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Standard of Care: Inpatient Physical Therapy Management of Patients withBurns

ICD 9 Codes:942 Burn of trunk

943 Burn of upper limb, except wrist and hand944 Burn of wrist(s) and hands(s)

945 Burn of lower limb(s)946 Burn of multiple specified sites

94 Burns classified accordin! to extent of bod" surface in#ol#ed 949 Burn, unspecified

99$ %ffects of reduced temperature (i&e& frostbite)

695&$ %r"thema multiforme, 'oxic epidermal nectol"sis ('%) thers ma" also appl" (e&!& #arious extensi#e wound dia!noses)

Case Type / Diagnosis: 'his standard of care applies to patients who are admitted to the Bri!ham and *omen+s

ospital (B*) for the mana!ement of their burns& - burn in.ur" can be sustained throu!h

a #ariet" of sources includin! thermal/heat (flame, flash, scald, and steam), chemicals,radiation, sunli!ht, or electricit"& Burn0like in.uries can also occur due to reduced

temperature 1frostbite and as a reaction to medication 1toxic epidermal necrol"sis'%,

also known as te#en0ohnson s"ndrome& n addition to in.ur" to the skin, patients can

also sustain dama!e to their respirator" s"stem due to inhalation in.uries that re7uireintensi#e mana!ement& Burns can ran!e from a minor in.ur" co#erin! $8 of a patient+s bod"

to a se#ere burn co#erin! 980$8 of the total bod" surface area& :atients are also

admitted to B* for on!oin! reconstructi#e procedures in the months and "ears followin! a

BRIGHAM AND WOMENS HOSPITAL

Department of Rehabilitation Services

Physical Therapy

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! ! p " !

Burns are classified y depth of in!ured tissue as detailed in the tale elow:

"ppearance "rea "ffected Sensation Blanching #ound Closure

$irst Degree

%Superficial&

:ink or red;Ca" be dr" or

moist

%pidermis ntact, painful :resent '"picall" heals within 305 da"swith no scarrin!

Second Degree

%Superficial

partial

thic'ness&

Bri!ht pink orred, wet, blisters

%pidermis andportion of dermis

ntact, painful andsensiti#e to chan!e in

temperature and

exposure to air or touch

:resent eals b" re0epithelialiDation in $0$4 da"s; t"picall" no scarrin! or

!raftin! needed

Second Degree

%Deep Partial

Thic'ness&

Cottled, red and

wax" white; wet

%pidermis and

deeper portion of

dermis

=ariable; ma" be intact

with areas of diminished

sensation

>iminished eals b" re0epithelialiDation in $40

2$ da"s or lon!er; scarrin! is likel"

if burn in E 38 'B-

Third Degree

%$ull Thic'ness&

*hite or tan; dr"

and leather",

non0pliable

%ntire epidermis

and dermis

:ainless; ma" be

sensiti#e to deep

pressure; anesthetic to

temperature

-bsent kin !raft re7uired

$ourth Degree Ca" be charredor dr"

>eep soft tissuedama!e to fat,

muscle, tendon,

fascia, ner#e

and/or bone

-bsent -bsent %xcision of necrotic tissue and skin!raft re7uired, possible amputation

in some cases

'he followin! criteria cate!oriDe patients that re7uire care at a specialiDed inpatient burn

center $5F

:atients who sustain partial thickness burns !reater than $8 of total bod" surfacearea ('B-) re7uire more intensi#e medical monitorin! and inter#ention due to

effects of si!nificant edema& 'he" are more likel" to ha#e mobilit" and

mo#ement issues and will re7uire earl" :'/' inter#ention&

:atients who sustain burns of the neck and face are at hi!her risk for si!nificant

edema that can cause respirator" distress& 'he" ma" need to be intubated for an

extended period& :atients who sustain burns in#ol#in! the hands, feet, !enitalia, perineum, or ma.or

.oints are at hi!her risk for decreased healin!, h"pertrophic scarrin! and

contractures 'hese parts of the bod" are crucial for normal function and re7uire

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:atients who sustain chemical burns re7uire more intensi#e mana!ement& 'hechemical can be absorbed into the skin and cause dama!e for an extended period

of time& 'hese patients often re7uire specialiDed cleansin! procedures and close

monitorin!&

:atients with inhalation in.uries often re7uire #entilation and intensi#e pulmonar"h"!iene&

