You have had:

• local anaesthetic
• regional anaesthetic
• general anaesthetic

What to expect after your operation

You will have a dressing and/or a plaster. Keep this clean and dry

Do not take it off unless told to do so. We will remove it for you at your follow up appointment

After your operation you will be given:

• A copy of your discharge summary (a copy will also be sent to your GP).
• Post-operative leaflet containing advice on commonly prescribed analgesia.
• Burns discharge booklet 

What to expect after your anaesthetic

After local anaesthesia

The area may feel numb or you may have pins and needles. This will start to wear off in a few hours

After regional anaesthesia (a block)

You should feel completely normal after our regional anaesthetic except that you will not feel any pain or sensation (such as heat or cold) in your arm.

You may also feel as though you don’t have control over the way your arm moves. You should take extra care not to burn or injure yourself until the block wears off.

Keep your arm in sling until the block has worn off. Shrug your shoulder 10 times every 1-2hours when you are awake.

The block will  last for up to 36 hours. It may feel tingly, warm or like pins and needles as it starts to wear off.

If your arm is still numb more than 36 hours after surgery contact the Burns Unit on 0203 315 2500.

After general anaesthesia

We use short acting anaesthetic agents so you will recover quickly. You may feel a little groggy or sick if you have had strong painkillers; this can last up to a few hours.

Your throat will be a little sore from the tube that helps you breath during the operation. This can last from a few hours to two days. Symptoms disappear without any specific treatment. If the pain is severe taking pain killers, drinking plenty of fluids and gargling help to reduce inflammation and pain.

Taking painkillers

You will be advised on commonly prescribed medications which can be bought in your local pharmacy to help you manage pain. These work best if you take them regularly for the first 24-48 hours when the pain is likely to be most troublesome.

Your nurse will tell you when to start taking your painkillers. You should start to take your painkillers before your block or local anaesthetic wears off.

Listed below are appropriate pain killers. These can be taken as a combination to manage your pain.

Paracetamol 500mg

1-2 tablets every 6-8 hours. No more than 8 tablets in a 24 hour period. (four times a day)

Do not take any other medicines containing paracetamol at the same time.

Note: some over the counter cold and flu tablets contain paracetamol.

Ibuprofen 200mg

Dose: 2 tablet every 8 hours (three times a day)

Precautions: Take with food. May cause allergic reaction, abdominal pain, heartburn, indigestion and headache. If you suffer from these stop taking these tablets and if it persists see your GP.

People that should avoid ibuprofen are those with a history of having stomach ulcers or kidney problems. We wouldn’t recommend ibuprofen for those aged over 75 years old

Dihydrocodeine 30mg

Dose: 1 tablet every 6 hours (four times a day)

Precautions: May cause drowsiness, nausea, vomiting, constipation and sweating. Note: this may make you sleepy; if this happens do not drive or use tools or machinery. Do not take alcohol.

Sometimes a doctor will prescribe dihydrocodeine, a stronger pain killer, to be taken alongside paracetamol and ibuprofen.

Taking Antihistamines/Anti-itch medication

Chlorphenamine 4mg

Dose: 4mg every 4-6 hours. No more than 24mg per day for an adult and 12mg per day for the elderly (>65ears old)

Precaution: May cause drowsiness. Cautions with epilepsy and avoid using during pregnancy.

Do not take any of these medications if you are allergic to them or have ever experienced a reaction to any of them.

If you continue to experience itching which is causing you discomfort despite taking antihistamines; please call the Burns Unit for further advice on 0203 315 2500.

After your Burns Surgery

Important Information

There may be a problem if:

• You have pain that is increasing or that you cannot control with painkillers
• Your bandage or splint feels too tight because of swelling
• You experience symptoms of a wound infection, such as; fevers, shivering, increased pain, vomiting and diarrhoea.
• Your plaster starts to get wet or break and your wound is exposed.
• You have bleeding through your dressing and this doesn’t stop even when you raise your wound above your heart and apply firm pressure for 5 minutes.

If you experience any of these symptoms or have any other concerns or questions please contact us. 

This leaflet answers some of the most commonly asked questions about Biobrane®.  If you have queries or concerns, or would like to talk about anything related to your treatment, please speak to one of the health care team responsible for your burn management.

What is Biobrane®?

Biobrane® (a type of artificial skin) is a man made skin substitute composed of nylon mesh, silicone and collagen (derived from pig skin).  It is a stretchable dressing that is used as a temporary cover for clean partial thickness burns and donor sites or as a protective covering over meshed skin grafts.  It will stay in place to protect your wound while it heals.

