Nurse Life Care Planning - Through the Ages Section 5 5 Workbook.pdf · Lund & Browder chart Adult TBSA differs from pediatric TBSA Children have proportionally larger heads and smaller

©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Section 5

Burns

WORKBOOK

Nurse Life Care Planning - Through the Ages

©2011, Shelene Giles. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Nurse Life Care Planning - Through the Ages Section 5 – Burns

OBJECTIVE 1: Explain the anatomy/physiology/function of the skin. Identify levels of impairment based on severity

of catastrophic burns.

OBJECTIVE 2: Describe acute and chronic complications of catastrophic burns. Identify long term treatment and

outcomes of catastrophic burns.

OBJECTIVE 3: Apply and demonstrate the nursing process as a life care planning foundation for a catastrophic burn

client.

_______________________________________________________________________________________

Agenda

Overview

Nurse Life Care Planning Process

Case Study

_______________________________________________________________________________________

Overview

Incidence

Over 2 million burn cases per year

National Burn Repository (1999 – 2008)

127,016 cases over 10 years

Majority of burns are less than 10% TBSA

_______________________________________________________________________________________

Age

Mean age for all cases - 32 years old

Ages 20-50 years old - highest prevalence of burns treated at burn centers

Patients age 60 or older accounted for 12% of all cases

Children under age 5 accounted for 17% of all cases

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©2011, Shelene Giles · [email protected] · (828) 698-9486

Ethnicity

63.0% - Caucasian

17.4% - African American

13.0% - Hispanic

Gender

Majority were men

_______________________________________________________________________________________

Etiology

Location

65.5% - Home

11.1% - Industrial

7.2% - Street/Highway

7.0% - Unspecified

4.5% - Recreation/Sports

2.5% - Public Building

1.1% - Residential Institution

0.9% - Farm

0.1% - Mine/Quarry

_______________________________________________________________________________________

Circumstance

65.0% - Accident/Non-Work Related

15.2% - Accident/Work Related

4.6% - Recreation

4.5% - Unspecified

1.6% - Suspected Assault/Abuse

1.2% - Suspected Self-Inflicted

1.2% - Suspected Child Abuse

0.2% - Suspected Arson

_______________________________________________________________________________________

Cause

41.8% - Thermal (fire/flame)

30.1% - Scald

9.0% - Other (non-burn)

8.5% - Contact with hot object

3.8% - Electrical

2.8% - Chemical

2.4% - Unspecified

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0.8% - Skin disease

0.3% - Radiation

0.3% - Inhalation

_______________________________________________________________________________________

Thermal

Exposure to heat from flame, steam, contact with hot surface, hot liquid, or sun

Most non-work related accidents - occurs at home

More common in adults

Most common cause of severe burns

Most common cause of admission to burn center

Causes superficial to 4th degree burns

_______________________________________________________________________________________

Scald

Severity of scald = temperature x exposure time

Most prevalent in children (under age 5) & elderly

More common in kitchen (not bathroom)

Product (clothing, food, drink, sauces, etc.) worsens severity of injury

_______________________________________________________________________________________

Electrical (HANDOUT - Electrical and Lightning Injuries)

<1,000 volts - low (home)

>1,000 volts - high (industrial)

Actual flow of current most important when considering extent of electrical burn injury

Skin burns where current enters/exits - contact points

Extent of injury deceptive - minimal epidermis/dermis damage & deep tissue damage, damage frequently progresses

_______________________________________________________________________________________

Poly-trauma

Secondary diagnosis - compartment syndrome, cardiac arrhythmias, respiratory, urinary (myoglobinuria),

musculoskeletal (electricity contracts muscles)

Multi-disciplinary team

Long term complications

Neurological symptoms – most common symptoms are memory loss, numbness, headache, chronic pain, weakness

and poor concentration

Musculoskeletal symptoms – most common symptoms are pain, limited range of motion, and contracture

_______________________________________________________________________________________

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Chemical

Alkalines (oven cleaners, fertilizer, industrial cleaners), acids (household products), hydroflouric acids ( inorganic

acids, used in metal processing/cleaning), organic compounds (gasoline, diesel fuel, chemical disinfectants)

Initially unaware of chemical burn

Progressive damage until removed or neutralized

Extent of injury deceptive - superficial progresses to full thickness

Severity depends on chemical, concentration, and contact time

_______________________________________________________________________________________

Inhalation

3 classifications of inhalation injury: carbon monoxide poisoning, upper airway, and lower airway