:atients who sustain a burn and also ha#e pre0existin! medical disorders re7uire

more intensi#e mana!ement and fre7uentl" ha#e slower pro!ress& 'heir medicalstatus can complicate mana!ement and prolon! reco#er"&

:atients with burns and concomitant trauma (such as fractures) in which the burn

poses the !reatest risk of morbidit" or mortalit" re7uire hi!her intensit" of care&

:atients with burn in.uries who will re7uire special social, emotional, or lon!0

term rehabilitati#e inter#ention&$5

Phases of Burn CareF

Burn mana!ement can be di#ided into three phases& -n interdisciplinar" approach includin!

:h"sical and ccupational 'herapist in#ol#ement is essential in all three phases 9F

o (mergent or )esuscitati*e Phase

Medical "ssessment

-ssess for the presence of an inhalation in.ur" and secure airwa"

-ssess siDe of burn ('B-) usin! the +)ule of ,ines:-

ead H 98

'runk H 368

Ipper extremit" H 98 each

:erineum H $8

Jower extremit" H $8 each

-ssess and classif" of burn depth

Be!in fluid resuscitation Caintain bod" temperature (pre#ent h"pothermia)

-chie#e cardiopulmonar" stabilit"

bli h d i f i d i f

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Physical Therapy Management

?omprehensi#e inter#ention addressin! positionin!, stretchin!, mobilit",

on!oin! skin assessment and scar mana!ement, education, balance,endurance, respirator" conditionin!

o )ehailitati*e Phase Medical .oalsF (follows acute phase until scar maturation)

ur!ical release of contractures

utritional support

econstructi#e or plastic sur!er" to maximiDe function and cosmesis

Physical therapy Management ntensi#e rehabilitation pro!ramscar mana!ement, ran!e of motion (C) and

stretchin! with techni7ues, mobilit" trainin! as needed, education reF self0 mana!ement

Indications for Treatment::atients with burn in.uries in#ol#in! superficial, partial, or full thickness skin with potential

extension into fascia, muscle, or bone, and at risk for contracture and scar formation will re7uireinter#ention& 'hese burns can result in impairments such as loss of .oint C, peri0articular or

intra0articular .oint chan!es, sensor" loss, edema, pain, impaired #entilation/aerobic capacit",

impaired acti#it" tolerance, impaired balance, coordination, and stren!th& 'he" can cause

functional deficits such as impaired mobilit", difficult" performin! acti#ities of dail" li#in!(->J+s) and instrumental acti#ities of dail" li#in! (->J+s)& :atients also lack knowled!e about

wound healin!, self0care, and copin!/ad.ustment strate!ies followin! burn in.ur"&

Contraindications / Precautions for Treatment:?ontraindicationsF

o :resence of femoral = access #enous access will make repetiti#e hip C contraindicated as it can

cause introduction of bacteria into access

arterial access precludes an" hip C as it increases the risk of arterial

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-utolo!ous skin !rafts>ifferentiate between full andpartial thickness

!rafts& oints crossed b" !rafts are immobiliDed for 50M da"s

Glapstotal immobiliDation to promote #iabilit"; await

ph"sicianclearance prior to resumin! C

o nfection controlF -ll care!i#ers should practice uni#ersal precautions& -dditional

measures are taken for burn patients& >ue to the fact that their burns cause a lar!e numberof open wounds, the" are at hi!her risk for infection&

Gull burn precautionsF -ll staff must wear a !own, !lo#es, sur!ical mask,

and hat when workin! with a patient who does not ha#e their wounds full"dressed

:artial Burn :recautionsF

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isk for scarrin! is related to depth of burn and rate of healin!& -lsocertain skin t"pes are more prone to scarrin!, such as skin of darker

pi!ment2

>etermine if use of cultured skin cells (?%-) is planned

and refer to special precautions and considerations that appl"$M

-ssessment of scarrin!$6

Cusculo0skeletal

C is measured usin! !oniometric measurements

tren!th ismeasured usin! manual muscle test (CC') if patient is able to

participate in exam& f not, assess functional and spontaneous motion b"obser#ation and reassess more specificall" later in course

:osture/ali!nmentcan be assessed b" obser#ation when patient is able to

sit or stand& -s"mmetries can indicate scarrin!

