Burns

Question 1

How is burn size estimated for adults and kids?

Answer 1

adults - rule of 9s

children - lund-browder chart

Question 2

superficial (first degree burn)

Answer 2

i. Involves the superficial epidermis.
ii. Pain is minimal to moderate; no blistering or erythema.
iii. Healing time is 3–7 days.

Question 3

Superficial partial-thickness (superficial second-degree) burn

Answer 3

i. Involves the epidermis and upper dermis layers.
ii. Pain is significant; wet blistering and erythema are present.
iii. Healing time is 1–3 weeks.

Question 4

Deep partial-thickness (deep second-degree) burn

Answer 4

i. Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands.
ii. Pain is severe, even to light touch.
iii. Erythema is present, with or without blisters.
iv. Burn has a high risk of turning into a full-thickness burn because of infection; grafting
may be considered to prevent wound infection.
v. Client may have impairment of sensation.
vi. Potential for hypertrophic scar is high.
vii. Healing time varies from 3–5 weeks.

Question 5

Full-thickness (third-degree) burn

Answer 5

i. Involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings.
ii. Burn is pain free, no sensation to light touch.
iii. Burn is pale and nonblanching.
iv. Requires skin graft.
v. Potential for hypertrophic scar is extremely high.

Question 6

Subdermal burn

Answer 6

i. Full-thickness burn with damage to underlying tissue such as fat, muscles, and bone.
ii. Charring is present; may have exposed fat, tendons, or muscles.
iii. If the burn is electrical, destruction of nerve along the pathway is present.
iv. Peripheral nerve damage is significant.
v. Requires surgical intervention for wound closure or amputation.
vi. Potential for hypertrophic scar is extremely high.

Question 7

Thermal

Answer 7

heat, cold, scald, or flame

Question 8

Radiation

Answer 8

sunburn, X rays, radiation therapy for cancer patients

Question 9

Chemical

Answer 9

i. Burn results in tissue necrosis rather than direct heat production.
ii. Degree of tissue injury is dependent on the toxicity of the chemical and the exposure
time.
iii. Alkali burn is usually more severe than an acid burn.

Question 10

Electrical burn: high voltage versus low voltage

Answer 10

i. High-voltage direct current usually causes a single muscle contraction and throws its
victim from the source. Client is more likely to have blunt trauma along with the burn.
ii. Low-voltage alternating current (AC) is more dangerous than direct current (DC) at the
same voltage. AC causes greater muscle contraction and, therefore, makes it more
difficult for the person to voluntarily control muscles to release the electrified object.
iii. Extensive burned areas, including organs, depending on the electrical current’s path
from entry to exit (grounded).

Question 11

Emergent phase: 0–72 hours after injury

Answer 11

Medical treatment focuses on sustaining life, controlling infection, and managing pain. It can
include intravenous fluids, intubation (if inhalant injury), escharotomy (surgical incision of eschar
or burned tissue to relieve pressure on extremities after burns), fasciotomy (a similar incision that
extends to the fascia), wound dressings with antimicrobial ointment for infection control, and
universal precautions for medical staff and family

Question 12

How do you control infections?

Answer 12

a. Skin serves as an environmental barrier and protects against bacterial invasion.
b. Open wound area increases chances of bacterial infection and can be a wound bed for
bacteria to grow.
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c. Wound-dressing products protect the wound against infection, superficially debride the
wound, and provide comfort.
d. Types of wound dressing include
i. Topical antibiotics
ii. Biologic dressing
• Xenografts—bovine skin, processed pig skin
• Allograft—human cadaver skin
iii. Nonbiological skin-substitute dressings—biosynthetic products such as Biobra

Question 13

Acute phase: 72 hours after injury or until wound is closed (may be days or months

Answer 13

Treatment focuses on infection control and grafts (removal of dead tissue and replacement of skin
or substitute over the wound); biological dressings may also be used to cover the wound.
Psychological support and team communication are important.

