BURN management, Rehabilitation, Splinting, physiotherapy, nutrition, and prevention

presented By- Gaurav Karanjekar

1. BURN REHABILITATION, PHYSIOTHERAPY, NUTRITIONAL MANAGEMENT, NURSING MANAGEMENT AND PREVENTION Presented By, Gaurav Karanjekar

2. Aim :- At the end of seminar students will able to know about management of burn.

3. REHABILITATION, PHYSIOTHERAPY, NUTRITIONAL MANAGEMENT NURSING MANAGEMENT PREVENTION OF BURN

4. Goals of rehabilitation Short term goal: To preserve the patient’s range of motion and functional ability. Long term goal: To return patient to independent living To train patients on compensating functional loss.   REHABILITATION PHASES OF REHABILITATION Acute phase Intermediate phase Chronic phase

5. ACUTE PHASE

6. ACUTE PHASE OF REHABILITATION This phase typically lasts from the time of injury up to several weeks afterward, depending on the severity of the burn. Aim :- To prevent deformity and contractures: Performing passive ROM. Splinting and antideformity positioning Reduce edema . Establishing a long – term relationship with the patient and family members.

7. CHEST PHYSIOTHERAPY AIMS: Prevent airway obstruction & accumulation of secretions Improve airway clearance, cough effectiveness Promote alveolar expansion and ventilation. Increase gas exchange. Maintain or improve chest mobility. Improve endurance, general exercise tolerance, and overall well-being

8. CHEST PHYSIOTHERAPY Nebulisation Breathing exercises Chest percussion/ vibration Suctioning Incentive spirometry Positioning

9. NEBULISER Nebulized medications such as bronchodilators or mucolytics may be administered to help dilate the airways, reduce bronchospasm, and loosen secretions for easier clearance.

10. BREAT H ING EXERCISE

11. CHEST PERCUSSION / VIBRATION

12. May be used to assist with airway clearance and mobilization of secretions in patients with impaired cough reflex or difficulty clearing mucus. SUCTIONING

13. SPIROMETRY Incentive spirometry is a device used to encourage deep breathing and improve lung function.

14. Anti – contracture positioning can be achieved through : Splinting Mechanical traction Cut out foam troughs and mattresses Pillow Strapping ANTI – CONTRACTURES POSITIONING

15. If a patient is unable to maintain proper position, and start losing ROM, splinting should be initiated. Positioning and splinting is an essential part of acute burn treatment regime and used for : protecting joints at risk of developing contracture or deformity. Preserving function. SPLINTING

16. Prevention or correction of deformity Positioning. Protection of exposed tendons and joints. Aiding in controlling edema , inflammation, or infection Indications for Splinting WARNING SIGNALS OF BAD SPLINTING Pain Sensory impairment Wound maceration

17. Proper fit and secure application Must be secured with straps or bandage Too loose and without adequate contour will not maintain proper position. A splint too tight causes pressure necrosis or nerve compression. Avoidance of pressure over a bony prominence. Daily checking and re – evaluation. Cleansing with each re – application . Requirements for all Splints

18. HEAD Elevate the head of the bed at 30 to 40 degree if the when hips not involved. Internal ear canal splints ear, Use ear cups for protection and preventing ear rim to contract toward the head. MOUTH Mouth splints are utilized to prevent oral microstomia. Mouth split could be: Horizontal vertical

19. NECK Burns to the anterior surface: The neck is positioned in neutral or in slight extension of approximate 15 degree In midline no rotation No pillows behind the neck Extension by using small towel roll behind the shoulder Custom thermoplastic collar AXILLA Maintained at 90 degree abduction as a minimum or 110 degree if possible Ensuring no pressure points: Produce brachial plexus compression 10 degree of shoulder flexion to prevent brachial plexus injury

20. SHOULDER ABDUCTION WITH WRIST HANGED IN SLING AEROPLANE SPLINT ELBOW

21. HANDS Palmer burns : Should be elevated on pillows to help reduce oedema. The wrist at 30 degree extended and the fingers supported in extension HIPS AND KNEES Hips: Should be positioned in neutral and in 20 degree abduction. This can be done with pillows/towels/sandbags. For infant : full extension, 0 degree rotation and symmetric of 15 to 20 degree.

