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Nurse practitioners and physician assistants are prime health care providers for chronic burn management.
Nurse practitioners and physician assistants are prime health care providers for chronic burn management, which can last anywhere from months to years.
The main goals of chronic burn management revolve around treating the wound, pain, and psychological stress.
Meghan Sullivan, PharmD, BCACP, director of the Center for Medication Therapy Management at Creighton University School of Pharmacy and Health Professions, and Patrick Dougherty, PharmD, BCPS, a clinical pharmacist at the Emergency Medicine Peninsula Regional Medical Center, recently discussed some steps for treating patients with burns.
At the 2015 American Society of Health-System Pharmacists Midyear meeting, Dr. Dougherty toldContemporary Clinicthat nurse practitioners and physician assistants can help patients take care of their skin post-injury.
“Working in conjunction with pharmacists [and] physical therapists, and helping these patients try to get back to their normal lives they had prior to the injury—I think there’s definitely a role for nurse practitioners and physician assistants,” he said.
Some of the challenges retail clinicians should expect to face when confronted with chronic burn management are pain variability, hyperalgesia, pharmacokinetics, and dosing of medication, Dr. Sullivan said.
She highlighted some good options for antibiotics, including bacitracin zinc/polymyxin B sulfate, erythromycin, mupirocin, and neomycin.
Chlorhexidine, Dakin’s solution, mafenide acetate, povidone-iodine ointment, and silver sulfadiazine can serve as topical antimicrobial agents.
Retail clinicians can also recommend a few skin protectants such as allantoin, cocoa butter, petrolatum, shark liver oil, white petrolatum, and vitamin E. Topical anesthetics may include benzocaine, dibucaine, lidocaine, promoxine, and tetracaine, according to Dr. Sullivan.
Here are 6 important facts to know about the chronic treatment of burns:
1. Maintain a moist environment.
When retail clinicians look for appropriate wound dressings, they should make sure that the wound is able to remain both moist and permeable to air.
Another consideration would be to make sure that the wound is completely free of particulate or toxic contaminants.
Clinicians are tasked with finding a delicate balance between keeping the dressing secure and allowing it to be removable in a way that will not disrupt new skin tissue.
2. The type of dressing matters.
If nurse practitioners and retail clinicians decide to use gauze on a wound, they should be sure that it is non-occlusive fiber, and it should also be accompanied with some sort of topical treatment.
While gauze can be a good fit for a wound temporarily, it should not be used long-term, Dr. Sullivan said. The wear time should be around 1 to 2 days.
Some potential non-adherent dressings include Nexcare Pads and Telfa.
Meanwhile, antimicrobial or silver-containing dressings, such as Acticoat and Aquacel, may have anti-inflammatory properties.
“These are a must-have for those who are at risk for infection,” Dr. Sullivan said, though she also cautioned that they should not be used “right off the bat.”
The recommended wear time for antimicrobial or silver-containing dressings is 2 to 7 days.
For patients with superficial partial-thickness burns in later phases of re-epithelialization, DuoDerm, Tega-sorb, and Ultec can be worn for up to 7 days.
Barrier dressings like Tegaderm and Carra Film, which are both waterproof, are good resources for managing burns of various sizes. These should be worn between 4 to 7 days.
For patients with first- and second-degree burns, semi-permeable, absorptive, inert foam dressings like Allevyn, Epigard, and Lyofoam may be good options. These foam dressings should not be used more than 3 days, and they should not be used for third-degree burns.
Finally, biosynthetic dressings like Biobrane can provide a semi-biologic skin substitute. This kind of product would best serve patients with full-thickness burns, those with large areas of burns, and patients who have burns on their hands, feet, and joints.
These dressings have a longer wear time of up to 2 weeks, but Dr. Sullivan noted that they can be expensive, so health care providers should consider insurance issues.
3. Patient education is key.
When a retail clinician sends home a patient with burns, the patient should know how to handle these 6 issues:
4. Patients should know what to expect about scar management.
For patients with scars, chronic management is key to repairing the skin. Some ways health care providers can help is through scar massage, topical silicone, and steroid injections.
Retail clinicians can also suggest that patients use compression garments. Surgery or serial casting may also be necessary.
5. Pain management can be broken down into several categories: background, procedural, breakthrough, and chronic.
Background pain may be treated with long- or short-acting oral opioid analgesics, oral nonsteroidal anti-inflammatory drugs, or intravenous (IV) opioid infusions.
For procedural pain, IV opioid analgesics, IV anesthetic agents, oral opioids, oral anesthetic agents, and oral transmucosal agents can help.
If there is breakthrough pain, it may mean that the patient has built up a tolerance or has had troubles with pain management in the past.
Chronic pain can be treated with non-opioid analgesics, neurologic agents, or antidepressants.
6. There are 3 stages to burn recovery.
After their injury, patients can expect to go through 3 phases.
The first step is to get over the critical injury. This may lead patients to feel as though they may not survive the ordeal. They may also experience fear, pain, and confusion.
The second phase is acute recovery, which is when depression, post-traumatic stress disorder (PTSD), fear, and sleep problems may set in.
The final stage is psychological recovery, when patients may experience some depression and waning PTSD.
“Before you’re discharging a patient, you really have to understand where they’re at in terms of their mindset and their ability to take care of themselves,” Dr. Sullivan said.