Question 14

Surgical Interventions

Answer 14

a. Nonsurgical intervention: maintenance of wound care until wound heals
b. Surgical intervention
i. Escharotomy and debridement: removal of burned or dead skin, allowing new
vascularized skin to close up the wound
ii. Skin graft
• Autograft: transplantation of the person’s own skin from an unburned donor site to the
burned receiving site
• Split-thickness skin graft
– Full epidermal and partial dermal layer are taken from the donor site.
– Chance of graft survival is high.
• Full-thickness skin graft
– Full thickness of the epidermal and dermal layers plus a percentage of fat layers are
taken from the donor site.
– Chance of graft survival is less.
– The outcome is functionally and cosmetically better if graft adherence occurs.
• Meshed versus sheet graft
– Meshed graft is when the donor graft is “meshed” and stretched to cover a greater area of
the receiving area.
– Sheet graft is when the donor graft is removed and laid down on the receiving area as is.

Question 15

What type of diet is needed for healing?

Answer 15

high protien

Question 16

What is included in the rehab phase?

Answer 16

Medical treatment continues with skin grafts and reconstruction surgery as needed for movement
and function

Question 17

What is OT intervention in the emergent phase? (splint positions)

Answer 17

a. Intrinsic plus for hands
b. Opposite client’s posture
c. Generally in extension for the neck, elbows, and knees
d. Shoulder in abduction and hip in extension
e. Anti–frog leg and anti–foot drop for lower extremity

Question 18

What is included in OT intervention in acute phase?

Answer 18

1. Occupational therapy evaluation: ADLs, psychosocial aspects, communication, cognition, ROM,
   muscle strength, and pain
2. Intervention: splinting and positioning in antideformity positions, edema management, early
   participation in ADLs, and client and caregiver education
3. Anticontracture positioning: Positioning is critical because the position of greatest comfort is
   usually the position of contracture
4. edema
5. early participation in ADLs
6. education

Question 19

neck splint position

Answer 19

neutral to slight extension

Question 20

check and abdomen position

Answer 20

trunk extension, shoulder retration

Question 21

axilla

Answer 21

shoulder abduction 100-120, slight external rotation

Question 22

elbow

Answer 22

extension

Question 23

forearm

Answer 23

neutral to supination

Question 24

wrist (dorsal and volar)

Answer 24

i. Dorsal wrist: wrist in neutral to 30° extension

ii. Volar wrist: wrist in 30°–45° extension

Question 25

hand

Answer 25

metacarpal, 70° flexion; interphalangeal 0° extension, thumb abducted and extended

Question 26

hip

Answer 26

10°–15° abduction, neutral extension

Question 27

knee

Answer 27

extension; with anterior burn, slight flexion

Question 28

ankle

Answer 28

Neutral to 5° dorsiflexion

Question 29

what is involved in edema management?

Answer 29

a. Elevation of extremities
b. AROM exercises, if movement is allowed
c. Wrapping with elastic bandage, unless bulky wound dressing is used

Question 30

when is ROM introduced?

Answer 30

No passive or active ROM with

exposed tendons or recent grafts (wait 5–7 days).

Question 31

how do you avoid pooling of blood in lower extremities?

Answer 31

apply compression wrapping to provide adequate vascular
support to lower extremities before walking, standing, or prolonged sitting with feet in
dependent position.

Question 32

how long is the wait time after graft surgery?

Answer 32

3 and 10 days or until graft adherence is confirmed.
c. Immobilization period of the donor site is usually 2–3 days, if no active bleeding occurs at
the donor site.
d. Walking is usually not resumed until 5–7 days after grafting in lower extremities

Question 33

What type of ROM occurs after surgery?

Answer 33

gentle AROM

Question 34

What is included in the rehabilitation phase?

Answer 34

Wound is healing, and wound closure is stable

Question 35

What is involved with skin conditioning?

