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The psychology of burn care.

I is difficult to comprehend all the needs of the patientwith 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. Emotional devastation is the culmination of the injury, hospital stay, and consequences of the burn. McNulty 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. 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. However, burn severity is not predictive of psychological sequela. 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. 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. 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. The critical stage is triggeredby stressors. Cognitive effects include drowsiness, confusion, and delirium. In patients who developed delirium within 48 hours, 30% to 70% were not related to sepsis. The patients may experience psychosis related to infection, alcohol withdrawal, metabolic issues, or drugs. Opioid medication and fluid and electrolyte imbalance may contribute to delirium, whereas lethargy and coma result in burn encephalopathy in this stage. 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. Jackie S. Smith, ARNP, DHSc, is an Advanced Registered Nurse Practitioner, Department of Trauma Surgery, Tampa General Hospital; Kirk R. Smith, ARNP, DHSc, is an Advanced Registered Nurse Practitioner, Orthopedic Associates of Tampa; and Susan L. Rainey, ARNP, DHSc, Tampa Regional Burn Center and Adjunct Faculty, College of Nursing, University of South Florida, Tampa, Fla. Corresponding author: Jackie S. Smith, ARNP, DHSc, 2635 N. Dover Road, Dover, FL 33527 (email: ksmith44@tampabay.rr.com). Janice DelGiorno, MSN, CCRN, ACNP-BC Section Editor