Most common cause of inhalation injuries & cause of death - house fire

Long term pulmonary complications

_______________________________________________________________________________________

Anatomy (HANDOUT - ABA White Paper)

Skin - largest organ in body

Two layers of skin

Epidermis (10%)

Dermis (90%)

Function of skin - identity, protection/barrier, regulate body temperature (perspiration - excretory gland), sensation

(nerves), elasticity (collagen), moisture (sebaceous glands), pigmentation (melanocytes), fluid conservation, absorb

sun to produce vitamin D

______________________________________________________________________________________

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Classification

Total Body Surface Area

% TBSA

Wallace Rule of Nines

Lund & Browder chart

Adult TBSA differs from pediatric TBSA

Children have proportionally larger heads and smaller legs

(A) Rule of "nines" (B) Lund-Browder

______________________________________________________________________________________

Classification

Superficial -1st degree, only epidermis

Partial thickness - 2nd degree, epidermis and dermis

Superficial partial thickness - superficial layers of dermis

Deep partial thickness - deeper layers of dermis

Full thickness - 3rd degree, complete dermis

Deep full thickness - 4th degree, beyond dermis, muscle, bone

______________________________________________________________________________________

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Superficial burns

First degree

Involves epidermis

Dry, red skin, no blistering

Blanches with pressure, edema

Painful

Example – sunburn

Heals in 1-7 days

No scarring

0% TBSA

______________________________________________________________________________________

Superficial partial thickness burns

Second degree

Involves epidermis & surface layers of dermis

Weeping, red/pink, blistering

Blanches with pressure, edema

Most painful

Example – scald

Will heal on own and minimal scarring - skin able to re-epithelialize - cells regenerate on top surface, usually no

scarring if healed within 2 weeks

______________________________________________________________________________________

Deep partial thickness burns

Second degree

Involves epidermis & deeper layers of dermis

Large blisters, mottled white/pink or cherry red

Less moist, less blanching, and less painful

Example - flame

Skin grafting and severe scarring - heals by scar contraction & scar deposition (limited epithelium in middle of

wound)

______________________________________________________________________________________

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Full thickness burns

Third degree

Involves epidermis & dermis - entire thickness of skin/into fat

Any color (white, gray, red, black/brown)

Dry skin, no sensation, no pain

Example – flame

Skin grafting and severe scarring - heals by scar contraction & scar deposition (no epithelium left in middle of

wound)

______________________________________________________________________________________

Deep full thickness burns

Fourth degree

Involves epidermis, dermis, blood vessel, nerve, tendon, muscle, and bone

Consider amputation

Skin grafting and severe scarring

Poor prognosis

Toxic Epidermal Necrotizing Syndrome (TENS) (HANDOUT - TENS)

______________________________________________________________________________________

Acute Care (HANDOUT - Burns at Extremes of Age)

ABA burn center referral criteria

2nd or 3rd degree burns >10% TBSA (under 10 years and over 50 years of age)

2nd or 3rd degree burns >20% TBSA (in other age groups)

2nd or 3rd degree burns involving face/hands/feet/genitalia/perineum/major joints

3rd degree burns >5% TBSA (any age group)

Electrical burns, including lightning injury

Chemical burns

Inhalation injury (smoke or chemicals)

Pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality

Concomitant trauma where burn injury poses greatest risk of morbidity or mortality

Children in hospitals without specialized pediatric unit

Patients requiring special social, emotional, or long-term rehabilitation support

______________________________________________________________________________________

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Acute Care (HANDOUT - Care of Outpatient Burns) (HANDOUT - Care of Burn Patients in Hospital)

(HANDOUT - Infection Control) (HANDOUT - Nutritional Care) (HANDOUT - Pain Management) (HANDOUT -

Respiratory Care)

Emergency room/transfer to burn center

ABC resuscitation

Fluid resuscitation Intubation

Sedation/Pain management

Diagnostic studies

Prevent infection

Nutritional support

Surgery

Emergency escharotomy and/or fasciotomy

Skin debridement /wound coverage- remove necrotic skin, aggressive wound excision/debridement

Skin grafting

Allograft/homograft - cadaver or porcine skin

Auto graft - own skin, donor site

Split thickness skin graft vs. full thickness skin graft

Cultured epidermal auto graft (CEA)

Wound care/dressing changes

Positioning/splinting/rehabilitation

Psychological support

Transfer to inpatient rehabilitation unit vs. discharge home

______________________________________________________________________________________

Acute Complications (HANDOUT - Review of Burn Injury Research)

