The Whole Puzzle - aer a Burn Trauma -...
Transcript of The Whole Puzzle - aer a Burn Trauma -...
TheWholePuzzle-a-eraBurnTraumaGre$aWilkinson,RNandMandyYelvington,MS,OTR/LArkansasChildren’sHospitalBurnCenter
ACHBurnCenter
• OnlyBurnCenterinArkansas• 10bedcriIcalcareandstep-downunit• TreatspediatricandADULTpaIents
Suppor8ngBurnSurvivorsInpaIent
MajorBurnTrauma/InhalaIoninjury/ICU/SedaIon/Assessment/Pain/Treatment/WoundCare
Circumstancesoftheevent/Loss
RehabilitaIon/LTAC/HomeHealth/ClinicAppointments/Pressuregarments/Therapy/Dressingchanges/Pain/ChronicPuriIs
Admission
Debridement/Allo-graSing/Auto-graSing/Donorsites/AmputaIons/Tracheostomy
Event
Surgeries
Discharge
nn
Inhala8oninjury
Intubatedformanyweeks,mulIpleBronchoscopies
Severelyburnedairway
Inseveralhoursforseveralweeks!!
Suppor8ngBurnSurvivorsFamily
TotaldisrupIonoflife/Work/Childcare/School/
Decisionsofcare/Surgeryconsents/Physicianupdates/
Learnwoundcare/Adaptthehome/ManagemedicaIons/Clinicappointments/Work/Children
DisrupIon
Managehomelife/Paybills/Needingtowork/Commute/Stayatthehospital/Selfcare/
Decisions
Management
Discharge
PhysicalRecoverya-eraBurnInjuryTheRehabilitaIonPhase
BurnInjuryComplexity• Long(1840)“Notasimpleinjurybutaverycomplicateddisease”• Burnsdirectlyaffectthelargestorganinthebody(integumentary)• ButcanhavedevastaIngeffectsonALLothersystems.
SystemicChanges• AllbodysystemscanbepotenIallyimpactedbyalargeburninjuryandshouldbeconsideredwhenformulaIngarehabilitaIonplan.• Respiratory• Renal
MusculoskeletalChanges• Osteoporosis• PeriostealnewboneformaIon• IrregularossificaIon• HeterotopicossificaIon• TendondesiccaIon• Muscleandjointcontractures• Nerveinjury
RehabFollowingaBurn
• ImmediatepriorityisLIFEpreservaIonandwoundcoverage• Doesnotprecludeaggressiverehab
• UrgentneedforimmediateandaggressivepaIentspecificrehab
• AtrophyofskeletalmuscleaspartofthecatabolicstateoftheburnpaIent• CatabolismdecreasesleanbodymassandmusclestrengthwhichareessenIalforADLs
• ShortTermGoal• PreserveROMandfuncIonalabiliIes
• LongTermGoal• ReturntoindependentlivingandtrainforcompensaIonsoffuncIonallosses
PainManagementinRehab
Becomfortablewithaprocessthatneverends,butwhichcanbringmanymomentsofreliefforthepaIentandsaIsfacIonforthecaregiver.
PainManagementAnxietyandPsychiatricIllnessesItching
80to100%ofpaIentsChronicissueMedicaIons
Non-pharmacologicalLasertherapyMassagetherapyCompressiongarments
“PosiIonofComfortIsthePosiIonOfContracture”
BurnScarContracture1-4daysTendonsandTendonSheaths5-21daysAdapIveMuscleShortening2-3weeksLigamentandJointCapsule1-3months
ReprintedwithpermissionfromBurnCareandRehabilitaIonTodayRegRichard,PTandMarlysStaley,PT
BurnRehabGoals• IncreasefuncIonalindependenceandrangeof
moIon• Minimizepain• ProvideconInuityofcareandconsultaIon• Limitcontracturedevelopment• Facilitatereturntoindependentlivingandhelpthe
paIentcompensateforanyfuncIonallosses.• TherapyshouldbepaIentspecificandstartas
soonaspossibleaSeradmission.
Therapeu8cPlan
AcuteStage:• PosiIoning–withorwithoutsplints
• RangeofMoIon• ReduceeffectsofedemaandimmobilizaIon
• MaintainfuncIonaljointmoIonandmusclestrength
Sub-AcuteStage:• RangeofMoIon• FuncIonalacIviIes(mobility,
ADLs,strength/enduranceacIviIes)
• HomeprogrameducaIon• SplinIng(PRN)• AdapIveequipment(PRN)• Facilitatecommunity
reintegraIon
“It’sComplicated”
• EvenwhenburnpaIentshaveassociatedtraumaorgraSs–itisimportanttodoasmuchtherapyasallowed.
• MayrangejointsnotcrossedbynewgraSs,rangewithinallowedlimitaIons,etc…–Alwaysdothemostthatyouareallowed!
