the whole puzzle - aer a burn trauma -...
TRANSCRIPT
![Page 1: The Whole Puzzle - aer a Burn Trauma - Arkansasstatic.ark.org/.../ATRC2016_Burns_Wilkinson-Yelvington.pdf · 2016-05-18 · Grea Wilkinson, RN and Mandy Yelvington, MS, OTR/L Arkansas](https://reader034.vdocument.in/reader034/viewer/2022050406/5f83823f6da6843acb57a498/html5/thumbnails/1.jpg)
TheWholePuzzle-a-eraBurnTraumaGre$aWilkinson,RNandMandyYelvington,MS,OTR/LArkansasChildren’sHospitalBurnCenter
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ACHBurnCenter
• OnlyBurnCenterinArkansas• 10bedcriIcalcareandstep-downunit• TreatspediatricandADULTpaIents
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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
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nn
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Inhala8oninjury
Intubatedformanyweeks,mulIpleBronchoscopies
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Severelyburnedairway
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Inseveralhoursforseveralweeks!!
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Suppor8ngBurnSurvivorsFamily
TotaldisrupIonoflife/Work/Childcare/School/
Decisionsofcare/Surgeryconsents/Physicianupdates/
Learnwoundcare/Adaptthehome/ManagemedicaIons/Clinicappointments/Work/Children
DisrupIon
Managehomelife/Paybills/Needingtowork/Commute/Stayatthehospital/Selfcare/
Decisions
Management
Discharge
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PhysicalRecoverya-eraBurnInjuryTheRehabilitaIonPhase
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BurnInjuryComplexity• Long(1840)“Notasimpleinjurybutaverycomplicateddisease”• Burnsdirectlyaffectthelargestorganinthebody(integumentary)• ButcanhavedevastaIngeffectsonALLothersystems.
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SystemicChanges• AllbodysystemscanbepotenIallyimpactedbyalargeburninjuryandshouldbeconsideredwhenformulaIngarehabilitaIonplan.• Respiratory• Renal
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MusculoskeletalChanges• Osteoporosis• PeriostealnewboneformaIon• IrregularossificaIon• HeterotopicossificaIon• TendondesiccaIon• Muscleandjointcontractures• Nerveinjury
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RehabFollowingaBurn
• ImmediatepriorityisLIFEpreservaIonandwoundcoverage• Doesnotprecludeaggressiverehab
• UrgentneedforimmediateandaggressivepaIentspecificrehab
• AtrophyofskeletalmuscleaspartofthecatabolicstateoftheburnpaIent• CatabolismdecreasesleanbodymassandmusclestrengthwhichareessenIalforADLs
• ShortTermGoal• PreserveROMandfuncIonalabiliIes
• LongTermGoal• ReturntoindependentlivingandtrainforcompensaIonsoffuncIonallosses
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PainManagementinRehab
Becomfortablewithaprocessthatneverends,butwhichcanbringmanymomentsofreliefforthepaIentandsaIsfacIonforthecaregiver.
PainManagementAnxietyandPsychiatricIllnessesItching
80to100%ofpaIentsChronicissueMedicaIons
Non-pharmacologicalLasertherapyMassagetherapyCompressiongarments
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“PosiIonofComfortIsthePosiIonOfContracture”
BurnScarContracture1-4daysTendonsandTendonSheaths5-21daysAdapIveMuscleShortening2-3weeksLigamentandJointCapsule1-3months
ReprintedwithpermissionfromBurnCareandRehabilitaIonTodayRegRichard,PTandMarlysStaley,PT
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BurnRehabGoals• IncreasefuncIonalindependenceandrangeof
moIon• Minimizepain• ProvideconInuityofcareandconsultaIon• Limitcontracturedevelopment• Facilitatereturntoindependentlivingandhelpthe
paIentcompensateforanyfuncIonallosses.• TherapyshouldbepaIentspecificandstartas
soonaspossibleaSeradmission.
