reference. The patient should also be turned frequently i. e. q2h, assessed for his/her susceptibility to pressure sores and appropriate preventive or therapeutic interventions.

For the critically ill, ventilated patient, the nurse pays close attention to the security of the airway – that the endotracheal tube is placed correctly, secured adequately to prevent accidental dislodgement during care or transport, and providing appropriate ventilation to the patient. The respiratory rhythm and character need to be monitored closely, along with signs of respiratory distress including nasal flaring, wheezes, stridor, intracostal/sternal retraction, tachypnea, and triggering the ventilator. When suctioning the patient, attention should be focussed on the colour (especially if there is soot from an inhalation injury), odour and amount of sputum. For non-intubated patients, the same assessment takes place when the patient coughs up sputum on his/her own. Chest excursion needs also to be monitored to ensure good expansion and quality of respirations and, whether or not a releasing escharotomy is needed or requires revision. The nurse alsoensuresthepatientisreceivingadequateamounts of analgesia to control pain and anxiolytics/sedating agents to minimize anxiety and agitation. Background pain (pain that is continuously present) and procedural pain (intermittent pain related to activity or procedures) must be continually assessed, through the use of evidence-based pain scales. Unrelieved pain can have long lasting effects, including stress-related immunosuppression, increased potential for infection, delayed wound healing and depression [11]. The patient’s level of responsiveness to his/her surroundings, family members and stimuli in the room should also be assessed each hour. The use of neuromuscular agents and sedatives also needs to be documented, along with the use of an evidence-based sedation scale.

Peripheral and central lines must be inspected frequently to ensure they are patent and secure as access is usually very limited in burn patients and so very necessary during the emergent phase. Fluid resuscitation, vasoactive drugs, pain and anxiety medications, along with numerous other intravenous drugs, require this method of access. Great care is taken not to pull them out during the admission procedure, dressing changes or transport. The urinary catheter should also be examined routinely for pa-

tency and the perineal area kept clean and dry. The bladder should be palpated for distention. Hourly urinary output is a crucial indicator of the success of emergent period fluid resuscitation, in addition to colour, clarity, odour and sediment.

Nursing interventions: Acute phase

As the patient progresses to the acute phase of care, the focus of nursing expertise is on wound management, psychosocial interventions, pain management and physical/occupational therapy. Wound care focuses on time-limited debridement of loose tissue, evacuation of blisters and gentle removal of exudate from the wound surface. A variety of dressings and/or biological/biosynthetic/synthetic skin substitutes are available and may be incorporated into the patient’s plan of care. If the patient requires surgery, the nurse can explain the procedures and care required. Patients are frequently too overwhelmed to remember the burn surgeon’s explanations pre-operatively.

Patient and family education about wound care procedures, rationale for particular dressings and pre and post-op care can be provided verbally and enhanced through booklets, articles and videos. Incorporating cultural and learning styles into the educational process increases the likelihood the knowledge will be retained by the patient and family. Burn patients continue to be hypermetabolic long after their wounds have healed. Proper nutrition plays a key role in their recovery. Increased caloric and protein requirements are usually met through nasogastric or nasojejunal tube feeding to maintain mucosal integrity. Nursing assessment includes frequent inspection of tube placement and patency. Placement is initially confirmed through radiographic confirmation. If gastric residuals are greater than the desired parameters stated in the patient’s care plan, modifications need to be made in a timely fashion. The involved nare should be assessed for pressure necrosis and the feeding tube secured to avoid premature removal. The tube may also be used for free water flushes, if the patient has high sodium levels, and for medication administration. The patient should also be assessed for a daily bowel movement. Progress during the acute phase can be slow. It may be a very frustrating time for patients and families when the efforts being put forward seem to result in such

small, daily gains. The nurse can play an important role as coach and cheerleader, bringing to the patient’s attention the progress that he/she notices. Nursing can also reinforce the rehabilitation therapists’ plans of care by ensuring exercises are performed and splints are worn according to schedule. Encouraging the patient to sit up in a chair for periods at a time and to ambulate to/from hydrotherapy and around the nursing unit, not only brings physical benefit, but emotional rewards as well. Staff and visitors alike comment on how well the patient is doing and how much improvement they see.

Families may need to be encouraged to take care of themselves now that their loved one is out of immediate danger. For some, that may mean spending more time taking care of things at home and less time at the hospital. Out-of-town families may return home for a few days. Upon their return, they may also be encouraged to participate in their loved one’s care, to the extent they feel comfortable. Activities include assisting with hygiene and skin care, helping apply splints, and coaching through the exercise routines. As the patient is able to demonstrate increasing levels of self-care, family may need to be advised when to help and when to stand back and offer encouragement. Emotional support may be needed as the patient can verbally lash out in frustrated anger when he/she is having difficulty doing something and family don’t intervene. It may also be helpful for family to see the patient’s wounds, from time to time, as it helps to put the recovery process into perspective. From then on, they have a reference point to compare how far the patient has come and what might lie ahead in the next phase.