22. KNEE Should be positioned in extension No pillow underneath the knee joint Posterior knee slap splint can be used ANKLES/FEET Place in neutral position This is usually achieved by a pillow at the base of the foot holding the position or splints.

23. INTERMEDIATE PHASE

24. STRETCHING Connective tissue deformation occurs to different degrees at different intensities of force. GOAL: To break the collagen bonds to increase flexibility . Joints affected by burns should be moved and stretched several times a day. Therapists use clinical judgment based on the appearance of the tissue as to whether passive ROM or active ROM is performed.

25. HAND MOBALIZATION

26. Complete an assessment of the patient’s functional activities of daily living such as dressing, feeding and hygiene. Relearn/ adapt skills and/ or educate new strategies Prepare and coordinate the return to work, school. Assess and provide patient’s need of specialized equipment e.g. supported seating, adapted cutlery Activities of Daily Living[ADL]

27. Scar management will be considered using: Pressure garments, and silicon massage therapy Tubigrip may be applied as a temporary measure if till the custom garment being ready. Patient and family education. Use moisturizer prior massage. Scar Management

28. LIMB PHYSIOTHERAPY AIMS To reduce edema To improve and maintain full ROM of joints and muscle power. Prevention of DVT and contracture

29. EARLY MOBILISATION AIMS Prevent respiratory complications Prevent DVT Control/reduce edema Prevent deformities Maintain joint ROM Protect/promote healing Maintain strength

30. TREATMENT Bed side sitting Bed side standing Spot marching Ambulation Chair sitting

31. ACTIVE EXERCISE PASSIVE EXCERCISE

32. CHRONIC PHASE

33. Beyond the acute stage of immobilisation, inpatient and outpatient rehabilitation typically consists of a variety of interventions including: Pressure garment therapy, Silicone therapy, Scar massage, Range of motion exercises Mobilisation techniques, Strengthening, Functional and gait retraining, and Balance and fine motor retraining CHRONIC PHASE

34. PARALLEL BAR WALKING CYCLING

35. NUTRITIONAL MANAGEMENT

36. Optimal wound healing and rapid recovery from burn injuries Minimize complications including infection To attain and maintain normal nutritional status To minimize the metabolic disturbances during the treatment process Goals of Nutritional Management Early enteral feeding i.e. - 6- 24 hours post injury Maintain pre injury loss with difference in 5-10% Prevent malnourishment Objectives of Nutritional Management

37. High Carbohydrate, High protein with low fat diet Carbohydrates - 60-65% Proteins - 20-25% Fats -10-15% Requirements

38. Dietary and fluid intake- History and present condition Clinical assessment- micronutrient deficiencies and malnutrition Anthropometry- weight/ height Pediatric- growth and development Assessment tools- SGA , MUST Nutritional Assessment

39. Curreri’s formula for Energy Estimation Age Formula 0-1 Year 1240 (RDA)+ 15 X % burn 1 - 3 Years 1060 (RDA)+ 25 X % burn For E.g.: 2y.2 m baby girl, wt.- 14 kgs with 10% scald burn =1060+25 X 10 Ans: kcals- 1310 4 – 15 years 1350 (RDA)+ 40 X % burn 16 – 59 Years 25 X BW + 40 X % burn For E.g.: 28y / male wt - 54kgs with 39% electrical burns =25 X 54 + 40 X 39 Ans: kcals- 2910 Above 60 Years 20 X BW + 65 X % burn

40. Early enteral feed is preferred in burns starting as early as 6 hours if bowel sounds are normal It is preferred over parenteral feeds as its an safe procedure and cost effective. Nasogastric tube of size 10-12 French is preferred Enteral Feeding

41. Nasogastric Tube Insertion Protocol Nasogastric tube is inserted to patient with burns above 20% TBSA. Paediatric and geriatric patients, nasogastric tube is inserted above 10% TBSA burned. Patients with inhalation injury with 5% TBSA burn nasogastric tube is inserted.