Therapeu8cExercise
• ReducetheeffectsofedemaandimmobilizaIon• MaintainfuncIonaljointmoIonandmusclestrength• StretchthescarIssue• ReturnthepaIenttotheopImalleveloffuncIon
StrengthandEndurance
Severely burned patients frequently spend hours daily on their rehabilitation, including stretching, strengthening, ambulation, activities of daily living, and pre-work skills.
Ac8vi8esofDailyLiving
• DirectlyrelatedtotheirwoundhealingandresultanthypertrophicscarcontractureformaIon.• Parry(2010)reportedthat“scarcontracturecancausesignificantimpairmentandfuncIonaldeficits”.• ScarcontracturesaredirectlylinkedtodecreasedphysicalfuncIon,occupaIonalrolelimitaIon,painanddecreasedqualityoflifefortheburnsurvivor.
TherapyTechniques
ROM–HelpfulHints
• With upper extremity range of motion, stretching should be done distal to proximal.
• UE Extensor tightness leads to difficulty making a fist. May need muscle relaxation techniques combined with stretching to obtain full ROM.
• Keep elbow straight with shoulder ROM• Don't forget about pronation and supination.• Take away pillows – for patient's with anterior neck burns• Passive and active facial exercises to achieve function ROM• For full lower extremity range - you must range the ankle with the hip at neutral and the knee in FULL extension.
• Patients should be discouraged from sleeping with knees flexed or with a pillow under their knees.
SustainedStretching• Gentle,sustainedstretchismoreeffecIvethanmulIplerepeIIvemovementstogainlengthinburnedIssue• EffecIvestretchingcausesblanching• IfmulIplejointsareinvolved–stretcheachseparatelythenstretchtheskinasawholeunit• PassiverangeistheprimaryfocusunIlfullROMachieved
Resis8veROM• Manualormechanicalresistanceisappliedtoamovement• TradiIonalweights,theraband• Manualresistanceprovidedbythetherapist• Hold,release,stretch
MassageandMyofascialTechniques• Performovernon-burnedareasofmuscleinserIonororigin• WorktowardIghtorscarredarea• Increasemobilityofskin,muscle,andunderlyingIssues• IncreasesROMbyelongaIngmuscleandskin
Inpa8entRehaborCommunityBasedTherapy
• LimitedamountsofaROM–thepaIentcandoaROMWITHOUTyourhelp.TherapyImeshouldbedevotedtothethingstheycannotdoalone.• Passivestretch• ResisIveROM• Myofascialtherapy• SplinIng• PaIent/caregivereducaIon
• BurnSurvivorswillonlyachievemaximalrecoveryifthepaIentisconsistentwiththerapyANDwithhomeprogramexercises.
BurnWoundHealing• WoundshealbyscarformaIontoreplacedestroyedIssue• DeeperburnsandwoundsthattakelongertohealareatgreatestriskofscarformaIon
HypertrophicScars• Definedasearlyas1790• Raised,erythematous,pruriIcandinelasIcmassofIssue• IfleSuntreated,canleadtocontractures,funcIonalimpairment,discomfort,cosmeIcproblems
Microscopicviewofnormalcollagen
versusHTS
ScarManagement
ScarMassageGoal:SoSeningorremodelingbyfreeingadheringfibrousbandsIncreaseselasIcityofscarsIncreasesjointmobilityAlleviatesitchingDesensiIzaIonIncreasesscarpliability
CompressionGarments
• Customgarmentsaremeasuredwhenwoundclosureisachieved(ifwoundclosurewas>21days)• Usuallyfirstpost-dischargevisit• Manufacturedin~2weeksandfitduringaclinicvisit• Mustwear23hours/day(2sets)• Re-measureevery~3months• Wear1-2years(unIlscarsaremature)
AcIveScar Compression
BlanchingDecreasedBloodFlow
DecreasedO2inTissue
DecreasedCollagenProducIon
RightShoulder4/23/09
RightShoulder5/18/09
Reconstruc8on• ASertherapyandcompressionhavebeenuIlized• ShouldbedelayedunIlrecoveryfrominiIalphaseofinjury• RestoraIonofdeformiIesthatimposefuncIonallimitaIonsshouldbeaddressedbeforecosmeIcs
DisabilityEvalua8on
• Respiratory• Musculoskeletal• Skin• DecreasedcoordinaIon,strength• Contractures• Garments(maylimitworkability)• Anxiety
• Heat/ColdIntolerance• SunlightSensiIvity• PAIN• NeuropathicPain• Itching• ChemicalsensiIvity• ChangesinsweaIngpa$ern• PTSD
PsychologicalRecoverya-eraBurnInjury
Suppor8ngBurnSurvivorsOutpaIent
Physical/Work/School/Society/RelaIonshipsEmoIonal/PTSD/Anxiety/FlashbacksVisiblescars/Hiddenscars/Hypertrophicscars/Contractures
