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Discharge information and support

Introduction

Whatever the length of your stay with the Burns Service, you may have questions once you leave us. Life back at home may be daunting at first, especially if you’ve been with the Service for a while and have become used to support from the team. You may have reduced energy, flexibility and dexterity that might make life more difficult until you learn to adapt.

However, most people are pleased to be going home and find that they are actually able to do more things than they were able to in hospital because of the more familiar surroundings.

This booklet goes through some of the most common questions people have. We hope it will be a good reference guide for you. If you have any questions regarding any of the issues raised in this book, please call the main ward (telephone numbers below).

Important phone numbers

The Burns Service is made up of several parts. If you’re not sure who to call, try the main ward where someone should be able to help. If you are calling for advice, please tell us this when you call as this will help us find the right person to answer your query:

Burns Service main ward (24 hours)

  • 020 3315 2500
  • 020 3315 8611
  • 020 3315 8612

Please bear in mind that we are a busy ward and there may be times when you need to call back if the lines are busy or if there’s no answer. Do keep trying.

Burns Dressing Clinic Chelsea and Westminster
T: 020 3315 2514 (Mon–Fri, 8:30am–4pm)

Burns Therapy Physiotherapists, occupational therapists & scar management
T: 020 3315 5680

Burns Psychology Team
T: 020 3315 2504

Burns Dietitians
T:
020 3315 8176

Immediately upon discharge

You may be asked to:

  • return for a change of dressing, either on the ward, or to our burns dressing clinics based at Chelsea and Westminster or Queen Mary’s Hospital in Roehampton
  • elevate any burnt areas of your body (eg sleep propped up on pillows if you have a burn to the face)—it is best to keep burnt hands elevated above heart level and support burnt legs and feet up on a stool when sitting to reduce swelling, which may become painful
  • use a flat pillow or no pillow following a neck burn to keep the area extended
  • look out for signs and symptoms of infection
  • take nutritional supplements to boost your calorie or protein intake
  • keep an eye on your bandages and dressings—make sure they are dry and have not fallen open or unravelled
  • take regular painkillers—as generally we want you to get on with your normal activities without worrying about pain
  • attend outpatient appointments with physiotherapists, occupational therapists and/or dietitians
  • continue a therapy programme which may involve exercises, stretches, positioning or the wearing of splints and/or pressure garments

Soon after discharge from the ward, you should receive a letter with an appointment for a consultant follow-up (usually scheduled three to four months following discharge). If you do not receive an appointment letter within two weeks of discharge, please call the Burns Service main ward and ask to speak to the ward clerk (Mon–Fri, 8am–4pm).

Signs and symptoms of infection

Before burns heal, they can provide an entry point for infection into the body. Please call the Burns Service (24 hours a day on 020 3315 2500) if you notice any of the following while you still have unhealed wounds:

  • temperature above 38.5°C (102°F)
  • flu-like symptoms
  • feeling extremely sleepy or lethargic
  • not wanting to or not able to drink enough fluids
  • diarrhoea or vomiting
  • rash or redness either around the burn or elsewhere on the body

Daily activities

Washing

Keeping your skin clean is an important part of getting better. This helps to keep away infection and to stop a build-up of the moisturising creams you will be using. Try to wash as much of your body as possible every day.

While you still have dressings on, make sure to keep that area dry—this usually means washing at the sink with a clean cloth or flannel, or asking someone to help you shower, avoiding your dressings.

Use simple products without any fragrances or harsh chemicals at first on newly healed skin so as not to irritate it—those developed for babies are ideal. As your skin becomes less sensitive you can start introducing your old products. Once home you can use your normal shampoo.

Clean your bath or shower regularly as you will lose more dead skin than usual, but don’t use harsh products, or those with bleach, as the residue may irritate your skin.

Always remember to test the temperature of your bath or shower with non-burnt skin as your scars and new skin will be more sensitive to temperature extremes. Do this before you get into the bath. The elbow is best for testing water temperature. We would always recommend using cold water first and then adding hot water to prevent scalds.

