Burns: an overview of clinical consequences affecting patient, staff, and family

Measuring the burden of pediatric burn injury for parents and caregivers: informed burn center staff can help to lighten the load

This study sought to identify which commonly experienced burn-related issues parents/caregivers of burn-injured youth deemed most stressful, difficult, and disruptive during their child's initial acute burn care hospitalization, and following the child's discharge. Parents completed an 11-item survey, asking them to rate the difficulty of items regarding their child's burn injury. The scale was created by burn doctors, nurses, and psychologists with an average of 10.5 (SD ± 4.8) years of experience. Items selected were among common parental problems reported in the burn literature. Respondents included 69 parents/caregivers of previously hospitalized, burn-injured youth. The majority were mothers, n = 51 (74%), and n = 34 (49%) were Caucasian. The most represented age group was 37 to 45 years, n = 31 (45%). Children were on average, 6.04 years out from their initial injury. All parents reported their child's pain as the most difficult part of the injury, n = 69 (100%). The second most common issue was the child's first hospital stay. The other two items found to be "very hard" or "pretty hard" were the time spent away from their other children, and feelings of hopelessness in being unable to fix everything for their child. In this study, key parental problems occurred during the child's initial hospitalization. Burn staff cannot alleviate all problems, however, staff education regarding distressing problems faced by parents, as well as possible solutions, can be made available.

Analgesia and sedation for children undergoing burn wound care

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.

Psychological rehabilitation of pediatric burn patients

Pediatric burns are devastating injuries, physically and emotionally; however, with progressive medical treatment even with the most severe burns, more burn patients are surviving. This leads to the introduction of a new area of medicine including the psychologic rehabilitation requiring the attention of reconstructive surgeons. Successful psychologic rehabilitation depends on a coordinated interdisciplinary burn care team, family, and the school environment, as well as the child.

Considerations for psychosocial support following burn injury—A family perspective

As part of a larger study involving burned adults and parents of burned children, family members were asked for their views regarding the impact of burn on themselves and the family (N=50). The aim is to describe the range of psychosocial issues that psychosocial support programmes may need to address. This paper reports on the content analysis of specifically designed self-completion questionnaires. The results reveal commonalities within support needs across the three study groups (siblings, children, and partners). These are recommended as key elements in a family support programme: (i) normalising of family member's reactions to the burn. (ii) Advice, support, and information regarding scar permanence, realistic outcome expectations, acceptance of altered appearance, and potential after-effects of burn. (iii) Support in understanding how a burned individual may change or respond following injury and advice regarding constructive methods of coping with altered family dynamics and after-effects of burn. (iv) Advice to enable family members and their burned relative to effectively deal with potentially uncomfortable social encounters.

Burn injury pain: the continuing challenge

The development of more effective methods of relieving pain associated with burn injury is a major unmet medical need. Not only is acute burn injury pain a source of immense suffering, but it has been linked to debilitating chronic pain and stress-related disorders. Although pain management guidelines and protocols have been developed and implemented, unrelieved moderate-to-severe pain continues to be reported after burn injury. One reason for this is that the intensity of pain associated with wound care and rehabilitation therapy, the major source of severe pain in this patient population, varies widely over the 3 phases of burn recovery, making it difficult to estimate analgesic requirements. The effects of opioids, the most commonly administered analgesics for burn injury procedural pain, are difficult to gauge over the course of burn recovery because the need for an opioid may change rapidly, resulting in the overmedication or undermedication of burn-injured patients. Understanding the mechanisms that contribute to the intensity and variability of burn injury pain over time is crucial to its proper management. We provide an overview of the types of pain associated with a burn injury, describe how these different types of pain interfere with the phases of burn recovery, and summarize pharmacologic pain management strategies across the continuum of burn care. We conclude with a discussion and suggestions for improvement. Rational management, based on the underlying mechanisms that contribute to the intensity and variability of burn injury pain, is in its infancy. The paucity of information highlights the need for research that explores and advances the identification of mechanisms of acute and chronic burn injury pain.

PERSPECTIVE

Researchers continue to report that burn pain is undertreated. This review examines burn injury pain management across the phases of burn recovery, emphasizing 3 types of pain that require separate assessment and management. It provides insights and suggestions for future research directions to address this significant clinical problem.

Practices that facilitate critically burned children's holistic healing

Advances in medical technology have enabled many children to survive injuries that less than 10 years ago would have caused death. The intense physical care and the children's and families' emotional needs place extraordinary demands on pediatric burn nurses. In this article, the author reports the findings of an interpretive study that examined the experiences of 16 pediatric burn intensive care unit nurses for the purpose of uncovering and articulating practices that help critically burned children to heal holistically. Following 112 hours of interviews and 134 hours of observing the nurses while they worked, she identified 12 practices and aggregated them into the theme Healing the Child Within. She observed the nurses laughing, playing, singing, talking, and praying with the children. These everyday practices were for the sake of maintaining or reestablishing harmony of the children's mind, body, and spirit.

Creating a social work link to the burn community: a research team goes to burn camp

Social work faculty and graduate students conducted focus groups with 52 burn-injured adolescents from three burn camps to explore perceptions of their camp experience. Three themes emerged from data analysis that suggest burn camps play an important role in participants' lives. Camp is a place where burn-injured adolescents: (1) feel "normal" and accepted; (2) acquire insight in regard to self and meaning in life; and (3) gain confidence, increase self-esteem, and develop empathy. This project highlights how the use of qualitative research methods with grassroots organizations such as burn camps can serve as a link to greater social work involvement with this community.

