covering may be used, allograft (homograft) or a xenograft (pigskin). This thin temporary covering is placed over the wound and allows for better pain control and provides a barrier to infection. These temporary grafts stick to the skin, but will be removed when the area is ready for a permanent skin graft (autograft). Skin grafts may take after the first surgery but sometimes they fail and the patient must be returned to the operating room, possibly several times, until all of the dead, burned skin has been removed (debrided or excised). A dermal replacement may also be used because it provides an outstanding
barrier for infection, is easy to apply, and adheres well to lesions. It can be very costly, so be sure to inquire if dermal replacement will be necessary for any reconstructive surgeries (Khosh, 2008).
It is important to note how many surgeries the burn patient has undergone in the narrative portion of the life care plan. It helps to illustrate just how burdensome and difficult the patient’s acute care stay was.
A seriously burned patient, especially a child, may need a great deal of post-acute care reconstructive surgery. The purpose of burn reconstruction is to provide the patient with function, comfort, and improved appearance. In children, reconstruction may also be done to allow for growth. The burn patient is likely to have a lifelong relationship with a reconstructive surgeon (Barret, 2008).
It is customary for definitive correction of burn scars to be postponed for at least a year or more. Scars mature over time, and some scars through the use of pressure garments and splints may not need surgical correction. Scar contractures can be uncomfortable as well as unsightly. They may also impede function. It is important for life care planners to inquire as to which reconstruction procedures will be necessary and how often it is probable that they will be repeated over the life span. It is especially important to address those scar contractures that are present over joints, and skeletal deformities also need to be considered.
Once the surgery has been performed, the patient will likely need home health care, physical or occupational therapy, and pressure garments. These items are all important to the long-term success of any reconstructive surgery. The surgeries may also need to be repeated multiple times over the life span, especially when the burn is sustained in early childhood.
Burn injuries that destroy dermis also cause elimination of the normal pressure that these layers of skin provide. Absent this pressure, hypertrophic scars can form, causing deformities and impairment of function. Pressure garments help to prevent and control the formation of hypertrophic scars by applying counterpressure to the wounded area. They also aid in reducing the effects of hypertrophic scarring, itching, and increased circulation to the area (Lisares, 1972). Pressure garments are fitted by a specialist, which is usually done prior to discharge from acute care.
Pressure garments can play a vital role in the proper healing of wounds and reduce the effects of scarring, but for the garments to perform their job properly, they need to fit tightly and be in good condition. Patients often wear their garments for anywhere from 12 to 24 months after initial discharge. They typically must be worn 23 hours per day. Therefore patients are prescribed two sets with each fitting. Patients will often be fitted for new garments after reconstruction procedures.
Positioning is also very important for the burn patient. Patients are often sent home with splints. They are also often ordered after reconstruction. The life care planner should inquire into the need and frequency of both garments and splints when discussing projected surgeries.
A very severe burn, a fourth-degree or circumferential third degree burn, may result in an amputation. This may involve a digit, hand, limb, or even a nose or ears. A prosthetist can provide
information regarding the cost, replacement schedule, and need for other accessories for the patient. An anaplastologist, an individual who has the ability to create and customize highly individualized prosthetics for the face, can be consulted for information regarding prosthetic eyes, ear, noses, fingers, and so on.
Burn injuries affect the body’s metabolic rate, and burn patients suffer from posttraumatic hypercatabolism. This well-known phenomenon causes the breakdown of tissue and exhausts the body’s energy stores. The magnitude of the problem is defined by the total body surface area and severity of the burns. Glucose uptake is compromised, cholesterol and lipoprotein concentrations are decreased, and protein catabolism causes patients to lose protein content. The increased metabolism is amplified by pain, anxiety, hypovolemia, and infection, as well as loss of body heat (Gallal & Yousef, 2002). Burn patients’ nutritional needs are of key importance, and patients are often given enteral feedings with a high caloric content to promote healing. Supplements are often prescribed after discharge from acute care as well as after reconstructive procedures to insure proper healing.