Shaving

If the parts of your body that you normally shave have been burnt, hairs may be growing back in the wounds and they can irritate your skin or delay healing. If this is a problem please talk to your burns doctors or therapists.

Moisturising

After every wash, and at least two to three times a day in total, make sure to moisturise your skin. This will become a very important part of your after-care as scar tissue and new skin may be much drier than your non-burnt skin. This is because oil and sweat glands are often damaged by burns. Moisturising can help soften scars and minimise itching.

Use a light, non-greasy, non-perfumed moisturising cream. The aim is to massage it into your skin well—you do not have to use too much.

Dressings

You will normally be instructed to keep your dressings intact (as the nurses left them) until your next appointment with us, however please get in touch with us if you notice any ooze coming through the dressing, the dressing gets wet or starts unravelling, or you experience worsening pain or discomfort. It can be normal for some types of dressings to smell, but just call us if you are worried.

Clothing

Natural fibres such as cotton, linen or silk may be more comfortable than synthetic fibres like polyester on damaged and healing skin. Burnt skin is often more sensitive to temperature extremes, so you should take this into account when dressing.

You may need to buy larger shoes, or wear slippers at first, if your feet have been burnt. The important thing is that they do not rub your feet.

Depending on the size and visibility of your burn and its dressings, you may be worried about people staring at you, indeed you may attract more attention than usual. At first you may feel you need to wear clothing that covers everything up, however over time your confidence should return which will make it easier to wear clothes to suit your style of dress.

Eating and drinking

What you eat plays an important role in looking after your skin, controlling your weight, promoting healing of wounds and keeping you fit and healthy.

When you have had a burn it is very important to eat well to assist healing. Your body may need extra protein and calories to help your wounds heal and this process may take up to a year if you have a large burn. Your dietitian will advise on any dietary changes you may need when you leave hospital.

Once your wounds have healed, you should go back to a healthy diet following the plate diagram in this section. At this stage it is easy to gain weight rapidly, especially if you stay on a high protein diet and your activity levels are low. You must try to eat a balanced diet (see the plate diagram) and drink at least 8–10 glasses of fluid a day.

If you have any questions about your diet, worries about weight loss, or would like advice on changing your diet and lifestyle, please call the burns dietitians on 020 3315 8178.

Use the plate diagram above and the following points to help plan your meals:

  • All foods can be enjoyed as part of a healthy diet. It is important to eat a variety of foods to get the right balance.
  • Eat regularly through the day. Base your meals on starchy foods such as bread, potato, pasta, rice, breakfast cereals, couscous, chapatti, naan, and yam.
  • Try to eat plenty of fruit and vegetables. Aim for 5 servings a day.
  • Eat normal portions from the protein and dairy food groups. You no longer need lots of extra protein, unless you are still healing.
  • Cut back on fatty and sugary foods. These foods are less important now and can provide unnecessary calories, which may result in unwanted weight gain.

Pain

Burnt skin and scar tissue can cause pain. The aim of long-term pain management is not to let this pain stop you from getting on with normal life. Pain messages can serve different purposes. Some pain warns us to stop doing something to avoid damage. Other pain tells us that a part of the body is already damaged, sore or tight. Your nurses or therapists may tell you to keep moving or to exercise parts of your body even if it gives you the second type of pain message. This is extremely important as it will improve your healing and recovery in the long term.

Most people only need over-the-counter painkillers like paracetamol and ibuprofen. It’s important to take these regularly before adding in anything stronger. You should have been discharged with adequate painkillers from the ward, but if you feel the need to continue these beyond what we’ve given you, talk to your burns doctors or your GP.

Distraction techniques can also help you manage pain, as well as itch

Itching

One of the most common problems for people healing from burns is dealing with itching. It is usually caused by your nerve endings growing back, which is a good sign. However it can also be a side effect of some medications, such as morphine. Itching may become worse in the heat (and at night) and can cause problems with sleep and reduced appetite.

