NURSING PROCESS: CARE OF THE PATIENT DURING THE REHABILITATION PHASE
Information about the patient’s educational level, occupation, leisure activities, cultural background, religion, and family inter-actions is obtained early. The patient’s self-concept, mental sta-tus, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern are also essential components of a comprehensive assessment. Information about the patient’s general self-concept, self-esteem, and coping strate-gies in the past will be valuable in addressing emotional needs.
Ongoing physical assessments related to rehabilitation goals include range of motion of affected joints, functional abilities in activities of daily living, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neuro-logic damage), activity tolerance, and quality or condition of healing skin. The patient’s participation in care and ability to demonstrate self-care in such areas as ambulation, eating, wound cleaning, and applying pressure wraps are documented on a reg-ular basis. In addition to these assessment parameters, specific complications and treatments require additional specific assess-ments; for example, the patient undergoing primary excision re-quires postoperative assessment.
Recovery from burn injury involves every system of the body. Therefore, assessment of the burn patient must be comprehen-sive and continuous. Priorities will vary at different points dur-ing the rehabilitation phase. Understanding the pathophysiologic responses to burn injury forms the framework for detecting early progress or signs and symptoms of complications. Early detection leads to early intervention and enhances the potential for suc-cessful rehabilitation.
Based on the assessment data, priority nursing diagnoses in the long-term rehabilitation phase of burn care may include the following:
· Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting, and limited endurance
· Disturbed body image related to altered physical appearance and self-concept
· Deficient knowledge about postdischarge home care and follow-up needs
Based on the assessment data, potential complications that may develop in the rehabilitation phase include:
· Inadequate psychological adaptation to burn injury
The major goals for the patient include increased participation in activities of daily living; increased understanding of the injury, treatment, and planned follow-up care; adaptation and adjust-ment to alterations in body image, self-concept, and lifestyle; and absence of complications.
Nursing interventions that must be carried out according to a strict regimen and the pain that accompanies movement take their toll on a burn patient. The patient may become confused and dis-oriented and lack the energy to participate optimally in care. The nurse must schedule care in such a way that the patient has periods of uninterrupted sleep. A good time for planned patient rest is after the stress of dressing changes and exercise, while pain interventions and sedatives may still be effective. This plan must be communi-cated to family members and other care providers.
Burn patients may have insomnia related to frequent night-mares about the burn injury or to other fears and anxieties about the outcome of the injury. The nurse listens to and reassures the patient and administers hypnotic agents, as prescribed, to pro-mote sleep.
Reducing metabolic stress by relieving pain, preventing chill-ing or fever, and promoting the physical integrity of all body sys-tems will help the patient conserve energy for therapeutic activities and wound healing.
The nurse incorporates physical therapy exercises in the pa-tient’s care to prevent muscle atrophy and to maintain the mo-bility required for daily activities. The patient’s activity tolerance, strength, and endurance will gradually increase if activity occurs over increasingly longer periods. Fatigue, fever, and pain toler-ance are monitored and used to determine the amount of activ-ity to be encouraged on a daily basis. Activities such as family visits and recreational or play therapy (eg, video games, radio, TV) can provide diversion, improve the patient’s outlook, and increase tolerance for physical activity.
Burn patients frequently suffer profound losses. These include not only a loss of body image due to disfigurement but also losses of personal property, homes, loved ones, and ability to work. They lack the benefit of anticipatory grief often seen in a patient approaching surgery or a person dealing with the terminal illness of a loved one.
As care progresses, the patient who is recovering from burns be-comes aware of daily improvement and begins to exhibit basic con-cerns: Will I be disfigured? How long will I be in the hospital? What about my job and family? Will I ever be independent again? How can I pay for my care? Was my burn the result of my care-lessness? As the patient expresses such concerns, the nurse must take time to listen and to provide realistic support. The nurse can refer patients to a support group, such as those usually available at re-gional burn centers or through organizations such as the Phoenix Society. Through participation in such groups, patients will meet others with similar experiences and learn coping strategies to help them deal with their losses. Interaction with other burn survivors allows the patient to see that adaptation to the burn injury is pos-sible. If a support group is not available, visits from burn survivors can be helpful to the patient coping with such a traumatic injury.
A major responsibility of the nurse is to assess constantly the patient’s psychosocial reactions. What are the patient’s fears and concerns? Does the patient fear loss of control of care, indepen-dence, or sanity itself? Is the patient afraid of rejection by family and loved ones? Does he or she fear being unable to cope with pain or physical appearance? Does the patient have concerns about sexuality, including sexual function? Being aware of these anxieties and understanding the basis of the patient’s fears enable the nurse to provide support and to cooperate with other members of the health care team in developing a plan to help the patient deal with these feelings.
When caring for burn patients, the nurse needs to be aware that there are prejudices and misunderstandings in society about those who are viewed as different. Opportunities and accommodations available to others are often denied those who are disfigured. Such amenities include social participation, employment, prestige, var-ious roles, and status. The health care team must actively promote a healthy body image and self-concept in burn survivors so that they can accept or challenge others’ perceptions of those who are disfigured. Survivors themselves must show others who they are, how they function, and how they want to be treated.
