Which action would the nurse perform immediately for a client who survived a severe burn injury?

Major burn injuries can change how the body looks and works. Burn injuries can also lead to body image concerns. Body image refers to how happy, comfortable, and confident a person is with how he or she looks. About one-third of burn survivors have severe distress about changes in the way their body looks, feels, and works when they are first hospitalized. Almost everyone has ups and downs as they heal. But most children and adults get used to the change in their appearance over time.

What causes body image concerns?

Many factors may cause body image concerns after a burn injury. These include how a person feels about his or her burns; flawed coping strategies; and a person’s gender, mental health history, and support network. Body image distress may involve:

• Grief or sadness about changes in appearance and physical abilities,
• Anxiety about social or intimate settings where the scars may be seen,
• Anxiety about actual and expected questions and stares from people in the community,
• Worry about how people will react when they see the scars, and
• A desire to be with a trusted person when in public places.

These feelings are normal. The following sections describe ways you can ease this distress and feel more positive about your body.

Phases of healing

After a burn injury, your skin goes through several phases of healing. During each phase, it’s important to follow the advice of your burn team to improve how your skin heals.

Wound Healing Phase

What you see: Lighter colored skin replaces open wounds. For darker skinned people, pink colored skin may replace the burn wound at first and then lessen with time. Generally, the faster a wound heals, the less scarring will occur.

What you can do: Get involved with your wound care as much as possible, such as helping with the dressing changes. A cleaner wound heals faster. The more aware and involved you are with your wound care, the more likely you are to take good care of your burn.

Scar Formation Phase

What you see: After the wound heals, the skin changes over the next 3–4 months. It becomes darker, stiffer, and raised.

What you can do: Scarring can be a problem because of how it looks. Scarring can also make skin stiff and painful

• Work with the rehabilitation team to lessen scarring. Your team may tell you to wear pressure garments or splints, massage the scar, or do stretching exercises.
• Protect your healing skin from the sun.

Scar Maturation Phase

What you see: Scar maturation can take up to 1–2 years. During this process, the scarred skin gradually returns to a more normal skin tone. It also becomes softer and flatter.

What you can do:

• The rehab team may tell you to keep wearing pressure garments or splints. The team may also tell you to keep massaging the scar and doing stretching exercises.
• Continue to protect your skin from the sun.
• Ask for help from people trained in using makeup or clothing to make scars less obvious. Some makeup techniques and clothing styles and colors can help improve the appearance of scars. The Phoenix Society has a referral service to help you find a makeup or hair replacement specialist in your area. For more information, visit: http://www.phoenix-society.org/programs/bestimageenchancement/creativemakeuptechniques/.
• You may want to meet with a plastic surgeon who is trained in burn reconstruction. They may have tips for how to improve the appearance of scars and restore function. Some of their techniques may include lasers and cosmetic tattoos.

Burn injuries change how your skin looks. They can also can change your appearance in other ways:

• Severe burns can damage structures under the skin. For example, when cartilage in the ears or nose is burned, there can be visible changes in these structures.
• Some burn survivors have many skin grafts and other reconstructive surgeries. These procedures can change the way a person looks.
• Healed skin or grafted skin may be permanently discolored. It may become lighter or darker than your uninjured skin.
• Skin grafts can cause hair loss because hair follicles don’t regrow.
• Sometimes burn injuries cause damage that requires fingers, toes, or limbs to be cut off.

Wanting to improve your appearance doesn’t mean you’re vain. Makeup, clothing, or plastic surgery can help you feel better about yourself and how you look. Even with the best care, rehab, and reconstruction, major burns can cause some permanent changes in how your body looks, feels, and works. Part of the emotional healing process is learning to accept these changes. It may be helpful to focus less on your physical appearance and more on internal strengths and interests that make up your self-image. For example, focus on the accomplishments or roles that make you proud. These may include your education, career, or being a good friend or parent. Accepting your scars doesn’t mean you have to like them. While some survivors report being completely at home in their changed bodies, others accept the changes and get their self-worth from a more inner reality.

Here is an excerpt from a burn survivor talking about the change in their appearance:

“I don’t like my appearance, some things not at all, but I likeme. The person I am. The contributions I make. The impact I can have on others. The kindness I can show.”

