Burns AOTA Exam Prep PDF

AOTA’s NBCOT® Exam Prep Burn Rehabilitation General Considerations Useful Resources Bearden, M. D. (2017). Burns. In H. Smith-Gabai & S. E. Holm (Eds)., Occupational therapy in acute care (2nd ed.; pp. 570–581). AOTA Press. Kurakazu, D. & Hirai, A. H. (2018). Burns and burn rehabilitation....

AOTA’s NBCOT® Exam Prep Burn Rehabilitation General Considerations Useful Resources Bearden, M. D. (2017). Burns. In H. Smith-Gabai & S. E. Holm (Eds)., Occupational therapy in acute care (2nd ed.; pp. 570–581). AOTA Press. Kurakazu, D. & Hirai, A. H. (2018). Burns and burn rehabilitation. In H. M. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy: Practice skills for physical dysfunction (8th ed., pp. 1048–1082). St. Louis: Mosby/Elsevier. Lund-Browder classification. (2020). Free dictionary. https://medical-dictionary.thefreedictionary.com/Lund- Browder+classification Ozelie, R. (2021). Burn injuries. In D. P. Dirette & S. A. Gutman (Eds.), Occupational therapy for physical dysfunction (8th ed., pp. 994–1013). Lippincott Williams & Wilkins. I. Skin anatomy and definitions (Kurakazu & Hirai, 2018, p. 1050) A. Skin consists of two layers: dermis and epidermis. 1. Dermis: also known as corium; composed of fibrous connective tissue made of collagen and elastin 2. Epidermis: outermost layer of epithelium; consists of four or five layers depending on location and type of skin B. Burn: A thermal injury that destroys layers of the skin. II. Classifications: size, depth, and mechanism (Kurakazu & Hirai, 2018 pp. 1051-1055; Ozelie, 2021, pp. 995-996) A. Burn size; estimating total body surface area that has been burned 1. Total body surface area (%TBSA): The Rule of Nines divides the body into 9s or multiples of 9s to calculate total body surface area of burns (Wedro, 2019). The head and neck area is 9%, each upper extremity is 9%, each lower extremity is 18%, the front and back of the trunk are each 18%, and the perineum is 1% (Kurakazu & Hirai, 2018). 2. The Lund-Browder chart is a more accurate method of calculating TBSA. It assigns a percentage of surface area to body segments, with calculations adjusted by age groups (Kurakazu & Hirai, 2018; Lund-Browder Classification, 2020). B. Burn depth (Kurakazu & Hirai, 2018, Table 42-1) Burn wounds are classified based on clinical assessment of appearance, sensitivity, and pliability. 1. Superficial burn a. Involves the superficial epidermis. b. Short term moderate pain; no blistering, minimal erythema, dry. c. Healing time is 3–7 days. d. Common causes: sunburn, brief exposure to hot liquids or chemicals e. Scar potential: no potential for hypertrophic scar or contractures. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 1 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep 2. Superficial partial-thickness burn a. Involves the epidermis and upper dermis layers. b. Pain is significant; wet blistering and erythema are present. c. Healing time is 1–3 weeks. d. Common causes include severe sunburn or radiation burn, prolonged exposure to hot liquids, brief contact with hot metal objects. e. Scar potential: minimal potential for hypertrophic scar or contractures if healing is not delayed. 3. Deep (partial-thickness) burn a. Involves the epidermis and the deep dermis layers, hair follicles, and sweat glands. b. Pain is severe, even to light touch. c. Erythema is present, with or without blisters. d. Burn has a high risk of turning into a full-thickness burn because of infection; grafting may be considered to prevent wound infection. e. Client may have impaired sensation. f. Common causes include flames; firm or prolonged contact with hot metal objects; prolonged contact with hot, viscous liquids. g. Scar potential is high. h. Healing time varies from 3–5 weeks. 4. Full-thickness burn a. Involves the epidermis and dermis, hair follicles, sweat glands, and nerve endings. b. No sensation to light touch except at deep partial-thickness borders c. Burn is pale and nonblanching. d. Requires skin graft. e. Common causes include extreme heat or prolonged exposure to heat, hot objects, or chemicals for extended periods. f. Scar potential is extremely high for hypertrophic scarring or contractures. 