42. Composition Amount Curd 1 Litre Eggs 4 Bananas 400grams Sugar 100grams Supplementing with protein and micronutrients is essential as the trauma affects the immune system causing oxidative stress which further releases free radicals. BUTTERMILK DIET

43. As high as 4000 mg is given. Antioxidant Wound healing Immune enhancer Vitamin C Omega 3 Natural sources of omega 3 which could be advised for the patients are chai seeds, walnuts , flaxseeds, salmon,  cod liver Glutamine Around 30gm of glutamine along with zinc is given to patients daily enteral

44. Parenteral Nutrition/TPN Parenteral nutrition is only used with severe inhalation injury where the oral route is compromised Prolong ventilatory support TPN can be used to meet excessive caloric requirements if not meet orally.

45. CHILD BURN PREVENTION Keep Hot Items Out of Reach Create a Child-Free Zone in the Kitchen   Use Microwave Safely   Monitor Bath Time Cover Electrical Outlets   Childproof Appliances Keep Matches and Lighters Out of Reach   Secure Cords and Cables Supervise Outdoor Play Teach Fire Safety

46. SINIOR CITIZEN BURN PREVENTION Home Safety Assessment   Kitchen Safety     3. Appliance Safety   4. Scald Prevention     5. Smoking Safety   6. Fire Safety   7. Clothing Safety   8. Home Care Assistance   9. Regular Health Checkups

47.   WORKPLACE FIRE SAFETY Fire Prevention Training   Emergency Response Plan     Fire Detection Systems   Fire Extinguishers   Electrical Safety   Proper Storage of Flammable Materials   Smoking Policies Maintenance of Fire Safety Equipment   Employee Awareness and Reporting   Emergency Communication Systems   Training for Fire Wardens

48. NURSING MANAGEMENT

49. NURSING ASSESSMENT History Taking Physical examination Vital signs Level of pain Site of burn Total body surface area % of burn Condition of wound Degree of burn Signs of infection Fluid and electrolyte balance: urine out, hypovolemia Temperature

50. • Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation • Ineffective airways clearance related to edema • Pain related to tissue and nerve injury and emotional impact of injury • Fluid volume deficit related to increased capillary permeability and evaporative losses from the burn wound  • Hypothermia related to loss of skin microcirculation and open wound • Risk for infection related to breakdown of skin integrity • Risk for inadequate tissue perfusion related to immobility. • Anxiety related to fear and emotional impact of burn.  NURSIN G DIAGNOSIS

51. Airway management   Assess breath sounds, and respiratory rate, rhythm, depth, and symmetry. Monitor patient for signs of hypoxia. Monitor ABG values, pulse oximetry readings, Maintain patent airway through proper patient positioning, removal of secretions, Provide humidified oxygen. Encourage patient to turn, cough, and deep breathe. Encourage patient to use incentive spirometry. Suction as needed.

52. Maintaining Adequate Tidal Volume and Unrestricted Chest Movement Observe rate and quality of breathing ; report if progressively more rapid and shallow. Assess tidal volume; report decreasing volume to health care provider. Encourage deep breathing and incentive spirometry. Place patient in semi-Fowler's position to permit maximal chest excursions if there are no contraindications, such as hypotension or trauma. Make sure that chest dressings are not constricting. Prepare the patient for escharotomy and assist, as indicated.

53. Supporting cardiac output Position the patient to increase venous return. Give fluids, as prescribed. Monitor vital signs, including apical pulse, respirations, and urine output at least hourly. Monitor sensorium. Document all observations and particularly note trends in vital sign changes.

54. Promoting Physical Mobility and Strengthening Ability • Encourage for deep breathing, and proper positioning • Maximize function • Splinting: to maintain proper joint position and to prevent or correct contractures. • • Passive and active range of motion exercise • Ambulation ( With Correct posture) • Performance of ADL  • Prevention of contracture.

55. Pain management • Includes the use of opioids, non steroidal anti- inflammatory drugs (NASIDs), anxiolytics, and anesthetic agents. • Administer analgesics before dressing. •Administer intravenous opioid analgesics as prescribed.  • Assess response to analgesic. • Provide emotional support and reassurance. • Relaxation techniques, distraction, hypnosis, therapeutic touch, humor, music therapy