Hypothermia

Compartment syndrome - compromises nerves/muscles/blood flow, loss of limb/life without intervention, emergency

escharotomy/fasciotomy, permanent nerve damage

Adult Respiratory Distress Syndrome (ARDS)

Rhabdomyolysis

Myoglobinuria

Respiratory failure - risk increases drastically after 4 days on ventilator, tracheostomy with prolonged ventilator

Organ failure

*Pneumonia - risk increases drastically after 4 days on ventilator, main complication in thermal burns

*Cellulitis - main complication in scald burns

*Urinary tract infection

*most common

Infection (wound/line/systemic)

Septicemia

Renal failure

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Arrhythmia

Psychological (HANDOUT - Emotional Distress & Resources) (HANDOUT - Anxiety During Wound Care)

(HANDOUT - Burn Pain and Patients' Responses)

_______________________________________________________________________________________

Length of Stay

61% transferred to burn center

1 day of hospitalization equals 1% TBSA

Mean length of stay in burn center was 9 days

Majority discharged home without home health

96.0% - Lived

4.0% - Mortality

Mean charge for 20-29.9% TBSA = $130,043



_______________________________________________________________________________________

Health Care Expenses

Primary Payor

21.4% - Government (Medicaid/Medicare)

19.7% - Private health insurance

12.3% - Self pay

8.8% - Workers' compensation

5.6% - Managed care

26.2% - No insurance

_______________________________________________________________________________________

Chronic Care

Discharge home

Wound care

Symptom management (HANDOUT - Neuropathic pain) (HANDOUT - Memories of Pain)

Scar management

Extensive rehabilitation

Psychological services (HANDOUT - Psychosocial Care)

Reconstructive surgeries (HANDOUT - Reconstructive Surgery)

_______________________________________________________________________________________

Wound Care

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Dressing changes twice daily

After epithelialization occurs, no further dressing changes

Begin scar management - creams/ointments, moisturizers, sunscreen & scar massage/stretching/ROM daily

Begin compression garments

Begin extensive rehabilitation - OT/PT

6 months to 2 years for burn wound to completely heal

_______________________________________________________________________________________

Nurse Life Care Planning Process

Assessment

Nurse Life Care Plan Assessment

Integumentary

Musculoskeletal

Neurologic

Respiratory

Cardiovascular

Gastro

Urinary

Psychosocial

FIM-FAM

Bathing/showering/hygiene

Grooming

Dressing

Feeding

Mobility

Transportation

Living arrangements

Safety

_______________________________________________________________________________________

Nursing Diagnosis

Impaired skin integrity

Risk for imbalanced body temperature

Risk for impaired nutrition

Impaired social interaction

Disturbed body image

Anticipatory grieving

Risk for infection

Risk for injury

Interrupted family processes

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Caregiver role strain

Post-trauma syndrome

_______________________________________________________________________________________

Outcomes

Focused on physical and psychosocial impairments and community re-integration

Life expectancy similar to general population - except organ involvement/long term complications

Long term physical, social, and psychological impairments

Symptom management

Prevent complications - physiological and psychological

_______________________________________________________________________________________

Symptom management - improve function/quality of life, reduce symptoms/pain, and prevent complications

Oral/topical medications

Home modalities

Scar management (HANDOUT - Emotional Associations with Skin)

Compression garments

Silicone gel/silicone gel sheets

Moisturizer/lotion

Sunscreen

OT/PT (HANDOUT - Restoration of Function) (HANDOUT - Hand Burns)

Scar massage/desensitization (HANDOUT - Itching, Pain & Anxiety Levels Reduced with Massage Therapy)

Thermo regulated clothing

UV protectant clothing

_______________________________________________________________________________________

Reconstructive surgeries

Excision and complex closure

Excision and advancement flap

Tissue expander - 2 procedures

Z-plasty, Y-plasty, W-plasty

Split/full thickness skin graft - donor site

Removal of lesions/tumors/neuromas

Orthopedic repair

_______________________________________________________________________________________

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Psychosocial (HANDOUT - Psychological Health and Function After Burn Injury) (HANDOUT - Community

Integration)

Crisis for patient, family, and social circle

Emotional trauma can physically alter brain

Trauma activates stress response system in brain (fight or flight syndrome)