5. Subdermal burn a. Full-thickness burn with damage to underlying tissue such as fat, muscles, and bone. b. Charring is present; may have exposed fat, tendons, or muscles. c. If the burn is electrical, destruction of nerve along the pathway is present. d. Peripheral nerve damage is significant. e. Requires surgical intervention for wound closure or amputation. f. Common causes: electrical burns and severe long-duration burns (e.g. house fire) g. Scar potential: extremely high for hypertrophic scarring or contractures. C. Mechanism of injury Table 1. Mechanisms of Burn Injury Mechanism Cause Additional Information Thermal Heat (e.g., flame, steam, hot liquid, hot object) Cold (e.g., dry ice) Chemical Acid (e.g., sulfuric acid, hydrochloric Burn results in tissue necrosis rather acid) than direct heat production. Alkali (e.g., dry lime, potassium hydroxide, sodium hydroxide) Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 2 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep Table 1. Mechanisms of Burn Injury Mechanism Cause Additional Information Degree of tissue injury is dependent on toxicity of the chemical and exposure time. Alkali burn is usually more severe than an acid burn. Electrical High-voltage direct current (DC): DC: client is more likely to have blunt usually causes a single muscle trauma along with the burn. contraction and throws its victim from AC: more dangerous than DC at the same the source) voltage. Low-voltage alternating current (AC): Extensive burned areas, including causes greater muscle contraction and organs, depending on the electrical makes it more difficult for the person to current’s path. voluntarily control muscles to release the electrified object) Radiation Sunburn, X-rays, radiation therapy for patients with cancer Source: Kurakazu & Hirai (2018). Medical Management I. Emergent Phase: 0–72 Hours After Injury 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 (see Kurakazu & Hirai, 2018, p. 1056; Ozelie, 2021, pp. 996–1002). A. Sustaining life 1. Risk of dehydration: One of the functions of the skin is that it serves as a moisture barrier. Depending on the TBSA burned, the client is at risk of dehydration through evaporation. 2. Hypo- or hyperthermia: Skin also serves as an organ for temperature regulation. Without protection from the skin, the client may not be able to perspire to cool the body surface or contain heat. 3. Fluid resuscitation: Rapid leakage of the protein-rich intravascular fluid into the surrounding extravascular tissues can result in decreased plasma and blood volume and reduced cardiac output. 4. Cardiopulmonary stability: Achieving this stability is especially important if the respiratory tract has sustained a smoke inhalation injury. 5. Escharotomy and fasciotomy: Circulation can be compromised when burn injuries girdle a body segment. The inelasticity of the eschar (burned tissue) can increase the internal pressure within fascia compartments and lead to compartment syndrome. Symptoms of compartment syndrome include paresthesia, coldness, and decreased or absent pulse in the extremities. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 3 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep Surgical excision of the eschars or incision into the fascia can release the pressure within the fascia compartments. B. Controlling infection 1. Skin serves as an environmental barrier and protects against bacterial invasion. 2. Open wound area increases chances of bacterial infection and can be a wound bed for bacteria to grow. 3. Wound-dressing products protect the wound against infection, superficially debride the wound, and provide comfort. 4. Types of wound dressing include a. Topical antibiotics b. Biologic dressing i. Xenografts—bovine skin, processed pig skin ii. Allograft—human cadaver skin c. Nonbiological skin-substitute dressings—biosynthetic products such as Biobrane® (Smith & Nephew, Warsaw, IN) C. Managing pain 1. Pharmacological; likely use of narcotic analgesics 2. Includes pain management for any associated injuries, such as organ injuries or fractures II. Acute phase: 72 Hours After Injury or Until Wound Is Closed 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. Team communication is important. The acute phase may last for days or months (see Kurakazu & Hirai, 2018; Ozelie, 2021). A. Infection control can be nonsurgical or surgical. 1. Nonsurgical intervention: maintenance of wound care until wound heals 2. Surgical intervention a. Escharotomy and debridement: removal of burned or dead skin, allowing new vascularized skin to close up the wound b. Skin graft: generally performed for all full-thickness burns and for large, deep partial- thickness burns Table 2. Types of Grafts Type of Graft Characteristics Autograft Transplantation of the person’s own skin from an unburned donor site to the burned receiving site Split-thickness skin Full epidermal and partial dermal layer are taken from the donor site. graft Chance of graft survival is high. Split-thickness autographs are considered gold standard. Full-thickness skin Full thickness of the epidermal and dermal layers plus a percentage of fat layers are graft taken from the donor site. Chance of graft survival is less. The outcome is functionally and cosmetically better if graft adherence occurs. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 4 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep Table 2. Types of Grafts Type of Graft Characteristics Meshed versus sheet Meshed graft is when the donor graft is “meshed” and stretched to cover a graft greater area of the receiving area. Sheet graft is when the donor graft is removed and laid down on the receiving area as is. Skin substitutes Used when there is not sufficient donor skin to cover all of the affected area with autograft (e.g. biologic such as allografts or xenografts vs synthetic) B. Pain management often includes use of narcotic analgesics. C. Proper nutrition and hydration must be ensured. 1. A high-protein diet promotes wound healing. 2. Maintain proper hydration. D. Cardiopulmonary stability is maintained. E. Psychosocial support is important (see Burn-related Complications and Management in this lesson). III. Rehabilitation Phase: 6 Months to 2 Years A. The rehabilitation phase follows the acute phase and continues until scar maturation (can take 6 months to 2 years). B. Medical treatment continues with skin grafts and reconstruction surgery as needed for movement and function. Considered complete when scar becomes pale and rate of collagen synthesis stabilizes. C. Continue management of components from preceding phases as needed, as well as consideration for psychosocial factors and scar monitoring/maintenance. Occupational Therapy Evaluation (AOTA, 2021; Kurakazu & Hirai, 2018, pp. 1063– 1064) I. Evaluation Components: Physical A. Obtain burn etiology, medical history, and secondary diagnoses B. Visually assess wounds, focusing on extent and depth of injury C. Assess joint mobility, strength, sensation, and functional use 1. Note wound location, severity, edema. 2. Assess passive range of motion (PROM), active range of motion (AROM), strength, gross and fine motor coordination, sensation. 3. Use goniometer for assessing ROM to accurately document baseline deficits and future changes. 4. Document pain, edema, tight eschar, or bulky dressings impacting ROM. II. Evaluation Components: Areas of Occupation Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 5 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep A. Assess areas affecting future occupational performance, including but not limited to hand dominance, previous injuries, prior conditions B. Assess performance skills and patterns, daily routines, and activities 1. Assess ADL performance level and functional status, when client is medically stable 2. Leisure activities C. Assess psychological status, cognitive functioning, and social support Occupational Therapy Intervention (AOTA, 2018; Kurakazu & Hirai, 2018, pp. 1065-1075; Ozelie, 2021, pp. 996-1006) I. Emergent Phase A. Prevention of early contracture formation through splints and position programs B. Ideal to initiate OT intervention as early as 24 to 48 hours after burn 1. Splinting a. Wear times are determined by tolerance and functional ability to use involved extremity b. Applied over burn dressing and secured with either gauze wrap or Velcro straps c. See Table 3 for common contracture or deformity positions, splinting positions, and splinting materials/positioning devices. d. Generally, any joint with superficial partial-thickness or worse has potential for contracture and is usually splinted 2. Positioning a. Antideformity position: used as adjunct to splinting for preventing contractures b. Initiated at first visit c. Can help minimize upper extremity edema however risk is potential for brachial plexus strain Table 3. Common Splints and Positioning Contracture or Splinting Materials and Joint Affected Deformity Position Splinting Position Positioning Devices Mouth Decreased vertical and Maximum vertical and Prefabricated microstomia devices on horizontal opening horizontal opening (may the market; many can be adjusted alternate) vertically, horizontally, or circumferentially Neck Flexion, limitations in lateral Neutral or slight extension Soft collar vs. hard collar for flexion and rotation (remove pillows from under prefabricating general splints head) Customized thermoplastic splints Towel roll behind neck or between scapulae Axilla Adduction 90° of flexion and abduction, Custom airplane splint made from commonly referred to as thermoplastic material (e.g., DonJoy® scaption (UE is positioned in S.C.O.I. brace [DJO; Vista, CA], which the plane of the scapula) includes the shoulder, elbow, wrist, and Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 6 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep Table 3. Common Splints and Positioning Contracture or Splinting Materials and Joint Affected Deformity Position Splinting Position Positioning Devices hand); allows 30°–150° of abduction at shoulder Elbow Flexion Extension Custom anterior-fitting elbow extension splint Knee immobilizer cut to size Wrist Flexion Neutral up to 45° of extension Prefabricated wrist cock-up vs. custom wrist cock-up Hand Flexion, loss of web spaces Intrinsic plus or safe position Custom safe position splint Finger extension splint or baseball glove splint (for deep palmar burns) Knee Flexion Extension Knee immobilizer Custom posterior-fitting knee splint Ankle Plantar flexion Neutral Burn MPO (multipodus boot) Custom posterior foot splint Source: Bearden (2017, p. 579). II. Acute Phase A. Occupational therapy focuses on continued assessment of ADLs/IADLs, psychosocial aspects, communication, cognition, ROM, muscle strength, and pain. 1. Observation during task performance 2. Interviews with patient/family 3. Other assessments: Patient and Observer Scar Assessment Scale, Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire Brief Burn Specific Health Scale (BSHS-B) ICF Core Sets for Hand conditions Jebsen-Taylor Hand Function (JTHF) Test B. Splinting and positioning in antideformity positions, edema management, early participation in ADLs, and client and caregiver education. C. Antideformity positioning: Positioning is critical because the position of greatest comfort is usually the position of contracture (Kurakazu & Hirai, 2018, Table 42-3). 1. Neck: neutral to slight extension 2. Chest and abdomen: trunk extension, shoulder retraction 3. Axilla: shoulder abduction 90° to 120°, slight external rotation 4. Elbow: extension 5. Forearm: neutral to supination 6. Wrist a. Dorsal wrist: wrist in neutral to 30° extension b. Volar wrist: wrist in 30°–45° extension 7. Hand: metacarpal 70° flexion; interphalangeal 0° extension, thumb abducted and extended 8. Hip: 10°–15° abduction, neutral extension 9. Knee: extension; with anterior burn, slight flexion Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 7 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep 10. Ankle: Neutral to 5° dorsiflexion D. Edema management 1. Elevation of extremities 2. AROM exercises, if movement is allowed 3. Wrapping with elastic bandage, unless bulky wound dressing is used E. Early participation in ADLs 1. Apply adaptive strategies, adaptive equipment, environmental adaptation, allowing early success in selected participation in self-care activities. Gradually discontinue use of adaptive equipment to encourage active movement. 2. Oral care, self-feeding, and communication if appropriate 3. Implement a ROM program and activity as tolerated. No passive or active ROM with exposed tendons or recent grafts (wait 5–10 days). a. Active, active-assisted, or passive exercises are used, depending on the client’s condition. b. The focus of exercise and activity is to preserve ROM and functional strength, build cardiopulmonary endurance, and decrease edema. c. Pain is often a limiting factor. It is best to coordinate with nursing on scheduled pain medications or short-term breakthrough pain relief. Treat 30 minutes after pain medication is administered. d. Use techniques such as visual imagery and relaxation to minimize pain. e. Respect pain. Stop before the client reaches the limits of pain tolerance. f. Explain procedures before starting an exercise or activity and allow the client to control the time limit on painful treatment sessions, if appropriate. g. To avoid pooling of fluid and blood in the lower extremities in dependent or standing position, it is important to apply compression wrapping to provide adequate vascular support to lower extremities before walking, standing, or prolonged sitting with feet in dependent position. h. Address the fear factor, which can exacerbate perceived pain early in the intervention. F. Support psychosocial adjustment: Patients may deal with anxiety, depression, and posttraumatic stress disorder. 1. Identify strengths 2. Validate sadness and fear 3. Assist goal achievement 4. Instill belief G. Client and caregiver education and training 1. Stages of burn recovery 2. Importance of activity and exercise participation 3. Pain management techniques 4. ROM exercises, safety precautions, and contracture preventions 5. Education for members of support system a. Ways to interact with and support patient (physically and emotionally) b. Potentially serve as source of information and resource III. Surgical and postoperative phase Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 8 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep A. Postoperative immobilization period 1. Immobilization is important after skin graft operation to allow for graft adherence. 