Nursing interventions: Rehabilitative phase

Patients and families alike eagerly anticipate the final, rehabilitative phase of care. The focus for nursing is on psychosocial interventions and discharge planning. But for some, the reality is harder to accept than they had imagined. Some patients have magical expectations about how things will be once they return home. Others express frustration at not being able to go home just yet and of the need to be transferred to a rehabilitation facility. Some patients may not want to participate in their exercise routines or wear their pressure garments and splints as often as

is really necessary. Nursing staff can play an important role of supportive listener/coach, acknowledging how hard it must be to keep going, day after day, knowing all the patient has been through and how long and difficult the journey back can be. Shortterm compromises can be negotiated to a full recovery in order to get the patient back on track towards optimal recovery. Every patient can benefit from a day off to recharge one’s energy and renew one’s commitment to the plan of care.

Wound care during the rehabilitation period is usually minimal. The healed skin, fresh grafts and donor sites are fragile and require a thin layer of polymyxin B sulphate (Polysporin ) ointment until they have “toughened” up a bit. At that point, waterbased moisturizers are applied to reduce the dryness, flakiness and itchiness. The gentle act of applying the cream serves as a form of beneficial massage during the scar maturation process. Nursing staff can also point out to patients that the act of applying creams is a useful, non-threatening way to both desensitize the skin and to familiarize oneself with the parts of one’s body that are burned. It can be a helpful strategy for family members also. For couples, it may be a helpful adjunct to restoring intimacy back into their relationship, as the spouse makes the slow transition from care-giver to lover. The time that nurses spend with patients performing wound care can be very therapeutic if the nurse takes cues from the patient and uses the opportunity to explore how the patient views his/her altered appearance.

During this final phase of care, patients are encouraged by their nurses to perform as many selfcare activities as possible. Rehabilitation routines are adjusted as the patient’s abilities improve. There may be periods, however, when patients are depressed, frustrated and angry, and don’t want to participate in care. Those very normal feelings need to be acknowledged and worked through in order to be able to move forward. Perhaps for the first time, patients are able to acknowledge the losses they have experienced since the burn injury. Now that physical survival is ensured, the body seems to shift its energies to the psychological impact of the trauma. Some of this realization begins in the acute phase, but the majority of the work begins now. Nurses can provide patients with opportunities to verbalize their feelings in a non-judgemental atmosphere. Talking

about their fears and anxieties is an important first step in overcoming them. Many therapeutic conversations take place between nurses and patients if the nurse is responsive to the sometimes subtle cues the patient gives out indicating a readiness to talk. In general, patients need someone to listen, to acknowledge what they are feeling, and to validate that other burn patients have felt the same things and successfully returned to a productive life. Burn nurses can see the possibility of a new and rewarding life at a time when the burn patient sees nothing but endless adjustments, physical and emotional. The leap from seeing oneself not as a “burn victim” but as a “burn survivor” takes time and helpful encouragement from people who know that things will get better. Nurses can encourage patients to link up with burn survivor support groups and seek support from a social worker, clinical nurse specialist, psychologist or psychiatrist. Family therapy may be helpful if there are issues between husband and wife, parents and children. Couple therapy may assist in overcoming difficulties with sexuality post-burn. In most instances, these problems correct themselves, with love and patience, as both partners need time to adjust to the burn survivor’s altered body image, fragile tissues and stiff joints.

Adapting to a facial difference can be a very difficult journey for patients and families. The biggest challenge is posed by the social response they experience. They can no longer blend into the crowd anonymously. Preparing the burn survivor to see him/herself for the first time requires careful thought and preparation. Nurses can assist patients to iden-

tify their pre-burn coping strategies and help apply them to the present situation. Social re-entry and communication skills need to be learned and practiced in order for patients to be able to move about in public with as much self-confidence as possible. Burn survivor, Barbara Kammerer Quayle [12] has developed the BEST program that teaches simple, effective ways to improve communication and create positive relationships, using STEPS to Self-Es- teem (Fig. 24). REACH OUT is based on “Changing Faces” founder, James Partridge’s work [13] on how communication skills can be used to help people cope with feelings of self-consciousness and others’ reactions (Fig. 25). More recently, his “3–2–1-GO” [14] program has given burn survivors another useful skill to develop, while navigating through the challenges of communicating and interacting with the public when you have a facial difference.

Nurses can begin to explore such opportunities with patients before and after discharge. Post-dis- charge, nursing care is provided in a burn clinic setting that may be staffed by burn centre nurses, a clinic nurse and/or a clinical nurse specialist. Fol- low-up during this time is extremely important as the transitions from hospital to home are difficult and complex. The need for support and guidance continues for several years post-burn. From a professional nursing perspective, the opportunity to work among the burned through months and years of recovery is a privilege. The courage and perseverance displayed by burned people and their families is truly a testament to the resilience of the human spirit.