1. Smith, Jackie S. ARNP, DHSc
  2. Smith, Kirk R. ARNP, DHSc
  3. Rainey, Susan L. ARNP, DHSc

Article Content

It is difficult to comprehend all the needs of the patient with burns. Caring for these patients can be a daunting task because the psychological demands of the patient remain long after the physical aspects of the burn are resolved. The challenge comes in developing a plan of care to address the complex psychological needs of each patient with burns. Nurses must venture into resources that may not be readily available to apply therapeutic intervention.


Psychosocial issues in the burn patient are profound. Psychological recovery parallels physical recovery. A psychological survey needs to be addressed and the patient's psychological status upheld.1 Emotional devastation is the culmination of the injury, hospital stay, and consequences of the burn. McNulty2 estimates that one half of all burn patients become permanently disabled, with a large segment having psychological impairment. Psychological sequela that impairs function includes fear, anxiety, stress disorder, and behavior regression.2 A significant number of men than women and boys than girls sustain burns. Women and girls, however, experience more psychosocial issues in the aftermath of burns, especially self-esteem issues due to disfigurement and notably in adjustments of body image and sexual dysfunction.


One of the most accurate predictors of mental-health symptomology after a burn is psychological health before the injury.3 However, burn severity is not predictive of psychological sequela.4 Preexisting psychological conditions may predispose to a disturbance after injury. This is especially the case when medications are involved. A psychological disorder may be brought to the forefront by chemical imbalances common to burn patients. Of central importance is timely identification of comorbidities of burns, such as posttraumatic stress disorder, substance abuse, and depression. Psychological issues are dynamic in nature, multifactorial, and should be assessed and treated as such.


Grief is a predominant emotion after a burn injury and may proceed a period of mourning. Denial is common, although intensity varies. Patients may experience the loss of family members or their former life. Loss of body image can result in low self-esteem. Disability and disfigurement take a toll on an already fragile mental state. A host of psychological sequela can impair function, not the least of which are fear, anxiety, acute stress disorder, and behavioral regression.2 Therapeutic intervention includes allowing the patient and family to ventilate feelings, focus on strengths, and find the positive meaning in recovery. Emotional support is the most beneficial strategy to combat against psychological symptoms.5


Psychological burn care parallels physical care and can be broken down into stages: critical, acute (first 3 months), chronic or subacute (after the first trimester), and delayed (greater than 6 months). Psychological symptoms range from mild, such as fear, sadness, uneasiness, worry, and lack of self-confidence, to severe, like depression, anxiety, delirium, and posttraumatic stress disorder. Adjustment is not necessarily directly affected by burn severity but may be related to its visibility.6


The critical stage is triggered by stressors. Cognitive effects include drowsiness, confusion, and delirium. In patients who developed delirium within 48 hours, 30% to 70% were not related to sepsis.3 The patients may experience psychosis related to infection, alcohol withdrawal, metabolic issues, or drugs.7 Opioid medication and fluid and electrolyte imbalance may contribute to delirium, whereas lethargy and coma result in burn encephalopathy in this stage.1


Sleep disturbances, depression, pain, phobias, anxiety disorders, and nightmares plague patients in the acute phase. Patients are given less sedation but must endure painful treatments. It is also in the acute phase that premorbid psychopathology begins to surface. Dysfunctional and disruptive behaviors and personality disorders become prominent. Pharmacotherapy can be augmented with therapy such as hypnosis and relaxation techniques.


The subacute or chronic phase signals issues that relate to appearance, function, and impact of injuries. Devastation, especially with facial wounds, is common in this phase.3 Patients may experience survivor's guilt, shame, and self-consciousness. Even minimal functional limitations give way to depression.8 The emphasis in the chronic stage is rehabilitation. Issues in this phase usually take place in the clinic setting.


Reentry into society is the period of recovery beginning after discharge. Long-term rehabilitation requires an adjustment to limitations caused by the burn. The goal of rehabilitation is to restore functionality. This is also the point that patients return to the workforce. Completion of vocational counseling begun in the hospital is continued. Concentration is on assets and limitations, assessment of the need for assistive devices, and other accommodations. Psychiatric outpatient care may be necessary in the long-term. Mood swings, anger, depression, and anxiety generally diminish after the first year. Health does improve as time from the injury evolves.


Personality traits and the individual's coping strategies developed preburn guide postburn adaptation. A coping strategy can simply be defined as any effort aimed at avoiding problems, especially stressors. Coping strategies can be characterized as any task that helps the individual maintain physical and psychological well-being. Care must be taken because at this stage, alcohol, drugs, and tobacco may be used to manage burn psychomorbidities. Other maladaptive behaviors are self-distraction, avoidance, and wishful thinking. Adjustment difficulties persist more than a year after discharge, decreasing quality of life and self-esteem. Working to help the family to help the patient is an important form of therapy.


One of the most difficult issues in burn care is pain. Pain is experienced through physical therapy, reconstructive surgery, and skin grafting. Responses may include maladaptive behavior such as aggression and dissociation. Patients may exhibit agitation, anxiety, and anger in anticipation of pain. Uncooperative behavior such as crying and shouting is common.


Background pain can be controlled by a combination of pharmacological and nonpharmacological approaches. Procedural pain may be easier to endure because of its transient nature. Long-acting opiates may be given on a schedule for background pain, whereas short-acting opiates can be given for procedural pain as needed. Pain should not be confused with anxiety. Anxiolytics can be added to control associated anxiety. Other methods of pain control may include behavior therapy, hypnosis, and virtual reality, to name a few. Finding the right combination to control the pain is paramount.


The key issue to coping after burn injury may be appearance. Even small burns can seem insurmountable. Again, preburn personality and coping strategies help patients deal with these problems. This may also be linked to functional limitations caused by pain, splints, and edema. However, disfigurement may be overwhelming. Patients may become childlike in their behavior, unable to perform simple self-care. Appearance is also linked to sexuality, although it is probably the least reported.


Children are a special population in burn care. Although children share similar physical experiences with that of adults, they differ greatly in behavioral responses.2 Behavioral problems range from hyperactivity to anxiety to attitude and sensation-seeking behaviors.9 Psychological counseling and support groups are important; however, burn camps and school are unique ways to touch a child's life.


Surviving the burn, the patient is reborn physically, psychologically, and spiritually. The first year is generally the most difficult. It is a time of vocational and emotional adjustment. Others may view the patient as disabled, even though the patient does not consider himself or herself as such. This may be due, in part, to patients relinquishing control to others. Practitioners need to encourage patients to make decisions regarding their care, thereby exerting their independence.


Social support assists patients in dealing with pain and incapacitation. This, in turn, promotes the best quality of life after burn experience. Psychiatric consultation is appropriate for all burn patients to provide psychological support and medication as needed.1 The continuum of care can be carried out in the community mental-health setting, providing services of counseling, active listening, and psychological support. Support groups and peer counseling round out the lengthy period of recovery. The goal of therapy is to maximize the patients' skill at returning to their life, altered as little as possible by the issue of the burn injury.




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