The nurse can help patients practice their responses to people who may stare or inquire about their injury once they are dis-charged from the hospital. The nurse can help patients build selfesteem by recognizing their uniqueness—for example, with small gestures such as providing a birthday cake, combing the patient’s hair before visiting hours, giving information about the avail-ability of a cosmetician to enhance appearance, and teaching the patient ways to direct attention away from a disfigured body to the self within. Consultants such as psychologists, social workers, vocational counselors, and teachers are valuable participants in assisting burn patients to regain their self-esteem.
With early and aggressive physical and occupational therapy, contractures are rarely a long-term complication. However, sur-gical intervention is indicated if a full range of motion in the burn patient is not achieved.
Some patients, particularly those with limited coping skills or psychological function or a history of psychiatric problems before the burn injury, may not achieve adequate psychological adapta-tion to the burn injury. Psychological counseling or psychiatric referral may be made to assess the patient’s emotional status, to help the patient develop coping skills, and to intervene if major psychological issues or ineffective coping is identified.
As the inpatient phase of recovery becomes shorter, the focus of re-habilitative interventions is directed toward outpatient care or care in a rehabilitation center. In the long term, much of the care of healing burns will be performed by the patient and others at home. Throughout the phases of burn care, efforts are made to prepare the patient and family for the care that will continue at home. Thus, they are instructed about the measures and procedures that they will need to perform. For example, patients commonly have small areas of clean, open wounds that are healing slowly. They are in-structed to wash these areas daily with mild soap and water and to apply the prescribed topical agent or dressing.
In addition to instructions about wound care, patients and families require careful written and verbal instructions about pre-vention of complications, pain management, and nutrition. In-formation about specific exercises and use of pressure garments and splints is reviewed with both the patient and family; written instructions are provided for reference. They are taught to recog-nize abnormal signs and instructed to report them to the physi-cian. All of this information will enable patients to progress successfully through the rehabilitative phase of burn manage-ment. The patient and family are assisted in planning for the pa-tient’s continued care by identifying and acquiring supplies and equipment that are needed at home (Chart 57-6).
Follow-up care by an interdisciplinary burn care team will be nec-essary. Preparations should begin during the early stages of care. Patients who receive care in a burn center usually return to the burn clinic or center periodically for evaluation by the burn team, modification of home care instructions, and planning for recon-structive surgery. Other patients receive ongoing care from the general or plastic surgeon who cared for them during the acute phase of their management. Still other patients require the services of a rehabilitation center and may be transferred to such a center for aggressive rehabilitation before going home.
Many patients require outpatient physical or occupational therapy, often several times weekly. It is often the nurse who is responsible for coor-dinating all aspects of care and ensuring that the patient’s needs are met. Such coordination is an important aspect in assisting a burn victim to achieve independence.
Patients who return home after a severe burn injury, those who cannot manage their own burn care, and those with inadequate support systems will need referral for home care. During visits to the patient at home, the home care nurse assesses the pa-tient’s physical and psychological status as well as the adequacy of the home setting for safe and adequate care. The nurse mon-itors the patient’s progress and adherence to the plan of care and notes any problems that interfere with the patient’s ability to carry out the care. During the visit, the nurse assists the patient and family with wound care and exercises. Patients with severe or persistent depression or difficulty adjusting to changes in their social and/or occupational roles are identified and referred to the burn team for possible referral to a psychologist, psychi-atrist, or vocational counselor.
The burn team or home care nurse identifies community re-sources that may be helpful for the patient and family. Several burn patient support groups and other organizations throughout the United States offer services for burn victims. They provide caring people (often recovered burn victims) who can visit a burn patient in the hospital or home or telephone the patient and fam-ily periodically to provide support and counseling about skin care, cosmetics, and problems related to psychosocial adjustment. Such organizations, and many regional burn centers, sponsor group meetings and social functions at which outpatients are wel-come. Some also provide school-reentry programs and are active in burn prevention activities. If more information is needed re-garding burn prevention, the American Burn Association can help locate the nearest burn center and offer current burn prevention tips (see Chart 57-2).
Because so much attention is given to the burn wound and the treatments that are necessary to treat the burn wound and to prevent complications, the patient, family, and health care providers may inadvertently ignore the patient’s ongoing needs for health promotion and screening. Thus, the patient and fam-ily are reminded of the importance of periodic health screening and preventive care (eg, gynecologic examinations, dental care).
Expected patient outcomes may include:
1) Demonstrates activity tolerance required for desired daily activities
a) Obtains sufficient sleep daily
b) Reports absence of nightmares or sleep disturbances
c) Shows gradually increasing tolerance and endurance in physical activities
d) Can concentrate during conversations
e) Has energy available to sustain desired daily activities
2) Adapts to altered body image
a) Verbalizes accurate description of alterations in body image and accepts physical appearance
b) Demonstrates interest in resources that may improve body appearance and function
c) Uses cosmetics, wigs, and prostheses as desired to achieve acceptable appearance
d) Socializes with significant others, peers, and usual social group
e) Seeks and achieves return to role in family, school, and community as a contributing member
3) Demonstrates knowledge of required self-care and follow-up care
a) Describes surgical procedures and treatments accurately
b) Verbalizes detailed plan for follow-up care
c) Demonstrates ability to perform wound care and pre-scribed exercises
d) Returns for follow-up appointments as scheduled
e) Identifies resource people and agencies to contact for specific problems
4) Exhibits no complications
a) Demonstrates full range of motion
b) Shows no signs of withdrawal or depression
c) Displays no psychotic behaviors
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