Social interactions after burn injury

When seeing or meeting someone with burn scars for the first time, some people may stare, avoid contact, or ask pushy questions.

If This Happens, Here Are Some Things You Can Do:

• To feel confident when you’re talking to someone, make eye contact. You should also use confident body language, smile, and use a friendly tone of voice.
• Have an answer ready ahead of time to explain “what happened.” For example, “I was burned when I was younger, but fortunately I am back to doing all the activities I did before.” Some burn survivors find that talking about their injury helps with emotional healing.
• If you don’t want to discuss your appearance, you can say you don’t want to talk about it. You also can guide the conversation to take the focus off you. Ask the other person open-ended questions (questions that a person can’t answer with “yes” or “no”). For example, “I heard you went on a vacation. That sounds exciting. Tell me about it.”
• For those with changes to their face, dealing with the public can be a daily struggle.
• When people stare or make negative comments, having a catch phrase—like “remember to be gracious”—can help you refocus and use social tools instead of reacting in a negative way.

Some burn survivors find it helpful to be with a trusted person when in public places.

Intimacy following burn injury

You may be worried about showing your burn scars during intimate experiences. Here are some ways to help you feel more comfortable and confident:

• Talk to your partner. Learn about the different stages he or she may go through as you recover. These include withdrawal, avoidance, or being irritable with you.
• Encourage your partner to have contact with your skin. Moisturizing or massaging your scars can help both of you to overcome any hesitation or the “fear of rejection.” Perhaps your partner can get familiar with the different feel and texture of your skin before you leave the hospital.
• Pursue grooming activities. This helps to improve your well-being and readjustments in body image.
• Get the support you need to address your concerns about intimacy. This may include talking to your health care team or other burn survivors.

Other Resources That Can Help You With Social Interactions

• Image Enhancement Program (http://www.phoenix-society.org/programs/bestimageenchancement/)
• “Handling Other People’s Reactions: Communicating With Confidence When You Have a Disfigurement” pamphlet (http://admin.changingfaces.org.uk/downloads/Handling%20Reactions.pdf)

Child burn survivors and teasing

Parents and teachers need to closely watch how child burn survivors act and interact with other people. Children often tease each other about even slight differences in appearance. Parents may not be aware of how severely their child is being teased. Children who are teased may become depressed or anxious when meeting new people. Often times, children tease because they are curious or don’t understand the situation or why the child looks different.

Adults can intervene early in a child’s life to help protect them from teasing by helping the child understand the difference between curiosity and teasing, and by educating other children. For example, it is helpful if adults explain to their child the differences between curiosity (questions asked based on curiosity) versus teasing (malicious or mean intent). Children can feel like they are being teased when kids are simply being curious when asking about their scars. Second, adults can give other children some basic information about burns. This might satisfy their curiosity in a more positive way. They can also teach children how to treat a burn survivor with respect. This can help create a supportive environment for child burn survivors.

Schools should have policies in place to minimize teasing and bullying and create a supportive learning environment. Parents should have an honest talk with the school administration about these policies. They should also ask how the policies are going to be used with their child.

School reentry and burn camp programs

Burn centers often have programs to help burn survivors return to school. Such programs may ask a burn expert to visit the burn survivor’s school before the child returns. The burn expert explains the burn recovery process to the survivor’s teachers and classmates. The burn expert also encourages students to be kind and supportive of the burn survivor. Many families find this process helpful in creating a supportive environment for the burn survivor.

The Journey Back: Resources to Assist School Reentry After a Burn Injury has helpful information about the school reentry process. For more information or to order this resource, visit http://www.phoenix-society.org/programs/schoolreentry/.

Some burn centers offer burn camps for children. These camps are often free. These camps give children a chance to play and interact with other children with burn injuries so they don’t feel so different.

Finding help

Recovering from a burn can be tough emotionally. Get help if you feel anxious or depressed, have nightmares, or relive how you were injured. Many burn survivors find it helpful to talk to a mental health provider who has experience with the challenges of recovering from a burn. Your local burn center or health care provider can refer you to a mental health professional in your area.

Getting the support you need

With burn injuries, emotional healing is just as important as physical healing. You should get support from family, friends, colleagues, health professionals, and other burn survivors who may share your experience.