Over-the-counter antihistamines such as chlorphenamine (Piriton) or prescribed medications can lessen itching, but unfortunately there is no cure. If you find itching is a severe problem, please ask to talk to one of your burns doctors. Some ways you can manage problem itching:

  • Good skin care—rinsing moisturising cream residue off before applying new moisturiser
  • Keep your moisturiser in the fridge to help cool the skin
  • Cool baths or using a cold flannel on the area
  • Careful washing of clothes, pressure garments and bed sheets, making sure any detergent used is thoroughly rinsed out
  • Using only natural fibres for clothes and bed sheets
  • Do not scratch—this might damage your skin
  • Try different moisturisers to see which suit you best
  • Further scar treatment—discuss with your burns consultant or scar management team
  • Fans and portable air-conditioning units can be helpful on healed skin if the itching becomes worse in the heat
  • Silicone gel and pressure garments may help some people—the scar management team would discuss this with you so ensure you have an appointment booked with them (020 3315 5680) once your wounds are almost healed

Distraction techniques

Distracting yourself can be a powerful way of temporarily relieving even the most intense pain or itching. However, you may have to try several things before you find the distraction technique that is right for you. Here are some ideas to get you started:

  • Watch your favourite television program
  • Do some physical exercise
  • Call somebody and chat about anything other than pain
  • Read a book
  • Participate in a relaxing hobby that occupies your hands, such as drawing, knitting or model-making
  • Do a challenging word puzzle
  • Listen to soothing music
  • Practise deep breathing or meditation exercises
  • Play a video game

While distraction techniques may not take your pain or itching away, they may make your symptoms easier to manage.

Daily routine

You may feel more tired than usual when you first go home from hospital—this is quite normal and to be expected. It is a good idea to pace yourself with whatever you try to do each day, taking regular breaks.

While you may not be able to get back to your usual activities straight away, it can be helpful to try to get into a routine of sorts. Have a ‘wake-up’ time to start the day, and try not to get stuck in front of the TV or on the Internet. Try to think of a range of things to do, some outside the home, and include other people in your activities so you do not become isolated. Go to bed at a regular time even if you do not need to get up first thing in the morning.

Remember: Preparing for the day will take longer than it did before your injury as you now have extra personal needs and your movement may be more difficult. Remember to include time in your routine for all the areas covered in the booklet: taking painkillers, washing, moisturising, completing your exercises and stretches as advised by burns therapist, protecting your skin from the sun, and choosing your clothes (including pressure garments where these have been recommended). At times this will be frustrating, but do not be discouraged if you cannot manage all your normal daily activities immediately.

If you had an inhalation injury with your burn (injury to your throat, lungs or breathing in smoke), you may feel short of breath or wheezy with even a small amount of activity. You may also notice that you get more coughs and colds, and that it takes longer to recover from these than it used to. Please make an appointment to see your GP if this becomes a problem.

Long-term issues

Skin changes and scars

Your burn injury may leave you with changes in your skin which could be temporary or permanent. The severity and permanence of scars is not easy to predict, and will depend on the depth of the burn, size of the burn, location on the body, length of time it took to heal and your genetics, such as your skin type.

Scars can change colour depending on body temperature, time of year, or during activities that increase your heart rate (and therefore blood flow to the skin). The skin’s natural colour might return to areas of more superficial burns after several months. Deeper burns are likely to have permanent discolouration and texture change.

Scar tissue will change in colour (red/purple/pink/brown), texture and flexibility over time. To help your scars become more supple, it is recommended that you:

  • Exercise and stretch as instructed by your burns therapists
  • Keep active
  • Massage and cream your scars as advised
  • Wear your splints as advised by your burns therapist—let your therapist know if they become uncomfortable, as it is important that they fit properly
  • Wear your pressure garments as instructed. If your garments do not fit properly, it is important that you ring the burns therapy team (020 3315 5680) and they can arrange a review appointment for you

Skin camouflage

Skin camouflage is the application of specialist makeup to improve the appearance of scarring and other skin conditions. Camouflage can only be applied to fully healed skin. If you are interested in finding out more about this, please ask a member of the scar management team or your burns consultant for more information.