Severe or chronic stress prevents brain from returning to relaxed state

_______________________________________________________________________________________

Trauma can damage cognitive, behavioral, and physical development in children

Surviving trauma depends on patient/family vulnerability and/or resiliency

Due to severity of medical condition, psychological condition often overlooked

Family psychological condition also often overlooked

_______________________________________________________________________________________

Psychosocial (HANDOUT - Positive Change After Severe Burn Injuries) (HANDOUT - Coping Strategies of Eight

Patients With Significant Burn Injury)

Early diagnosis & intervention improves outcome

Symptoms - sadness, hopelessness, insomnia, nightmares, anxiety

Diagnosis - adjustment disorder, anxiety, depression, Post-Traumatic Stress Disorder (PTSD)

(HANDOUT - Posttraumatic Stress Disorder & Pain Impact Functioning)

Treatment - counseling (individual and family), medications

_______________________________________________________________________________________

Educational/Vocational (HANDOUT - Barriers to Employment)

Restrictions/limitations

Environmental - temperature controlled environment, allergen free/limited dust particles, limited sun exposure

Physical - lifting/carrying/pushing/pulling/reaching, standing/walking, stairs, endurance/stamina

Psychological - societal reaction, disturbed body image

Return to school (HANDOUT - School Re-entry) (HANDOUT - Bullying on Burn Children)

Delayed growth and development

Excessive absences

Learning environment

Classmates/peers

Social scene

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Return to work (HANDOUT - Return to Work after Low Voltage Electrical Injury) (HANDOUT - Return to Work

Barriers) (HANDOUT - Barriers Impacting Employment)

Predictors of return to work - classification, TBSA, and location

1 year post burn - predictors of return to work shift to physical abilities, psychosocial factors, and working conditions

Pain and neurological impairments most common reasons for not returning to work

_______________________________________________________________________________________

Outcomes

Collaboration

Burn specialist

Physicians

Therapists (OT, PT, psych)

Home health providers

Equipment vendors

_______________________________________________________________________________________

Medical Research

Model Systems Knowledge Translation Center - Burn

2001 Clinical Practice Guidelines for burn care

American Burn Association/Journal of Burn Care & Research

International Society of Burn Injuries/Burns Journal

(HANDOUT - TENS Clinical Guidelines)

_______________________________________________________________________________________

Chronic Complications (HANDOUT - Long Term Outcomes) (HANDOUT - Long Term Sequelae of Low Voltage

Electrical Injury) (HANDOUT - Risk Factors for Ophthalmic Complications in Patients With Burns)

Hypertrophic or keloid scarring

Pruritis

Pigmentation changes

Altered sensations

Fragile skin

Temperature regulation (HANDOUT - Temperature Responses)

Loss of sebaceous glands

Pimples/blackheads

Altered hair growth pattern

Peripheral neuropathy

Vision impairment

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Epidermal inclusion cysts

Marjolin's ulcers (HANDOUT - Marjolin's Ulcers)

Skin cancer

Nerve impingement (HANDOUT - Compression Neuropathy)

Amputation

Contractures (HANDOUT - Joint Contracture)

Heterotopic ossification (HANDOUT - Heterotopic Ossification)

Osteomyelitis

Osteoarthritis/degenerative joint disease

Vascular compromise

Loss of ability to protect from sun exposure

Ulcerations and skin breakdown

Poor temperature regulation

Pain (HANDOUT - Pain Management after Electrical Injury)

Inhalation injury - progression of pulmonary insufficiency

Electrical injury - cardiovascular disease, progressive degeneration of neurological system, early arthritis, early cataract

Psychological factors (HANDOUT - Psychiatric Sequelae) (HANDOUT - Nightmares & PTSD)

_______________________________________________________________________________________

Planning

Treatment Recommendations in Nurse Life Care Plan

Medical

Physician appointments/evaluations

Burn Specialist

Plastic Surgeon

Dermatologist

Physiatrist/Pain Management

Neurological

Musculoskeletal

Respiratory

Cardiovascular

Genitourinary

Gastrointestinal

Endocrinology

Vascular

ENT

Psychiatrist

Audiologist

Ophthalmologist

_______________________________________________________________________________________

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Surgeries/Procedures (invasive vs. non-invasive)

Reconstructive surgeries

Kenalog injections

Laser resurfacing

Dermabrasion

Tattooing

Orthopedic - contractures

Hospitalizations

Pneumonia

Infection

_______________________________________________________________________________________

Therapeutic Evaluations

OT

PT

Lymphadema

Neuropsych - cognitive

Nutrition

Speech

Psychological (HANDOUT - Acute Stress in Young Children) (HANDOUT - Rates, Trends, and Severity of