Answer 35

a. Skin lubrication should be performed several times a day to prevent dry skin from splitting
because of shearing forces or overstretching during movement and exercise.
b. Use skin massage to desensitize the hypersensitive grafted sites or burn scars. Massaging a
tight scar band can reduce shearing forces and prevent splitting of immature or problematic
scar tissue.
c. Use sunblock or sun protective clothing; avoid unprotected sun exposure.

Question 36

What are the guidelines for compression wear?

Answer 36

Custom-made pressure garments are constructed to provide gradient pressure, starting at 35
mm Hg distally.
• The garment should be worn 24 hours a day except during bathing, massage, and other skin
care activity.
• A minimum of two sets of garments should be ordered for changing and laundering.
• To conform to body contours and prominences, additional flexible inserts o

Question 37

what is the purpose of a dynamic splint or serial casting?

Answer 37

reverse disabling or disfiguring contracture
formation. For the hands, attend to extensor tendon injury and web space contracture
management

Question 38

What are the psychosocial adjustments?

Answer 38

a. Client may experience symptoms of posttraumatic stress disorder.
b. An adjustment period may be needed, especially if disfigurement or contracture has
occurred.
c. Client may require counseling, a support group, training in pain management, relaxation,
and stress management.

Question 39

How does a contracture occur?

Answer 39

1. Results from tight scar band, hypertrophic scar, or prolonged immobilization.
2. Addressed with early implementation of anticontracture positioning, continuous exercise and
   activity programs, and serial splinting programs to prevent or reverse deformity.

Question 40

hypertrophic scar

Answer 40

1. Scar is most apparent 6–8 weeks after wound closure.
2. It is most active in the initial 4–6 months.
3. Because of increased vascularity, the scar becomes firmer and thicker and rises above the
   original surface level of the skin.
4. It can happen at the donor site, at the original burn area, or with a wound that does not close
   spontaneously after 2 weeks.
5. Apply compression therapy early, and continue it until the scar matures in 1–2 years.
6. Use scar gel pads and/or inserts to provide compression to scar.

Question 41

Heterotopic ossification

Answer 41

1. Heterotopic ossification is the formation of bones in abnormal areas. It typically occurs in soft
   tissue around the joint or joint capsule.
2. Common areas in which it occurs are the elbow, knee, hip, and shoulder.
3. Loss of ROM is rapid, and pain is localized and severe.
4. Hard end feel during PROM activity.
5. Once diagnosis is confirmed, discontinue passive stretching (including use of dynamic splint)
   and begin AROM exercise within the pain-free range to preserve as much joint movement as
   possible.
6. Heterotopic ossification usually requires surgical intervention if functional activity is limited.

Question 42

what is a complication about heat intolerance after burns?

Answer 42

1. Loss of the ability to sweat may occur as a result of loss of sweat glands with split-thickness
   skin graft.
2. Client may sweat excessively in the unburned areas.
3. Special accommodations and modifications (air conditioning) may be required at home or in the
   work or school area

Question 43

what are complications with the sun after the burn?

Answer 43

1. The risk for sunburn is higher.
2. Extra care should be taken to use sunscreen and sun protective clothing, and avoid prolonged
   sun exposure, especially without protection.
3. May affect returning to outdoor work or, for children, playground activity

Question 44

what is pruritis?

Answer 44

1. May lead to skin maceration and reopening of the wound as a result of scratching.
2. Use of a compression garment, maintenance of skin lubrication, and use of cold packs and
   antihistamine medications may alleviate itching.

Question 45

what is the special consideration for splints for the dorsal hand?

Answer 45

take care to maintain Boutonniére precaution and avoid
having the client form active or passive composite flexion of the fingers during
evaluation and intervention

Question 46

what burns have sensory impairment?

Answer 46

any burn deeper than a deep partial-thickness burn

Question 47

when can you use a volumeter for edema?

Answer 47

only after the skin has healed