Skin problems

Skin problems can be common for people with scar tissue or healing donor sites. Blisters can be caused by rubbing from clothes or pressure garments, or from accidental knocks to the skin. If you experience this leave the blister alone (do not burst it). Use a dressing if you want to protect it under clothes. If you feel unable to manage the blister, or if it becomes larger, or looks infected (swelling, redness or visible pus), contact the Burns Service for advice.

Another common problem is getting more whiteheads and blackheads than before. These may be caused by cream, dirt or soap collecting in uneven scar tissue. If you are prone to these, good skin hygiene is essential. Always gently wash the area before applying new cream to remove residue from moisturiser and dirt.

Although in some cases skin problems are unavoidable, there are some things you can do to try to prevent them:

  • Follow the skin care instructions detailed in this booklet carefully
  • Wash clothes and pressure garments daily
  • Make sure pressure garments are well-fitted
  • Wear comfortable clothing that will not rub or chafe

Body temperature

It is not unusual for your body to have more difficulty regulating its temperature after a burn injury. This may be because burns can damage hair follicles, sweat glands and pores, all of which help to control the temperature of your body. Your metabolic rate may also change to help you heal and this can affect how you experience temperature. You may feel hot or cold when you would not expect to do so. You may also find that you sweat more or less, or from different parts of your body, than you did before.

No one can predict how long these changes will last. We recommend that you dress in light layers that you can put on or take off as necessary. If you are sweating a lot, make sure you drink plenty to avoid dehydration.

Pressure garments

A pressure garment is a tight Lycra-style piece of clothing, made to your measurements, to provide constant pressure over an area of the body. Pressure garments limit the growth of scar tissue by exerting constant pressure over the scar.

Not all patients need pressure garments. However, if your therapist recommends them for you it is important you wear them as advised. Your occupational therapist or physiotherapist will take measurements for a pressure garment once your open wounds have healed or almost healed. The garments are then made on-site by garment technicians. Your therapist will monitor the fit of your garments over time.

Swollen limbs

Different burn injuries can affect the way that fluids circulate through your body. Oedema (swelling) is caused by a build up of fluid under the skin. This may be a problem for some time after you are discharged. To help control swelling you should:

  • Exercise regularly
  • Elevate your arms and legs (if these were burnt) when you are sitting or lying
  • Wear pressure garments or oedema gloves if your therapist has provided them

Exercises and stretches

The aim of exercises after a burn injury is to regain as much normal movement as possible in and around the injured area. Exercises and stretches help to lengthen tight scar tissue, improve joint movement, increase strength and promote functional use of your injured area.

A physiotherapist or occupational therapist may give you a home programme of exercises which is tailored to your needs. It is important that you follow this exercise programme as advised by your therapist and that you continue this when you leave hospital.

Scar tissue tightens (contracts) as it heals. It is especially important to stretch scar tissue that crosses joints as it can limit movement and cause you to adopt unnatural or uncomfortable positions. You may be given splints to help prevent this from happening.

Returning to leisure activities

Return to your regular exercise and leisure activities as soon as you feel able. Keep in mind other advice from this booklet, such as sun protection, wearing the right clothing, and washing and moisturising afterwards. Remember that you might sweat differently and that you may need to drink more. Make sure to warm up before, and cool down after, physical activity.

If you want to go swimming, remember high chlorine content in water may cause itching or a rash, and you should shower and moisturise thoroughly after swimming.

Going out in the sun

It is essential to protect burnt or grafted skin from the sun because your skin is more likely to be affected than before. Always use total sunblock—designed for sensitive skin—on areas you are unable to protect with clothing, even on a cloudy day.