Gunctional mobilit" (assisti#e de#ices as needed):

appropriate assisti#e de#ices

pre0ambulation e7uipment such as tilt table

lift de#ices as neededeuro0muscular

:ain: (if able to communicate b" pain scale; if not assess b" monitorin!heart rate, blood pressure, respiration rate, facial !rimacin!, !esturin!)&

?ommunicate with nursin! reF need for additional pain medication, instruct

patient in deep breathin! and relaxation for pain control& :lan treatmentsessions to coincide with either pre0medication or the abilit" to recei#e

bolus pain medication& %n!a!e the patient and the staff in coordinatin! the

optimal time for inter#ention with their pain control re!ime& n the acutephase of treatment, patients are often recei#in! a lar!e number of narcotic

medications which can be sedatin! and keep patient obtunded for an

extended period which impacts components of :h"sical 'herap" treatment

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-bilit" to follow direction:s"cholo!ical ?onsiderations

?opin! with altered bod" ima!e and appearance

Jearnin! st"le

:atientAs !oals for reco#er"

mpact of ps"chiatric disorders on participation and reco#er"22

"ssessment:Prolem 1ist(mpairments and d"sfunctions)

mpaired ran!e of motion/risk for contractures %dema

isk for h"pertrophic scarrin!

mpaired mobilit"

mpaired respirator" status

mpaired endurance

mpaired inte!ument

mpaired balance eed for optimal positionin!

Nnowled!e deficit reF aspects of burn rehab and self0care

:ain

Prognosis: #er the last thirt" "ears, medical technolo!" and inter#entions ha#e

impro#ed, increasin! the sur#i#al rate of patients with lar!e percenta!e burns& Between

$995 and 25, 94&48 of patients admitted to a burn center sur#i#ed 6, $& 'his bein! said,pro!nosis can be hi!hl" #ariable& ome considerations that impact pro!nosis are depth of

burn, surface area in#ol#ed, t"pe of burn (chemical and electrical ma" increase len!th of

sta"), presence of an inhalation in.ur", si!nificant ps"chiatric or substance abuse issuesd bidi i h hi f ki di b i k f l

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burns can Oachie#e functional independence and reasonable 7ualit" of life in the lon!

termO22&

Suggested .oalsF

'imeline is hi!hl" #ariable dependin! on pro!nosis noted abo#e&

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Cobilit" pro!ression usin! appropriate >C%, lifts

%ndurance acti#ities

espirator" conditionin!

tructured schedule

$re3uency 4 DurationF 'hese patients are t"picall" seen 50M times weekl"& >uration is

dependent on extent and se#erit" of burns and need for intensi#e acute care inter#ention&

Jen!th of sta" can #ar" from 203 da"s for a localiDed burn (such as partial thickness burnto hand or foot) to man" weeks to months for a hi!h percenta!e, deep burn that re7uires

multiple sur!ical procedures and prolon!ed intubation&

Patient / family education:

Burn patient and famil" education book is a#ailable from the 'rauma ursepecialist

>iscussion with patient and famil" reF :h"sical 'herap" in#ol#ement with patient

and expected pro!ression

>iscussion with patient and famil" reF optimiDin! patient+s independent mobilit"and self0care and pro#idin! the appropriate le#el of assistance to the patient

nstruction of patient and famil" in appropriate exercises and acti#ities with written

exercise pro!ram and exercise/acti#it" lo!

>iscussion of lon!er term issues common followin! a burn in.uries

$& phases of burn healin!, estimated time line, risk of scarrin!

2& wa"s to minimiDe scarrin! and contracture

3& proper mana!ement of pressure !arments, >C%4& proper skin care and protection

)ecommendations and referrals to other pro*iders:

ccupational 'herap" peech 'herap"

ocial *ork/?are ?oordination

:s"chiatr"

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Discharge PlanningCommonly e0pected outcomes at dischargeF

eturn to independent function

Caximal ran!e of motion

Cinimal h"pertrophic scarrin!