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Therapeu8cPlan
AcuteStage:• PosiIoning–withorwithoutsplints
• RangeofMoIon• ReduceeffectsofedemaandimmobilizaIon
• MaintainfuncIonaljointmoIonandmusclestrength
Sub-AcuteStage:• RangeofMoIon• FuncIonalacIviIes(mobility,
ADLs,strength/enduranceacIviIes)
• HomeprogrameducaIon• SplinIng(PRN)• AdapIveequipment(PRN)• Facilitatecommunity
reintegraIon
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“It’sComplicated”
• EvenwhenburnpaIentshaveassociatedtraumaorgraSs–itisimportanttodoasmuchtherapyasallowed.
• MayrangejointsnotcrossedbynewgraSs,rangewithinallowedlimitaIons,etc…–Alwaysdothemostthatyouareallowed!
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Therapeu8cExercise
• ReducetheeffectsofedemaandimmobilizaIon• MaintainfuncIonaljointmoIonandmusclestrength• StretchthescarIssue• ReturnthepaIenttotheopImalleveloffuncIon
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StrengthandEndurance
Severely burned patients frequently spend hours daily on their rehabilitation, including stretching, strengthening, ambulation, activities of daily living, and pre-work skills.
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Ac8vi8esofDailyLiving
• DirectlyrelatedtotheirwoundhealingandresultanthypertrophicscarcontractureformaIon.• Parry(2010)reportedthat“scarcontracturecancausesignificantimpairmentandfuncIonaldeficits”.• ScarcontracturesaredirectlylinkedtodecreasedphysicalfuncIon,occupaIonalrolelimitaIon,painanddecreasedqualityoflifefortheburnsurvivor.
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TherapyTechniques
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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.
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SustainedStretching• Gentle,sustainedstretchismoreeffecIvethanmulIplerepeIIvemovementstogainlengthinburnedIssue• EffecIvestretchingcausesblanching• IfmulIplejointsareinvolved–stretcheachseparatelythenstretchtheskinasawholeunit• PassiverangeistheprimaryfocusunIlfullROMachieved
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Resis8veROM• Manualormechanicalresistanceisappliedtoamovement• TradiIonalweights,theraband• Manualresistanceprovidedbythetherapist• Hold,release,stretch
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MassageandMyofascialTechniques• Performovernon-burnedareasofmuscleinserIonororigin• WorktowardIghtorscarredarea• Increasemobilityofskin,muscle,andunderlyingIssues• IncreasesROMbyelongaIngmuscleandskin
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Inpa8entRehaborCommunityBasedTherapy
• LimitedamountsofaROM–thepaIentcandoaROMWITHOUTyourhelp.TherapyImeshouldbedevotedtothethingstheycannotdoalone.• Passivestretch• ResisIveROM• Myofascialtherapy• SplinIng• PaIent/caregivereducaIon
• BurnSurvivorswillonlyachievemaximalrecoveryifthepaIentisconsistentwiththerapyANDwithhomeprogramexercises.
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BurnWoundHealing• WoundshealbyscarformaIontoreplacedestroyedIssue• DeeperburnsandwoundsthattakelongertohealareatgreatestriskofscarformaIon
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HypertrophicScars• Definedasearlyas1790• Raised,erythematous,pruriIcandinelasIcmassofIssue• IfleSuntreated,canleadtocontractures,funcIonalimpairment,discomfort,cosmeIcproblems
Microscopicviewofnormalcollagen
versusHTS
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ScarManagement
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ScarMassageGoal:SoSeningorremodelingbyfreeingadheringfibrousbandsIncreaseselasIcityofscarsIncreasesjointmobilityAlleviatesitchingDesensiIzaIonIncreasesscarpliability
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CompressionGarments
• Customgarmentsaremeasuredwhenwoundclosureisachieved(ifwoundclosurewas>21days)• Usuallyfirstpost-dischargevisit• Manufacturedin~2weeksandfitduringaclinicvisit• Mustwear23hours/day(2sets)• Re-measureevery~3months• Wear1-2years(unIlscarsaremature)
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AcIveScar Compression
BlanchingDecreasedBloodFlow
DecreasedO2inTissue
DecreasedCollagenProducIon
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RightShoulder4/23/09
RightShoulder5/18/09
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Reconstruc8on• ASertherapyandcompressionhavebeenuIlized• ShouldbedelayedunIlrecoveryfrominiIalphaseofinjury• RestoraIonofdeformiIesthatimposefuncIonallimitaIonsshouldbeaddressedbeforecosmeIcs
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DisabilityEvalua8on