Impact on the family: psychosocial adjustment of siblings of children who survive serious burns

This study examined the psychosocial adjustment of 79 siblings of children suffering from burn injuries. Nonparametric statistics were used to compare psychosocial adjustment of the study group, as measured by the Child Behavior Checklist with an age-matched and gender-matched reference groups. Analyses found that the study group was better adjusted than the normative group on psychological dimensions; however, the study group fared worse than the normative group on overall competence, particularly social competence. Further analyses found significant differences in sibling adjustment as a function of the severity of the burn injury. The siblings of children with moderate burn injuries did significantly better on psychological adjustment than the normative group, and siblings of children with moderate and severe burn injuries did significantly poorer on social competence. Descriptive analysis of measures developed for the study for parent and sibling reports supported findings of the Child Behavior Checklist quantitative analysis and offered insight into reasons for findings. Results indicate that the burn injury to one child in a family significantly impacts the siblings of that child. The noninjured child may be strengthened in the process of adapting to the changes imposed on the family, but it is also possible that the sibling's growth in one dimension is at the cost of success in another dimension.

How do nurses deal with their emotions on a burn unit? Hermeneutic inquiry

Burn unit nurses work in an emotionally exhausting environment and are frequently exposed to emotional trauma. Emotion is a difficult concept to define. This study used a hermeneutic-phenomenological approach to establish the experiences of nurses working on a burn unit to find out how they deal with their emotions. The findings suggest that nurses have little or no time to deal with their emotional experiences. This study has shown that current support services might be ineffective. Nurses realize that they have emotions. They also recognize the need to address these emotions. Recommendations for nursing practice are made as a result of these findings.

Depression and burn wounds

The biopsychosocial impact of a burn injury on the individual hospitalized for severe burn wounds begins at the moment of injury and extends throughout that person's life. Medical and emotional problems do not exist in clinical isolation but instead interact to confound and complicate treatment outcomes, accentuating the importance of providing optimal treatment of patients' medical illnesses without neglecting their mental distress. Identifying, and responding to, the signs and symptoms of depression is integral to the burn patient's recovery and rehabilitation.

Emotional disturbances in trauma patients during the rehabilitation phase: studies of posttraumatic stress disorder and alexithymia

Recent studies have shown a partial similarity between posttraumatic stress disorder (PTSD) and alexithymia. In this study, the authors examined the relationship between PTSD and alexithymia in two samples of 26 patients with burn injury and 27 patients with digit amputation during rehabilitation. The prevalence rates of DSM-III-R PTSD and alexithymia assessed by the Toronto Alexithymia Scale (TAS) were significantly higher for injury patients than for healthy volunteers. The rate of PTSD symptoms of avoidance and emotional numbing was significantly and positively correlated with the TAS scores in injury patients. The PTSD symptoms of avoidance and emotional numbing had a significant relationship with function after digit replantation. Alexithymia also had a similar relationship with physical conditions. These results suggest that 1) in some cases, alexithymia may be evident when PTSD emotional symptoms appear in injury patients, and 2) emotional disturbances (i.e., PTSD symptoms of avoidance and emotional numbing and alexithymia) may be influenced by the level of functional recovery after digit replantation.

Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries

In order to provide burn patients with adequate pain relief, the nurses must be able to accurately evaluate the patients' pain levels and to assess whether sufficient analgesia is achieved or not. The present study examined this issue by comparing the pain ratings in 42 patients hospitalized for burn injuries and 42 nurses. The patient and the attending nurse were asked to rate, independently of each other, the intensity of the pain felt by the patient during a therapeutic procedure and at rest. When analgesic medication was given prior to the procedure, both the patients and the nurses were asked to estimate the degree of pain relief. All ratings were obtained using visual analogue and verbal scales. The results revealed significant but small correlations between the nurses' and patients' ratings. Frequently, the nurses underestimated or overestimated the patients' pain. Discrepancies were also observed in the evaluation of pain medication efficacy, the nurses showing a tendency to overestimate the degree of pain relief. The accuracy of the nurses' perception did not vary as a function of the patients' age, socioeconomic status or burn severity. However, the number of years of experience in burn-nursing had a significant influence on the nurses' estimation of the patients' pain during therapeutic procedures. Theoretical and clinical implications of these results are discussed with a particular emphasis on the need to implement systematic procedures to assess pain and success of analgesia. Additional recommendations to optimize pain management in burn patients are also made.

The burn victim--a review of psychosocial issues

Over recent decades, with the introduction of specialist units for the treatment of severely burnt patients, a volume of literature on psychological aspects of burns has accumulated, containing anecdote and opinion as well as research of varying quality. This literature is reviewed under three headings: epidemiology and prevention; reactions following acute hospitalisation; and long-term outcomes. Adverse personal, health, and social factors may predispose to burn injury. In hospital, the psychological course of the patient proceeds in stages that can be related to the well-recognised reactions to loss and overwhelming stress, modified by the major physiological insult. Reactions of family and staff are of great significance. In the longer term, rehabilitation prospects are generally good, although recovery may be complicated by a gradually subsiding level of neurotic symptoms and relationship difficulties.