Depression after Burn Injuries)

_______________________________________________________________________________________

Therapeutic Modalities

OT (HANDOUT - The Effect of Hand Burns on Quality of Life in Children)

PT

Lymphadema

Cognitive

Nutrition

Speech

Psychological (individual & family) (HANDOUT - Behavioral Perceptions)

Recreational

_______________________________________________________________________________________

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Diagnostic studies

Musculoskeletal - x-rays, MRI/CT scan, bone scan

Neurological - EMG/NCV studies

Vascular -ultrasound, Venous Doppler study

Lab work

Comprehensive metabolic panel - includes BUN & creatinine (liver & kidney function - should establish baseline &

then periodic follow-up

_______________________________________________________________________________________

Medications

Analgesic

Non-steroidal anti-inflammatory

Itching

Vitamin D supplement

Depression/anxiety

Sexual function

_______________________________________________________________________________________

Medical supplies

Wound care/dressing changes

Skin care

TED hose

_______________________________________________________________________________________

Scar Management

Compression garments

Silicone gel sheets

Splinting

Scar massage

Moisturizer

Sunscreen

UV protectant clothing

Thermo regulated clothing

Cooling agents

_______________________________________________________________________________________

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Durable Medical Equipment/Aids for Independent Function

Specifics of DME is dependent on level of physical/functional ability, and secondary issues related to burns

Examples of DME

Hospital bed

Wheelchair/walker/crutches/cane

Humidifier

Air purifier

Allergen free products

Climate controlled environment

Mattress/overlay

Anti-scald hand held shower head

Shower chair

Adaptive clothing

Household aids

_______________________________________________________________________________________

Prosthesis/Orthosis

Upper extremity splints

Upper extremity prosthesis - for function or cosmesis

Lower extremity orthosis

Lower extremity prosthesis - for function or cosmesis

Customized shoes

OT evaluation/re-evaluation

_______________________________________________________________________________________

Mobility

Wheelchair evaluation

Manual wheelchair

Power assist wheelchair

Power wheelchair

Scooter

Wheelchair maintenance/repair

Wheelchair accessories

_______________________________________________________________________________________

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Non-medical

Home care/living arrangements

Present options (present pros & cons)

Home - apartment, renovate home vs. purchase home

Assisted living

Skilled nursing facility

Housekeeping

Home/lawn maintenance

_______________________________________________________________________________________

Home health care vs. respite care

Levels of home care

Skilled (RN or LPN)

Unskilled (Certified Nursing Assistant/Home Health Aide, Personal Care Attendant, or Companion) -

bathing/showering, hygiene, grooming, dressing, feeding, cooking, cleaning, transportation, errands

Level of skilled or unskilled care dependent on nursing board in state of residence

_______________________________________________________________________________________

Architectural renovations

Safety

Barrier free

Wheelchair accessible design

Assistive technology

OT home evaluation

Contractor home evaluation

_______________________________________________________________________________________

Transportation

Airfare/overnight expenses

Driver evaluation

Wheelchair accessible transportation

Personal vehicle

Handicap parking permit

Tinted windows

Climate controlled vehicle

Public transportation

_______________________________________________________________________________________

Page 20 of 27


Educational/Vocational (HANDOUT - Military Return to Duty & Civilian Return to Work)

Vocational evaluation

Vocational case management

Vocational retraining

Vocational modifications

Restrictions - climate controlled environment, limited sun exposure, limited dust particles, limited

lifting/carrying/pulling/pushing, limited standing/walking/stairs

_______________________________________________________________________________________

Other (HANDOUT - Summer Camps) (HANDOUT - Burn Camp) (HANDOUT - Sources of Support)

(HANDOUT - Burn Survivor Perspective)

Case management

Support group - burn associations/conferences - Burn World Conference

Burn camp/family camp

Fitness - gym vs. home

Recreational modifications

Cosmetics

_______________________________________________________________________________________

Page 21 of 27


Case Study

Name: Mr. Burned

DOB: 10/19/79, Age 31

DOI: 12/19/06

Brief description of injury/accident:

Flash/flame burns

41% TBSA

Complications requiring extended 3 month hospital stay

Diagnoses:

Deep partial to majority full thickness burns to 41% total body surface area (TBSA) including face, mouth, neck, hands,

upper extremities, abdomen, back, and lower extremities

S/P compartment syndrome of upper extremities

S/P emergency escharotomies & fasciotomies, S/P skin debridement/grafting

late affects of thermal burns

hypertrophic scarring

abdominal contour deformity

inclusional cysts

chronic pruritis

S/P coccygeal and buttocks pressure ulcers (stage II – III)

S/P acute respiratory failure

S/P pneumonia

S/P hypermetabolism

S/P malnutrition

S/P pinning & arthrodesis of right little proximal interphalangeal (PIP) joint

MRSA

diffuse/chronic pain

neuropathy

adjustment disorder

post traumatic stress disorder (PTSD)

major depression

Acute Care:

escharotomies and fasciotomies

skin debridement

skin grafting (temporary & permanent)

ventilator support for ARDS

Cardiac pulmonary monitoring

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OT/PT

Psychological support

3 months in hospital

Complications:

Life threatening compartment syndrome/escharotomies and fasciotomies

Adult Respiratory Distress Syndrome (ARDS)

Systemic infections

Pneumonia

Difficulty weaning from ventilator

Decubitus ulcers

Hypertension

Hypertrophic granulation tissue

Insomnia

Intense pain

Current Care:

Dr. Turner (Burn Specialist) deferred future reconstructive surgery recommendations to Dr. Fogert (Reconstructive

Surgeon). Dr. Turner's last dictation - MMI (12 months) after last reconstructive surgery - timeframe unknown, long term

disability related to the burn accident.

Dr. Fogert's last dictation indicated – recovering from recent reconstructive surgery to right upper extremity, post-op

dressing changes, wound care, medications, OT, customized Jobst compression garments, and physician follow up.

Dr. Whetherford – chronic pain evals every two months, long term medications for pain management

Mr. Cary – psychological care every two weeks, suggested marriage counseling due to strain of injury

Urologist – evaluation recommended due to erectile dysfunction related to PTSD

Dr. Primary Care - see prn for overall health related to burn accident

OT - continues OT sessions twice weekly during recovery of right upper extremity reconstructive surgery, goal –

transition to independent home program

Scar management – wife provides care at home

Nurse case management services - coordinate medical care

Health for home based therapies & home health aide as needed after surgeries

Medical supplies/DME - see below

Page 23 of 27


Medications:

Oxycontin 30mg every 8 hours

Oxycodone 2-3 pills every 4-5 hours

Ibuprofen 800mg 1-2 times daily

Neurontin 600mg twice day

Valium 5mg twice day

Zoloft 50mg twice day

OTC Zyrtec as needed (1-2 times per week)

OTC Benadryl as needed (average daily)

Vitamin D supplement (#30)

Centrum multivitamin (#120)

Medical Supplies/DME/Aids for Independent Function:

Customized right upper extremity splint, neoprene sleeve - daily

Medical supplies for dressing changes (Xeroform, Aquacel, Silvagel, gauze, tape, etc.) - daily

Gel mattress pad (queen size)

Allergen control products (non-allergenic soaps, laundry detergent, lotion)

Humidifier

Air purifier

Shower head with anti-scald valve

Medical alert bracelet

Symptoms/Limitations:

Skin

Hypertrophic scarring on burn sites/graft sites

Pigmentation changes on burn sites/graft sites/donor sites

Significant muscle loss/atrophy on abdomen/flank/back

Scar contractures on right arm, abdomen, and back

Extreme skin tightness/scar bands/scar contractures causing limited range of motion

Takes a while to stretch and get going in the mornings due to scar tightness/scar bands/scar contractures

Skin tearing/shearing with range of motion due to scar bands/scar contractures

Extremely fragile skin, frequent breakdown/shearing/open areas of skin with slightest friction

Chronic skin breakdown/ulcerations/open wounds on arms and back

Several areas of ulceration/discoloration/bruising

Delayed wound healing

Chronic itching, increased with warm/hot environment

Clothes rub/irritate/blister skin, especially flank/waist line

Bleeding on clothes and bed sheets, frequent replacement

Excessive dryness/flaking/peeling skin, requires frequent moisturizer

Impaired temperature regulation

Inability to regulate body temperature

Temperature hypersensitivity

Easily overheated, prefers to stay inside, only outside when going to/from car

Only able to tolerate being outside for few minutes in shade/indirect sunlight (i.e., father building covered

back porch)