2. The immobilization period varies; confirm the specific period of time with the surgeon. Generally, it is between 3 and 10 days or until graft adherence is confirmed. 3. Immobilization period of the donor site is usually 2–3 days, if no active bleeding occurs at the donor site. 4. Walking is usually not resumed until 5–7 days after grafting in lower extremities. B. Positioning 1. May be the same as anticontracture positioning. 2. Surgeon may specify optimal positioning. The goal is to promote the greatest surface area for graft placement. 3. Donor site should be treated similarly to a burn site, involving elevation and wrapping with an elastic bandage. C. Exercise and activity 1. Exercise, daily activity and movement of the uninvolved extremities should be continued. 2. Movement of other joints involved should be continued if able to avoid tension on grafts. 3. After immobilization period, start with gentle AROM to avoid shearing of the new grafts. D. ADLs 1. Self-care activities should be continued and are often difficult due to immobilization positions 2. Adaptation of activity and adaptive equipment for involvement in ADLs E. Psychosocial support IV. Rehabilitation phase: Inpatient At this stage, the wound is healing, and wound closure is stable. A. Skin conditioning 1. 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. 2. 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. 3. Use sunblock or sun protective clothing; avoid unprotected sun exposure. B. Scar management (includes massage and pressure garments) Initiate compression therapy for both edema control and scar compression. 1. Temporary interim pressure bandages or garments a. Elastic bandages b. 3M Coban™ (3M, St. Paul, MN) wrapping of the fingers c. Elasticated tubular support bandages d. Thigh-high or knee-high thromboembolism-deterrent hose e. Spandex bicycle pants Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 9 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep f. Isotonic gloves with impression silicone (Otoform®, Dreve Otoplastik, Unna, Germany), elastomer, closed-cell foam, or silicone pad inserts 2. Measurement for custom-made compression garment: Use of compression garments is indicated for all donor sites, grafted sites, and burn wounds that take more than 2 weeks to heal spontaneously. 3. Custom-made pressure garment and insert a. Custom-made pressure garments are constructed to provide gradient pressure. b. The garment should be worn 24 hours a day except during bathing, massage, and other skin care activity (only when the skin is healed to withstand shearing of application and removal). c. A minimum of two sets of garments should be ordered for changing and laundering. d. To conform to body contours and prominences, additional flexible inserts or conformers are often added under the garments to distribute the pressure more evenly. C. Therapeutic exercise and activity 1. Exercise and activity should be progressively graded to regain strength and activity tolerance. 2. Client needs to be taught to perform skin lubrication and massage as pretreatment skin care before exercise and activity program. 3. Includes daily stretching, resistive exercise, activity to tolerance, and coordination activities D. Splinting 1. Continue anticontracture positioning to prevent contracture formation. 2. Use dynamic splint or serial casting to reverse disabling or disfiguring contracture formation. For the hands, attend to extensor tendon injury and web space contracture management. 3. Splint of volar surface of hand for dorsal or volar hand burns for better positioning and comfort. E. ADLs 1. Apply adaptive strategies or adaptive equipment to promote independence in ADLs and a return to a typical daily routine. 2. Identify atypical movement pattern early; client needs to relearn normal movement patterns. F. Client education to aid transition from hospital to home 1. Independent skin care protocol 2. Understanding of wound-healing process 3. Compression therapy and positioning with practice opportunity to apply garment and splint 4. Preservation of independence in ADLs and IADLs with continuing exercise and activity program G. Desensitization for hypersensitivity if needed V. Rehabilitation Phase: Outpatient and community reintegration A. Scar management 1. Continue compression therapy, skin conditioning, splinting and positioning, and exercise program till the scar is mature. 