Loss/Grief/Depression/Anger/Loneliness/Poorself-esteem/
Challenges
AmputaIons/ProstheIcs/Contractures/
Appearance
DisabiliIes
EmoIons
Suppor8ngBurnSurvivorsConInualAdjustment
Dry/SensiIve/Painful/Ta$ooofTrauma/Revisions
Stares/Awareness/Namecalling/Bullying/IsolaIon/LossofIdenIty
Scars
Stayhidden/Denial/Lifestylechanges/IsolaIon
Visual
Hidden
Suppor8ngBurnSurvivors[SUR·VI·VOR]Defini8on:
Someonewhoperseveres,someonewithgreatcourageandstrength,atrueinspira8ontoothers
CampSunshineAges:4-16(Campers)Youngerthan4:• ParentsreceivesupportfromSOARvolunteers
• EarlyinformaIononCampSunshinebeforedischarge
YoungAdultEventsAges:16-23• Y.A.RatCampSunshine• JuniorStaff/CIT/VITrolesatCampSunshine
• Y.A.Conference(Tulsa)
AdultSurvivorGroupAges:23+• YearlyFallRetreat• MonthlyDinners• CampCounselor• BuildingaSupportGrouponFacebook
• SOARSupporterTraining• WBC
TheThreePiecePuzzle ProvidingalifeImeofsupport
Suppor8ngBurnSurvivorsCAMPSUNSHINE
Age4to16/10%fullthicknessinjury/scarring/disability/HandsandfaceOpportunitytobewithothersurvivors/counselingwithanacIvity/achievesocialacceptance/camper–counselorpairing
IAFFCampinDC/PhoenixSocietyPEGgrant/AngelFacesRetreat/YoungAdultConferenceWiseFoundaIonChangeChallenge
Criteria
APFF–payrolldeducIonandfundraisers/totallyfree/volunteers
Goals
Funding
OpportuniIes
24th Camp Sunshine August 2015 August 1991 with 6 campers!
IAFFCampinWashingtonD.C.
Angel Faces A Soft Place to Fall, a solid Foundation for Growth
Howhascamphelpedyoucopewithyour
burnexperience?“I’vebeena
bletomeet
peoplejustlikemeandcampgivesme
courageandstrengthtotake
onanother
year.”
Howdoyoufeelaboutyourscarsnow?“Is8llstruggleeverydayaboutmyscarsbutthemorecampIreceivethebe^erIfeelanddealwithmyselfesteem.”
JuniorStaff17-18YearsofAgeCounselorinTraining18-23YearsofAgeVolunteerinTraining18-23YearsofAgeFullCounselororVolunteer23yearsofageandabove
“Seeingthestrengthofthese
childrenand
knowingthatIhaveplayeda
partintheirlives
isimmeasurable”
“IhopeImakeadifferenc
ein
theirlivesliketheydo
mine!”
“ItposiIvelyimpactsallthecampersandbooststheirself-confidenceandhelpsthemrealizetheyaren’tlimitedtowhattheirskinandscarsshow”
Suppor8ngBurnSurvivorsYoungAdultRetreat
Age16to23years/Campa$endanceorgreaterthan20%fullthicknessinjuryAvoidsagingout/YoungAdultConference/WiseFoundaIonscholarship/PhoenixPEGscholarship/
Selfimage/RelaIonships/MoneyManagement/SocialMedia/ApplicaIon-Interviewskills/Goalsetng
Criteria
ConInuewithCampa$endanceprograms/Meetbehavioralrequirements/Actasrolemodels/TransiIontoCounselor
OpportuniIes
ExpectaIons
Development
First Camp Sunshine Young Adult Event August 2013 August 2015 with 12 Young Adults!
PhoenixEducaIonGrantP.E.G.
YoungAdultConference
Suppor8ngBurnSurvivorsSOAR–SurvivorsOfferingAssistanceinRecovery
BurnSurvivor/Mature/Stable/Acceptance/Compassionate/ReadyApplicaIon/Profile/Interview/Fulldaytraining
PhoenixSocietyPrograms/WorldBurnCongress/PEG/Survivor–FamilyDinners/Camp/Retreat
Criteria
Consents/Match/Arrangement/Followup/EvaluaIon
Training
Visits
OpportuniIes
First SOAR Training October 2011 Repeated in 2012 and 2014!
Suppor8ngBurnSurvivorsAdultRetreat
Age23andabove/Greater20%FT–Hands–Face/WoundshealedIndependent/MedicalHistoryCommunicaIon/Acceptance/Support/TransiIon/
PhoenixPrograms/FamilyFacebookGroup/Discussions/MoIvaIonalSpeaker
Criteria
Grants/Fundraisers/DonaIons
Goals
Funding
OpportuniIes
First Adult Retreat March 2012 November 2015 with 30 Survivors!
2013
“This was one of the best experiences of my life because you share your experience with others
who can truly grasp and understand” “We were on automatic pilot – one
day at a time. Once you come to the Retreat, you find out that the folks
here have been through what you’re going through – it gives you
a sense of relief…”
“You have support and encouragement to find your dream”
Burninjuriesarelifechanging.Burnscarswillneverfullygoaway.Butthroughconsistenttherapy,scarmanagementandmedicalcare,burninjuriesdonothavetobedebilitaIng.ItisourjobtohelptheburnvicImbecomea
burnsurvivor!