Patient-specific rehabilitation services begin immediately during acute burn injury care and continue after, often long after, the patient is discharged from initial hospitalization. The literature suggests that recovery from a major burn may take several years to return a patient to a satisfactory level of function (Brown, Helm, & Weed, 2004; Warden & Warner, 2007). The depth and location of the burn are key factors in determining the type and goals of immediate and aggressive therapeutic intervention. The preservation of function and mobility are the short-term goals of rehabilitation. Long-term goals involve returning the patient to independence through the ability to perform activities of daily living, compensation for functional loss, management of scars and pain, and reintegration into the home and community (Serghiou, 2007).
It is important to remember that discharge from the hospital does not mean that the patient is restored to good health. A burn patient’s wounds have been covered, but they may have to return to the hospital for additional surgeries and will likely have orders for outpatient physical therapy and/or occupational therapy, burn clinic visits, pain management, psychological care, as well as the need for pressure garment fittings. Ongoing wound care, as mentioned previously, is also a facet of the rehabilitative phase of burn recovery.
Rehabilitation should begin immediately so that the scars do not mature and cause more severe contractions and limitations, which can increase complications, diminish function, and result in additional treatment and a greater cost of care. Burn scar maturation can vary from 6 to 18 months and longer. During this period it is important to mobilize the burn area to decrease the likelihood of contractures, deformities, and hypertrophic scarring. Once scar maturation has occurred, correction of most deformities and cosmetic abnormalities involves costly surgical procedures with physical/occupational therapy, home health care, and burn clinic or doctor office follow-up in order for functional gains to be maintained (Cromes & Helm, 1993).
Scar massage has been found to be beneficial to burn patients and provides several important functions, including the promotion of collagen, the remodeling of scars, decreased itching, decreased
anger, and decreased anxiety while providing moisture and pliability to the burned areas and donor sites (Field et al., 1998). It may be recommended by the physician after scar revision surgeries or for ongoing pain and scar management.
Over 60% of the 40,000 patients who are hospitalized annually for their burn injuries are admitted to the 125 hospitals that have burn centers or units (National Hospital Discharge Survey, 2003). Many of these specialized care centers are regional in nature. Therefore, patients must sometimes relocate, temporarily, to a burn center in order to receive ongoing and appropriate outpatient burn and rehabilitation care (Hartford, 2007).
A comprehensive burn rehabilitation course may require as much as 6 hours of therapeutic intervention per day, 5 days per week. The frequency usually decreases gradually to three times per week and eventually to two times per week. The patient often requires attendant care from a family member or health care provider for dressing changes, exercise routines, and activities of daily living. A severely burn-injured individual may have need of assistance for weeks or even months. If parents, spouses, or other family members are providing attendant care or transportation, an estimate of compensation for their time and effort should be considered for inclusion in the life care plan.
Physician follow-up visits are needed approximately every 1 to 2 weeks in the initial outpatient stage, with frequency decreasing to once or twice per month as long as the patient is on physical therapy or occupational therapy treatment, and for the first few weeks after treatment is stopped. Typically treatment lasts for anywhere from 12 to 16 weeks. To make sure the patient is maintaining function after therapy has stopped, typical physician follow-up should continue but gradually decrease to once every 3 months for 12 to 18 months, then biannually for another 12 to 18 months, then annual visits, unless unforeseen complications arise. However, the number of weeks or months and the actual physician follow-up plan is always specific to the patient; therefore, a physician should make the actual recommendation.
Life care plans for severely burn-injured children can be very complicated. Pediatric patients often need multiple reconstructive surgeries as they grow. Children may have cognitive problems due to trauma and/or inhalation injury, and there will be great demand placed on their parents and family in order to support them in their need for ongoing care. Educational needs also should be considered. Summer burn camp is a rehabilitation program that can bring great benefit to a burn-surviving child and should be considered for inclusion in the life care of a pediatric burn- survivor. The World Burn Congress, an annual event sponsored by the Phoenix Society, can also be beneficial for children and their families and can be extremely helpful for adult burn survivors and their families as well.
Psychological adjustment to a severe burn injury can often be profound (Smith, 2006). A significant number of burn-injured patients will suffer from posttraumatic stress disorder and experience intrusive memories related to the event during the acute care phase (Ehde, 1999). Depression and
anxiety on the part of the patient and/or the family may also occur. Psychological intervention may have begun in the burn center during the acute care stage of hospitalization, if it was available. However, not all burn centers or units have psychological services available as a regular part of their care protocol.