2. Maturation may take from 1 to 2 years to occur. B. Community reentry Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 10 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep 1. Improve skin tolerance for friction and shear from the compression garments and inserts during activities with skin-conditioning activities and exercises. 2. Promote ROM and strength tolerance to activity with activity tolerance training. 3. Adapt activity demands and environment if any limitations in movement result from tight scar band or contracture. C. Psychosocial adjustment 1. Client may experience symptoms of posttraumatic stress disorder. 2. An adjustment period may be needed, especially if disfigurement or contracture has occurred. 3. Client may require counseling, a support group, training in pain management, relaxation, and stress management. Burn-Related Complications and Management (AOTA, 2021; Kurakazu & Hirai, 2018, pp. 1075–1077; Ozelie, 2021, pp. 1005–1008) I. Contracture A. Results from tight scar band, hypertrophic scar, or prolonged immobilization. B. Addressed with early implementation of anticontracture positioning, continuous exercise and activity programs, and serial splinting programs to prevent or reverse deformity. C. Microstomia: Oral commissure contracture with facial burns D. Webspace contracture II. Hypertrophic scar A. Scar is most apparent 6–8 weeks after wound closure. B. Scar is most active in the initial 4–6 months. C. Because of increased vascularity, the scar becomes firmer and thicker and rises above the original surface level of the skin. D. Scarring can happen at the donor site, at the original burn area, or with a wound that does not close spontaneously after 2 weeks. E. Apply compression therapy early, and continue it until the scar matures in 1–2 years. F. Use scar gel pads and/or inserts to provide compression to scar. III. Heterotopic ossification A. Heterotopic ossification is the formation of bone in abnormal areas. It typically occurs in soft tissue around the joint or joint capsule. B. Common areas in which it occurs are the elbow, knee, hip, and shoulder. C. Loss of ROM is rapid, and pain is localized and severe. D. It is characterized by a hard end feel during PROM activity. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 11 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep E. Once diagnosis is confirmed, discontinue passive stretching (including use of dynamic splints) and begin AROM exercise within the pain-free range to preserve as much joint movement as possible. F. Heterotopic ossification usually requires surgical intervention if functional activity is limited. IV. Pain A. Pain interferes most with the rehabilitation process. B. Respect pain. C. Coordinate with nursing on scheduled pain management; breakthrough pain relief can improve compliance with therapy program (consider treating 30 minutes after pain medication is administered). D. Educate the client and family on the importance of frequent ROM exercise and activity in spite of pain to prevent deformity formation. E. Teach the client proper skin care and lubrication to avoid maceration of skin because of friction and shear during exercise and activity. F. Reinforce pain management and stress reduction management techniques throughout the whole continuum of care. V. Heat intolerance A. Loss of the ability to sweat may occur as a result of loss of sweat glands with split- thickness skin graft. B. Client may sweat excessively in the unburned areas. C Special accommodations and modifications (air conditioning) may be required at home or in the work or school area. VI. Sun exposure A. The risk for sunburn is higher after a burn. B. Extra care should be taken to use sunscreen and sun protective clothing, and avoid prolonged sun exposure, especially without protection. C. May affect returning to outdoor work or, for children, playground activity. VII. Pruritis (persistent itching) A. May lead to skin maceration and reopening of the wound as a result of scratching. B. Use of a compression garment, maintenance of skin lubrication, and use of cold packs and antihistamine medications may alleviate itching. VIII. Neuromuscular complications A. Peripheral neuropathic conditions 1. Occur with high-voltage electrical burns or burns of >20% TBSA Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 12 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep B. Localized compression or stretch injuries of nerves IX. Psychosocial adjustment A. Contracture, disfigurement, and pain are the primary stressors after burn. B. Depression, anxiety, posttraumatic stress disorder, and withdrawal reactions are some of the common psychological reactions postburn. Special Considerations (Kurakazu & Hirai, 2018, pp.1053–1076; Ozelie, 2021, pp. 996–1008) I. General A. With the exception of the