The Phoenix Society, a nonprofit organization based in the United States, offers the Phoenix Survivors Offering Assistance in Recovery (SOAR) program. This program connects people with new burn injuries to survivors and family members who have been impacted by a burn injury. Trained burn survivors are available across the United States to offer support. For more information, visit https://www.phoenix-society.org/resources/peer-support/.

You may want to talk to your health care provider about the following treatment options:

Cognitive behavioral therapy (CBT): CBT is a treatment approach used in behavioral health. CBT shows people how to understand and improve the connections between their thoughts, emotions, and behaviors. It is effective in treating severe depression and anxiety. CBT also helps people with body image distress.

Physical activity: Exercise may improve a person’s body image. Exercise can increase energy and build confidence. It can also lessen feelings of hopelessness and lead to an appreciation of one’s body. Even if you have never been physically active, you can start with 20 minutes of walking every day. Talk to your health care team about a structured exercise program.

Additional Resources 

The Model Systems Knowledge Translation website has many resources available; one that may be helpful for parents is "Help Your Child Recover - Build Your Child's Resilience after a Burn Injury'. See: http://www.msktc.org/burn/factsheets/Build-Childs-Resilience-After-Burn-Injury.

The Phoenix Society is “dedicated to empowering anyone affected by a burn injury.” For more information, visit http://www.phoenix-society.org or call 1-800-888-BURN. The Phoenix Society offers the following resources:

• Weekly online chats with moderators (http://www.phoenix-society.org/community/chat/); and
• A catalog of books, videos, and CDs for burn survivors (https://www.phoenix-society.org/resources/parent-child-resources)
• Social skills online courses (https://www.phoenix-society.org/our-programs/online-learning/beyond-surviving-tools)

Changing Faces is an advocacy organization in England. Its mission is “to create a better and fairer future for everyone who has a disfigurement to their face or body from any cause and their families.” For more information, visit http://www.changingfaces.org.uk/Home.

References

Blakeney, P., Partridge, J., & Rumsey, N. (2007).Community integration. A review of the issues related to community integration of burn survivors. Journal of Burn Care & Research, 28, 598–601.

Corry, N., Pruzinsky, T., & Rumsey, N. (2009). Quality of life and psychological adjustment to burn injury: social functioning, body image, and health policy perspectives. International Review of Psychiatry, 6, 539–548.

Kammerer Quayle, B. (2006). Behavioral skills and image enhancement training for burn survivors: essential interventions for improving quality of life and community integration. In R. Sood & B. Achauer (Eds.), Achauer and Sood’s burn surgery: reconstruction and rehabilitation. Elsevier Health Sciences. Partridge, J. (2006). From burns unit to board-room. British Medical Journal, 332, 956–959. This article gives a personal perspective of the psychosocial challenges faced by burn survivors.

Thompson, A., & Kent, G. (2001). Adjusting to disfigurement: Processes involved in dealing with being visibly different. Clinical Psychology Review, 21, 663–682.

Authorship

Understanding & Improving Body Image after Burn Injury was developed by John Lawrence, PhD., James Fauerbach, PhD, and Shawn Mason, PhD, in collaboration with the University of Washington Model Systems Knowledge Translation Center.

Factsheet Update

Understanding and Improving Body Image After Burn Injury was reviewed and updated by Nadia Quijije, MD (Massachusetts General Hospital, Psychiatry); Shelley Wiechman, PhD (Northwest Regional Burn Model System/NWRBMS investigator and UW Medicine Regional Burn Center Psychologist); Mona Krueger (Aftercare Coordinator, Oregon Burn Center); and Claudia Baker, BA (UW Medicine Regional Burn Center SOAR volunteer coordinator). The review and update was supported by the American Institutes for Research, Model Systems Knowledge Translation Center under a grant (number 90DP0082) from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR). The contents of this fact sheet do not necessarily represent the policy of the U.S. Department of Health and Human Services, and you should not assume endorsement by the federal government.

Source: Our health information content is based on research evidence whenever available and represents the consensus of expert opinion of the Burn Model System directors.

Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider regarding specific medical concerns or treatment.

Copyright © 2017Model Systems Knowledge Translation Center (MSKTC). May be reproduced and distributed freely with appropriate attribution.

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