The medical chart should be reviewed to ascertain what psychological problems may have arisen during inpatient care and what psychiatric or psychological services, if any, were delivered. Supportive services and crisis management care are often offered to patient’s families in the burn center; however, as basic survival becomes the major goal during the initial phase of hospitalization, psychological matters may not have been addressed, or may have been addressed inadequately.
Acute stress disorder may be diagnosed during acute hospitalization. Posttraumatic stress disorder, a complication which longitudinal studies have found to affect up to 45% of adults who were hospitalized for their burn injury 1 year postburn and nearly a third of burn patients within
1 years of their burn, cannot be diagnosed until at least 30 days after the initial traumatic event (Perry, Difede, Musngi, Frances, & Jacobsberg, 1992; Wiechman et al., 2001). Therefore, it is important to address psychological issues of both the patient and the family, not only during the inpatient stay, but after discharge from the burn center or burn unit as well.
Many burn-injured patients persist with periods of fear and anxiety. These symptoms often recur when the patient has to return to the hospital for reconstructive surgeries. Adults may express their anxiety through physical symptoms such as palpitations, perspiration, nausea, and shaking. Children may become clingy or fearful, cry often, have headaches and stomachaches, or become disruptive and angry. The psychological impact of burn injury has become a major focus of burn care. “Health care professionals are increasingly recognizing that they cannot neglect the psychological and social dimensions both for patients and their families. Research has shown that patients and clients who receive psychosocial support as part of their rehabilitation are more likely to adjust positively to living with a disfigurement” (Partridge, 2008).
A psychosocial survey should be performed for the patient. As mentioned earlier, the patient and the patient’s family may have been unable to address psychological and social issues such as posttraumatic stress disorder, financial pressures, or depression before discharge from acute care. They may be experiencing new problems at home such as sleep disturbance, anxiety, sexual concerns, body image problems, itching, identity issues, inability to return to work or school, and unresolved pain issues. If the patient or the family expresses concerns regarding any or all of these matters, there should be an evaluation by a psychologist or psychiatrist. A neuropsychology evaluation, used to examine brain function and possible impairments, is often recommended for severely burned pediatric patients and may be ideal for any burn patient who has experienced an inhalation injury or trauma to the head concomitant with the burn injury.
Life care planners should make inquiries regarding any currently prescribed psychotropic drugs and the length of need for such medications. If medication is needed on an ongoing basis through life expectancy, it is likely that the patient will need ongoing visits with a psychiatrist. Consideration should be made for immediate psychological intervention if problems are occurring, as well as for the need for ongoing psychological care during major life shifts and periods of reconstructive surgery. Play therapy for children, individual therapy for adolescents and adults, and couples counseling for both spouses and parents should be considered as well.
There is limited literature available on the details surrounding return to work following a serious burn injury. One study revealed that the majority of burn survivors do return to work within 2 years with an average of 17 weeks off the job (Byrch et al., 2001). However, there are a number of reported factors that tend to impede return to work. The most common risk factors associated with longer durations of work absence following serious injury and found to increase the unlikelihood of returning to work include the patient’s admission to intensive care units, a lengthy hospitalization, and a low education level. These are not unusual circumstances for individuals who have sustained severe burn injuries.
Other factors impeding return to work, which are related directly to burn injury, include total body surface area, length of hospitalization, thickness of burns, number of surgeries, age, presence of hand burns, reduced endurance, alcohol or drug dependence, and prior psychological or psychiatric problems. The longer the time lapse since the burn injury, the higher the likelihood of returning to work. Positive factors for likelihood of returning to work include pre-employment status, age, good coping skills, and higher level of education. However, having more full-thick- ness burn injuries was associated with a lower likelihood of returning to work (Dyster-Aas et al., 2007).
Several studies have shown that burn patients who are able to return to work report more satisfaction and a better overall quality of life than those who remain unemployed. Therefore, vocational rehabilitation issues should be taken into consideration during the early part of outpatient rehabilitation. Employers should be contacted on a regular basis to keep them updated on the status of the patient, in order to encourage a good relationship, and to diminish the patient’s fears that former employment will be lost. A comprehensive job description can be utilized to determine therapy needs in order to assist the patient in maintaining job skills. Part-time employment or light duty should be discussed in order to diminish financial stress and to avoid establishing a pattern of dependency (Weed & Berens, 2005).