Reapply as per manufacturer’s instructions. Try to stay inside when the sun is at its strongest, between 11am and 3pm. Remember that you can still get burnt through parasols, sun umbrellas, pressure garments, and even on cloudy days.

If you swim in the sea, we recommend that you apply sun block, wear clothes that cover burnt or grafted skin and only stay in the water for half an hour at a time. Rinse your skin thoroughly and apply more sun block afterwards.

Choose sun creams which provide protection for UVA (represented by star ratings) and UVB (represented by a factor rating, eg 20, 30) exposure. UVB causes burns, but UVA is believed to play a greater role in skin cancer.

Driving

If you drive, you will need to contact your insurance company directly to provide advice on this.

Low mood

People tell us that they can experience periods of feeling low, restless, have problems with sleeping, or relive the memory of getting the burn. You may find you have new worries over finances, about other people’s reactions to your injury, how and when you are going to heal, and how your body may look in time. These concerns are quite common. You might experience some days when you feel you have returned to normal and others when you are overwhelmed by what has happened to you and feel unable to cope.

Remember that these emotions and feelings are normal and will usually pass with time, just as your physical injuries will heal with time. If you find that you are feeling low for several days, you may find it helpful to discuss your feelings with someone you can trust. There is also a specialist psychology team within the burns service and you can contact them directly on 020 3315 2504 or speak to any other member of the burns team and ask for a referral to psychology.

Make sure you make time for yourself, getting back to things that you find relaxing and enjoyable, which may help to lift your spirits.

Relationships and sex

After a burn injury, you may find your relationships change with people around you. Many people feel concerned and have questions about their sex life. This may be because of physical discomfort, pain, skin sensitivity or tiredness.

It might also be due to anxiety, depression or worries about how your body looks or feels to touch. It is important to be honest with your partner, or prospective partner, about how you feel.

With time and understanding, difficulties around intimacy can resolve. It can take time to adjust, so don’t put pressure on yourself to resume sexual activity before you are ready. If problems with intimacy persist, please get in touch with one of the burns psychologists.

3-2-1 GO!

Some people may feel very self-conscious about their injury, especially if it is visible to others. There are often lots of questions from family, friends, and even strangers, about what happened and this can feel overwhelming.

If you’re unprepared to answer these sorts of questions, you can feel upset, surprised, or taken aback. Changing Faces, the UK disfigurement charity, advises the 3-2-1 GO! strategy to help prepare ready answers to the typical questions asked.

It suggests that you come up with:

  • 3 things to do if someone stares at you
  • 2 things to say if someone asks you what happened
  • 1 thing to think if someone appears to turn away

Having prepared answers can really help some people deal with what may otherwise be uncomfortable questions.

London Area Burns Adult Support Group

Some people benefit from making contact with others who have experienced burns at some point in their life. The London Area Burns Adult Support Group is a support group for adults (aged 16 and over) who have experienced a burn of any sort and any size at any age and have been treated at any hospital.

Many people who join find it beneficial to meet others who have been through similar experiences. This group meets roughly four times a year and meetings alternate between discussions with invited speakers and social events.

The group recognises that there is no direct link between the size, seriousness or site of a burn with regards to the size of the impact it can have on people’s lives. This group offers an opportunity not only to get support, but to give support to other burns survivors.

There are always new people joining, so never feel worried that you won’t know anyone. If bringing family or friends means you would feel more comfortable coming along then they would also be very welcome.

See the Burns Support page or contact the group coordinator with any questions (all calls are confidential) on 020 3315 2504.

Further support

Several charities have been set up to assist those with burns. If you would like more support try looking up the following web sites:

Acknowledgements

This information has been adapted from the original material The BUGS Booklet... I’m Leaving Hospital—What Now? (Jan 2006) by the Salisbury Burns Service by:

  • Georgia Platman, Burns Staff Nurse
  • Dr Lisa Williams, Principal Burns Clinical Psychologist

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