post–graft operation immobilization period, gentle AROM and PROM to the client’s tolerance should be implemented as early as possible. B. After post–graft operation immobilization, begin with AROM initially, and resume PROM after graft adherence has been confirmed. C. Close monitoring of scar contracture and deformity development through the continuum of care, and making changes to splinting and positioning as often as needed, are of utmost importance. D. Careful attention should be given to burned joint surface areas, and the presence of circumferential burns should be noted, especially when splinting is considered 1. Palmar extension splint for palmar hand burn: wrist extension, MCP joint extension, IP joint extension, digital abduction, and thumb abduction and extension 2. Antideformity splint for dorsal hand burn: wrist in extension, MCP joints in maximal flexion as tolerated, IP joints in full extension, and thumb abduction and opposition E. With dorsal hand burns, take care to maintain Boutonniére precaution and avoid having the client form active or passive composite flexion of the fingers during evaluation and intervention. Do ROM to MP with IP straight and ROM to IP with MP and DIP straight. The integrity of the extensor hood should be confirmed before composite flexion is allowed. F. With any burn deeper than a deep partial-thickness burn, sensory impairment may occur. Sensory testing for peripheral nerve damage should be performed as soon as the wounds are closed. G. For electrical burns, a gross sensory screening should be performed on the involved limb to identify the extent of the peripheral sensory nerve involvement. II. Considerations for Children A. Children respond well to structured play to achieve full ROM of affected body parts. B. Child-life specialists are beneficial to help reduce fear and stress when treating children. C. When a child sustains a burn, it may result in a range of emotional effects on parents. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 13 2nd ed. October 2023  AOTA’s NBCOT® Exam Prep 1. Parents may feel guilty. 2. Parents may feel incompetent and may resist taking over the scar management program at home. 3. A balance between scar management, exercise, and reestablishing the parent–child relationship should be attained through careful intervention and high vigilance on the scar condition. D. Children may have a more difficult time reintegrating into student and playmate roles than adults. 1. The predischarge plan should include a community-based therapist working in the school system to help with adjustment issues. 2. A return-to-school program, with or without the child present, can be beneficial. References American Occupational Therapy Association. (2018). The role of occupational therapy in wound management. American Journal of Occupational Therapy, 72(Suppl. 2), 7212410057. https://doi.org/10.5014/ajot.2018.72S212 American Occupational Therapy Association. (2021). Improve your documentation and quality of care with AOTA's updated Occupational Profile Template. American Journal of Occupational Therapy, 75, 7502420010. https://doi.org/10.5014/ajot.2021.752001 American Occupational Therapy Association. (2021). Position Statement—Role of occupational therapy in pain management. American Journal of Occupational Therapy, 75(Suppl. 3), 7513410010. https://doi.org/10.5014/ajot.2021.75S3001 Bearden, M. D. (2017). Burns. In H. Smith-Gabi & S. E. Holm (Eds)., Occupational therapy in acute care (2nd ed.; pp. 570–581). AOTA Press. Kurakazu, D. & Hirai, A. H. (2018). Burns and burn rehabilitation. In H. M. Pendleton & W. Schultz-Krohn (Eds.), Pedretti’s occupational therapy: Practice skills for physical dysfunction (8th ed., pp. 1048–1082). St. Louis: Mosby/Elsevier. Lund-Browder classification. (2020). Free dictionary. https://medical-dictionary.thefreedictionary.com/Lund- Browder+classification Ozelie, R. (2021). Burn injuries. In D. P. Dirette & S. A. Gutman (Eds.), Occupational therapy for physical dysfunction (8th ed., pp. 994–1013). Lippincott Williams & Wilkins. Wedro, B. C. (2019). Burn percentage in adults: Rule of nines. eMedicineHealth. http://www.emedicinehealth.com/burn_percentage_in_adults_rule_of_nines/article_em.htm Additional Resources Asher, I. A. (2014). Asher’s occupational therapy assessment tools (4th ed.). AOTA Press. Patnaude, M. E. (Ed.). (2021). Early’s physical dysfunction practice skills for the occupational therapy assistant (4th ed.). Mosby. Copyright © 2023 by the American Occupational Therapy Association. All rights reserved. This material is for the exclusive use of the purchaser and may not be photocopied, shared, or redistributed. 14 2nd ed. October 2023