A majority of burn patients are able to return to work but they are often unable to return to the job they had prior to their burn injury (Byrch et al., 2001). If job modifications or return to the same type of employment is unlikely, vocational evaluation and training should be considered as soon as the patient is healthy enough to begin. Research from the University of Washington revealed that only 37% of survivors, 2 years out from their injury, had gone back to the same job, and to the same employer without accommodation. Almost 50% had received disability, not gone back to work, or had some degree of employment interruption (Brych et al., 2001).
Those individuals who have been deemed permanently impaired will benefit from the assistance of a knowledgeable rehabilitation counselor (a board-certified rehabilitation counselor/CRC is preferred) who has the necessary background to conduct an assessment of the person’s physical, cognitive, and emotional functioning levels. A vocational evaluation by a certified vocational evaluator may be justified. A psychological assessment and functional capacity evaluation should also be considered.
A burn patient’s ability to return to work is highly individualized. The infirmity can range from no loss of function to living with an amputation and the need to adjust to a prosthesis. Life care planners are often confronted with electrical burns, which may have resulted in amputation,
cognitive and emotional impairment, and vision problems. One study, which involved patients who had endured amputation from electrical burns and had been cared for at a burn center of excellence, reported a superior return-to-work rate than people with disabilities in general (Weed
& Atkins, 2004). Productivity is a highly valued personal characteristic; therefore, helping clients with their return to work or assisting them in finding a new vocation or different form of recreation is a vitally important outcome.
Complications after burn injury can be extensive and wide-reaching. They may affect any or many body systems (Warden & Warner, 2007). It is important to ask the treating physician what the potential complications are for a particular patient. The following chart includes common complications associated with burn injury. They have been divided by body systems with recommendations for intervention, and the likely frequency and duration of treatment, and surgical options. The list includes the most significant and usual burn-injury-related complications. The most common treatment options are also included.
Serious burn injuries are considered catastrophic injuries. There is usually significant cost associated with the recovery and rehabilitation of the burn patient, which can necessitate lifelong care. Pediatric burn patients often require extensive reconstruction and rehabilitation, especially during but not limited to their growth and developmental years. A burn injury impacts the entire family system, so it is important to consider the family’s needs as well.
Patients may need a variety of physicians to care for them including but not limited to plastic reconstructive surgeons, physiatrists, orthopedic surgeons, pediatric intensivists, cardiologists, internists, pulmonologists, and psychiatrists for lifelong care.
Allied health care, including psychological, physical, occupational, and vocational therapies, as well as the need for case management are important items to consider. In-home assistance, respite care, home maintenance and cleaning services, and assisted living in advanced years are also often a necessity.
Patients often have an ongoing need for pain medications, moisturizers, pressure garments, prosthetics and orthotics, splints, special makeup, and other supplies. Transportation and mobility assistance as well as exercise for optimum function should also be considered.
Can occur anywhere on burned, grafted, or donor site skin. Most often is poorly vascularized areas, areas under tension, or areas of contact or friction.Open, painful, wounds, often with bleeding or exudateDebridement of devitalized tissue and local wound care with a plethora of wound care products; improved nutrition; treatment of infections (which may not be clinically obvious); hyperbaric oxygen therapy (unproven)Primarywound
closure; partial thickness skin grafting; full thickness skin grafting; soft tissue rotation or flaps
Wound care is an art, not a science: what works for one patient may not work for another. A key element is patience. Assume wound closure of about 1 cm per month of therapy.As previous entry; often associated with infections such as MRSA or vascular insufficiency.As in previous entry; nonhealing or lack of progression over weeks or months; breakdown of a previously healed woundClinical exam; wound culture; non invasive vascular studiesAs in previous entry; antibiotics; good nutrition is keyMay occur anywhere; most often seen in freshly healed wound or donor sites.Superficial, pink, moist painful open wounds on a site that had been previously healedPatient history; clinical examLocal wound care with a variety of wound care productsRarely requires split-thickness skin graftingUsually heals with conservativecare
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