Takes a while to „cool down‟ once overheated, causes fatigue/exhaustion

Altered sensation over burn scars/graft sites

Unable to feel light touch on burn scars/graft sites

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Extreme sensitivity with loss of fascia/muscle and thin skin on bone

Unable to feel shower water on skin, unable to determine temperature of shower/bath water

Altered hair growth pattern

Altered perspiration

Excessive perspiration on unburned areas

Self conscious of burn scars and disfigurement

Upper extremity

Right little finger nonfunctional

Unable to flex/extend right little finger, fusion of PIP joint

Limited range of motion in right upper extremity, including shoulder

Scar band/contracture radiating from right flank into right shoulder/elbow/hand

Limited strength in right upper extremity

Limited grip strength in right hand

Limited gross motor coordination in right hand

Extremely limited fine motor coordination in right hand (i.e., unable to pick up small objects)

Vibration bothersome, both hands

Limited writing or typing with right hand

Unable to perform repetitive motion in right hand/wrist

Left hand/wrist pain with repetitive motion due to scar tightness

Right hand numbness/tingling

Right hand/wrist pain/throbbing

Drops objects when lifting/carrying with right hand

Limited abduction in right wrist

Increased symptoms with activity (less than 5 minutes) of right hand (i.e., washing dishes)

Numbness/tingling with prolonged position (longer than 20 minutes)

Tends to hold arms above head to lessen symptoms

Cold weather exacerbates symptoms

“Pain to the bone” during cold weather

Constantly wears insulated leather gloves during cold weather

Joints click/pop

Limited with caution and short timeframe for reaching/lifting/ pushing/pulling due to skin graft tightness and pressure on

scars, causes increased symptoms

Lower extremity

Lower extremity numbness/tingling with prolonged position (20 minutes)

Knee stiffness

Joints click/pop

Slow, guarded walking

Able to walk short distances

Prolonged walking/standing causes increased symptoms and fatigue (i.e., grocery shopping)

Aches/pains with prolonged walking/standing

Unable to run

Sitting causes increased symptoms (i.e., prefers to sit in recliner chair or lie on couch at home)

Unable to sit on hard surfaces due to loss of buttocks muscle, back pain, tightness with scarring, and skin

sensitivity

Limited with caution and short timeframe for crawling/kneeling/squatting/bending/stooping due to skin graft

tightness and pressure on scars, causes increased symptoms and numbness/tingling

Legs go to sleep with kneeling

Page 25 of 27


Difficulty with rising from sitting position or getting up from floor

Unable to climb ladders/heights

Other

Sharp, aching, burning, throbbing pains on 24/7 basis

Back pain

Difficulty with bending at waist

Low back pain due to weakness and skin tightness

Pain/symptoms increase with activity/prolonged position (longer than 10-20 minutes)

Pain/symptoms increase with warm/hot temperature

Pain/symptoms decrease with medications and rest/lying down

Vision worse

Sensitivity to outside light, wears sunglasses

Prefers lights off while inside

Noise sensitivity & distraction (i.e., prefers radio off while riding in car)

Throat soreness following each surgery due to intubation

Difficulty starting/stopping urine stream (Foley catheter for two months while hospitalized)

Easily fatigued/tired (i.e., became drowsy/sleepy after 3 hours into Life Care Plan assessment)

Fatigue/tiredness, needs frequent rests/breaks

Decreased stamina/endurance

Frequent breaks/rest with shopping/running errands

Overall weakness

Overall limited range of motion

Overall limited strength

Piddles around on good days

Stays on couch/recliner chair on bad days

Psychological & cognitive

No loss of consciousness during burn accident

Detailed memories of accident

Remembers fire, jumping off ladder, and being on fire

Remembers seeing clothes burning and burned/melted skin on arms

In/out of consciousness during emergency room

Hallucinations/nightmares/reliving accident while in sedated coma and on medications

Sadness/depression

Anxiety/nervousness toward accident

Increased anxiety/nervousness “over things I cannot control, such as wife driving or electrical”

Easily agitated

Easily frustrated

Easily angered

Anger toward accident, limitations, and lifestyle changes

Becomes emotionally upset with limitations and pain/symptoms

Becomes upset following EMDR sessions which surface feelings/emotions

Short tempered

Responses to situations are over exaggerated

Unable to concentrate with environmental stimuli

Short term memory deficit (i.e., forgets little things)

Requires reminders of appointment dates/times (i.e., forgot time of Life Care Plan assessment)