:atient is independent with exercise pro!ram and skin mana!ement

Transfer of Care(if applicable)

ehabilitation facilit"

ome with ser#ices

ome with famil" assistance

ome with independent pro!ram

Ipon dischar!e, most patients are seen re!ularl" at the Burn ?linic which is a

wound care clinic staffed b" nurses& 'he" can facilitate referral to other ser#ices

as needed& 'hese patients are sometimes seen in the B* outpatientrehabilitation clinic b" :h"sical 'herap" and and 'herap"

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"uthors: -lisa ept& Biobrane dressin!& Brigham and Womens Hospital Burn Trauma Unit

Nursing Protocol.

4& ?hristiansen ?, ed& Ways of Living: elf!"are trategies for pecial Needs.2nd ed&Bethesda, CdF -merican ccupational 'herap" -ssociation, nc&; 2&

5&

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$& -merican Burn -ssociation, Burn ncidence and 'reatment in the IF 2M Gact heet&

-#ailable at httpF//www&ameriburn&or!/resourcesPfactsheet&php& -ccessed une $3, 2&$9& ichard J and tale", C&,Burn "are and %eha&ilitation: Principles and Practice,

:hiladelphia, :-F G& -& >a#is ?ompan"; $994F chapter 2/25&

2& ichard J and tale", C&,Burn "are and %eha&ilitation: Principles and Practice,

:hiladelphia, :-F G& -& >a#is ?ompan"; $994F chapter $4/350M&2$& %delman >-,*hite C', '"burski ecember 26; 2M (6)F 4053&22& >ruer" C, Brown 'im Ja , Culler, C& Jon!term Gunctional utcomes and Uualit" of Jife

Gollowin! e#ere Burn n.ur"&Burns. eptember 25; 3$ (6)F69205&

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-::%>R ':?-J BI '%-:Q (from tefan tro.was, B* urse %ducator, M?>)

-=-'-%-'

-cticoat il#er impre!nated

!auDe

-ntimicrobial ?an remain in place up to

3 da"s so decreasesdressin! time

eeds to be applied wet 0deep dressin! moist with

sterile water0monitor pt& 'emperature

due to wet dressin!s

Bacitracin Bactericidal ointment ecreases pain, remains

in place until re0

epithelialiDation occurs&-llows for mo#ement

*ound surface must be

debrided and clean before

application

eed to obser#e for

si!ns/s"mptoms of

infection and adherence

?ada#er

kin

'emporar" wound

co#erin!

educes heat and water

loss, controls pain

%as" to appl", prepares

wounds for !raftin!

ot alwa"s a#ailable eed to obser#e for

infection

Gine Cesh

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-=-'-%-'

epartment of ehabilitation er#ices& -ll ri!hts reser#ed

$4

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-=-'-%-'

'ransc"te

>erma!raft0'?

Bi0la"er, temporar"

skin substitute

?ontains acti#e

human woundhealin! factors

?ontrols pain, retains

heat and moisture,stimulates wound re0

epitheliaDation

*ound must be debrided

prior to placement& as noantibacterial effects

Conitor for adhesion

and infection

'riple antibiotic

ointment

Cixture of

neom"cin,pol"mixin,

bacitracin

Bactericidal for

!ram V/0 or!anismsfor partial

thickness burns

o pain on applications ?annot be used for full

thickness burns

Conitor for infection

=itamin -T> :etroleum based

ointment

Gat soluble

#itamins assist

with healin!

CoisturiDed newl" healed

tissue

o antibacterial effects

Reroform

bismuth

tribromphenate

Qellow substance on

=aseline

impre!nated !auDe

>ebrides and

protects wounds,

donor sites and!rafts

?onforms to wound,

nontoxic

?an stick to wounds, no

antibacterial

?areful remo#al from

new !rafts essential

Standard of Care: Physical Therapy Management of Patients with Burns

?op"ri!ht @ 2 'he Bri!ham and *omenAs ospital, nc&, >epartment of ehabilitation er#ices& -ll ri!hts reser#ed

$5