• Respiratory• Musculoskeletal• Skin• DecreasedcoordinaIon,strength• Contractures• Garments(maylimitworkability)• Anxiety
• Heat/ColdIntolerance• SunlightSensiIvity• PAIN• NeuropathicPain• Itching• ChemicalsensiIvity• ChangesinsweaIngpa$ern• PTSD
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PsychologicalRecoverya-eraBurnInjury
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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
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Suppor8ngBurnSurvivorsConInualAdjustment
Dry/SensiIve/Painful/Ta$ooofTrauma/Revisions
Stares/Awareness/Namecalling/Bullying/IsolaIon/LossofIdenIty
Scars
Stayhidden/Denial/Lifestylechanges/IsolaIon
Visual
Hidden
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Suppor8ngBurnSurvivors[SUR·VI·VOR]Defini8on:
Someonewhoperseveres,someonewithgreatcourageandstrength,atrueinspira8ontoothers
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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
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Suppor8ngBurnSurvivorsCAMPSUNSHINE
Age4to16/10%fullthicknessinjury/scarring/disability/HandsandfaceOpportunitytobewithothersurvivors/counselingwithanacIvity/achievesocialacceptance/camper–counselorpairing
IAFFCampinDC/PhoenixSocietyPEGgrant/AngelFacesRetreat/YoungAdultConferenceWiseFoundaIonChangeChallenge
Criteria
APFF–payrolldeducIonandfundraisers/totallyfree/volunteers
Goals
Funding
OpportuniIes
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24th Camp Sunshine August 2015 August 1991 with 6 campers!
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IAFFCampinWashingtonD.C.
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Angel Faces A Soft Place to Fall, a solid Foundation for Growth
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Howhascamphelpedyoucopewithyour
burnexperience?“I’vebeena
bletomeet
peoplejustlikemeandcampgivesme
courageandstrengthtotake
onanother
year.”
Howdoyoufeelaboutyourscarsnow?“Is8llstruggleeverydayaboutmyscarsbutthemorecampIreceivethebe^erIfeelanddealwithmyselfesteem.”
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JuniorStaff17-18YearsofAgeCounselorinTraining18-23YearsofAgeVolunteerinTraining18-23YearsofAgeFullCounselororVolunteer23yearsofageandabove
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“Seeingthestrengthofthese
childrenand
knowingthatIhaveplayeda
partintheirlives
isimmeasurable”
“IhopeImakeadifferenc
ein
theirlivesliketheydo
mine!”
“ItposiIvelyimpactsallthecampersandbooststheirself-confidenceandhelpsthemrealizetheyaren’tlimitedtowhattheirskinandscarsshow”
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Suppor8ngBurnSurvivorsYoungAdultRetreat
Age16to23years/Campa$endanceorgreaterthan20%fullthicknessinjuryAvoidsagingout/YoungAdultConference/WiseFoundaIonscholarship/PhoenixPEGscholarship/
Selfimage/RelaIonships/MoneyManagement/SocialMedia/ApplicaIon-Interviewskills/Goalsetng
Criteria
ConInuewithCampa$endanceprograms/Meetbehavioralrequirements/Actasrolemodels/TransiIontoCounselor
OpportuniIes
ExpectaIons
Development
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First Camp Sunshine Young Adult Event August 2013 August 2015 with 12 Young Adults!
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PhoenixEducaIonGrantP.E.G.
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YoungAdultConference
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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
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First SOAR Training October 2011 Repeated in 2012 and 2014!
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Suppor8ngBurnSurvivorsAdultRetreat
Age23andabove/Greater20%FT–Hands–Face/WoundshealedIndependent/MedicalHistoryCommunicaIon/Acceptance/Support/TransiIon/
PhoenixPrograms/FamilyFacebookGroup/Discussions/MoIvaIonalSpeaker
Criteria
Grants/Fundraisers/DonaIons
Goals
Funding
OpportuniIes
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First Adult Retreat March 2012 November 2015 with 30 Survivors!
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2013
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“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”
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Burninjuriesarelifechanging.Burnscarswillneverfullygoaway.Butthroughconsistenttherapy,scarmanagementandmedicalcare,burninjuriesdonothavetobedebilitaIng.ItisourjobtohelptheburnvicImbecomea
burnsurvivor!