Forgetful (i.e., lost train of thought several times during Life Care Plan assessment)

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Difficulty planning ahead, relies on wife

Difficulty with watching others perform work (i.e., “I feel less a man”)

High fear of re-injury (i.e., putting up Christmas lights)

Overly cautious with electrical and flames (i.e., increased anxiety/fears when children around electrical

products and open flames)

Very protective regarding family due to high fear/anxiety/paranoia of injury

Increased fear/anxiety when “I cannot control situation”

Limits children‟s play/activities due to increased anxiety/fear of injury (i.e., playing outside)

No longer attends bon fire with friends

No longer uses lighter fluid on charcoal when grilling out

No longer comfortable around electricity

Self conscious toward burn/graft site scars, affects community outings/social interaction

Bothersome with public stares, directness of inquiries, and comments

Doesn‟t leave house without wearing compression garments and long sleeves to cover scarring/disfigurement

Nightmares (i.e., burn accident, trauma, hallucinations, and family being injured)

Flashbacks with seeing flames or being around electrical equipment

Difficulty sleeping, doesn‟t sleep thru night, doesn‟t feel rested in morning

“My life is centered around this”

Sexual/erectile dysfunction

Psychosocial:

Lives with common law wife since 1999

Has two children ages 6 & 8 (daughters)

Lives in mobile home

Very sedentary lifestyle indoors

Limited recreational activities/outings to the spring, fall and winter

Activities limited due to fatigue/tiredness and reducing sun exposure

Relies on his wife for wound care/dressing changes

Wife provides assistance with ADL‟s

Requires assistance with home maintenance, yard work, finances, and errands/shopping

Wife does not work outside the home

Fearful of strangers reactions to his scars

Right hand dominant

Height: 6‟ inches

Weight: 205 lbs.

Educational/Vocational:

High school graduate 1998

Attended electrical classes in high school

Started working in 10th grade as electrical apprentice

Employed with same employer since 10th grade

Performed odd jobs on the side

Out of work since accident

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Collaboration (communication with treating providers):

Medical questionnaires - forwarded to Dr. Fogert, Dr. Turner, Dr. Whetherford, Mr. Cary to address Mr. Burned‟s present

and future medical treatment.

Evaluation performed and discussions held with Dr. Burncare/Bernice Smith - Physician Assistant:

Dr. Burncare (Burn Specialist) noted: severe unstable scarring with chronic, open areas - attributed to scar

bands/contractures, delayed healing - immuno-compromised system, recommended long-term medical care, specialty

consultations, diagnostic studies, reconstructive surgeries/procedures, therapeutic evaluations/modalities, psychological

evaluations and counseling sessions (individual and family), medications for symptom management, lab work, long-term

scar management, and anticipated complications. Complications more likely than not in future: hypertrophic scarring,

pigmentation changes, altered sensations, tenderness at burn/graft sites, heat/cold intolerance, at higher risk for sunburn,

at higher risk for skin cancer (Basal cell carcinoma), allergic reactions/sensitivity to products

Dr. Turner‟s response: Diagnosis: S/P 40% TBSA

Current treatment plan: long-term medical care, specialty consultations, periodic diagnostic studies, reconstructive

surgeries/procedures as per Dr. Fogert, intermittent psychological evaluations and counseling sessions (individual and

family), long-term medications for symptom management, periodic lab work, long-term scar management, and anticipated

complications

Will Mr. Burned need ongoing/lifetime medical care related to burns? Yes

Will Mr. Burned need ongoing/lifetime medical care under specialty physicians? Yes

Dr. Whetherford‟s response: Diagnosis: diffuse pain to back/arms/abdomen 2nd

to scar formation with skin graft

placement.

Current treatment plan: long-term medical care, periodic diagnostic studies, psychological evaluations/ counseling

sessions (individual and family), long-term medications unknown duration, periodic lab work, anticipated complications

of drug dependency and constipation

Mr. Cary‟s response: Diagnosis of PTSD, major depressive episode, pain associated with both psychological factors and a

general medical condition

Current treatment plan: EMDR for PTSD, and cognitive behavioral therapy for depression and chronic pain management;

long term psychological care every two weeks; anticipated complications of adjustment to chronic pain, marital issues,

social issues, occupational issues, support issues, and economic issues

Documents

Nurse Life Care Planning - Through the Ages Section 5 5 Workbook.pdf · Lund & Browder chart Adult TBSA differs from pediatric TBSA Children have proportionally larger heads and smaller