What are the benefits of Biobrane®?

• It reduces pain and anxiety when compared to traditional treatments and dressing changes
• It reduces pain and trauma throughout the whole healing process
• It offers more mobility due to greater flexibility (stretch ability) of the dressing
• It acts as a barrier to external contamination
• It reduces healing time which allows for a quicker discharge home and return to activities of daily living

What is an alternative option?

There are a range of similar dressings that can be used to cover a wound.  However, when indicated, Biobrane® provides immediate wound cover.

Ethical issues

Use of this dressing has been discussed with representative leaders of all major faiths in this country including Christian, Islamic, Jewish and Hindu *. They have suggested this dressing is acceptable; however you should make a decision based on the information given to you by the Burns team, including what the product is made of. Ultimately this is personal choice.

Is it safe? Are there any side effects?

If in the rare instance a patient shows evidence of an allergic reaction to the product, it would be removed immediately and its use discontinued.

There are no known problems that have been identified by health care professionals when using Biobrane®.

Will I need a general anaesthetic?

Most patients have Biobrane® applied under a general anaesthetic in an operating theatre or similar clean environment.

You are perfectly within your rights to choose not to have this procedure and alternatives can be discussed with a member of the health care team.

What should I expect?

You will receive clear instructions from a member of the healthcare team. For the first few days after application do not remove the outer dressing and do not get the dressing wet. 

After this time the staff will remove the outer dressing down to the Biobrane® and check for adherence (whether it is stuck down).

It may be necessary for the staff to trim away any areas of the Biobrane that have not adhered, or where a collection of fluid has built up. The Biobrane will also not adhere to healed areas of the wound.

For the first few days, some fluid from your wound or donor site will drain through the Biobrane®. This is normal, and the outer dressing will absorb this fluid.

As your wound or donor site heals, the Biobrane® will become dry and the healing areas may itch.  The outer dressing is no longer required.

About 7 to 14 days after the dressing was placed, it will begin to lift off at the edges.  The staff will trim any Biobrane® that is lifting and not stuck down.

Once the Biobrane® is removed, the skin will be pink or dark red with white flaky areas. This is normal.  Moisturising cream or lotion should be applied to these healed areas as advised by the burns staff. Massage, moisturising and sun protection are the key elements of healing at this stage.

The pink or dark red colour should fade away in time.

Will I feel it?  Does it hurt?

You may require pain relief if your wound hurts during the first few days after application of the Biobrane®. 

Take pain medication as directed by your doctor and nurses.

As time passes and the wound begins to heal you may feel the area becomes tender or itchy – this is normal, but if it becomes irritating please inform one of the staff.

Will I be able to have a bath or shower?

The burns staff will advise you when you may bathe or shower.

Will it work?

Biobrane® has proven to be an effective part of our burn wound management programme.

What are the risks of Biobrane®?

There are risks associated with any procedure, and in the case of burn wound care these are pain, bleeding and infection. These happen very rarely and if any of them do occur, the health care professional will take appropriate action, including seeking assistance if required.

Will I have a scar?

This will be dependent on the length of time it takes for the wound to heal, and can vary between individuals.  It is a consequence of the burn injury and not the dressing. 

The burns staff will advise you on how to best manage the healed  area once your wound has completely healed.

What happens after this type of treatment? 

The nursing staff will make a follow-up appointment when you are discharged.

Please call the burns staff if any of the following occur:

• Increased redness, swelling or warmth in the skin around the wound
• Fluid building up under the Biobrane® (looking ‘mucky’)
• Bad smell coming from the wound
• Any nausea or vomiting
• Feel feverish or shivery with a temperature above 100.5°F or 37.5ºCF
• Increasing pain
• Bleeding

Why use Gabapentin?

Itchiness after a burn is a common problem experienced by many patients (both adults and children) when the wound area begins to heal. It can slow recovery and cause unnecessary agitation and distress to your child. The intense sensation of itching can cause your child to scratch at fragile areas such as the burn itself and any donor sites. Medicines such as chlorphenamine (Piriton®) and hydroxyzine (Ucerax®, Atarax®) are commonly used to control itch but in many cases these treatments alone are not enough to control the itching. Gabapentin is a medicine normally used to treat epilepsy and certain types of pain, however it has also been found to have powerful anti-itching properties. Gabapentin will sometimes be prescribed to help relieve your child’s itching. It can be prescribed alone or in combination with other medicines that are used to treat the itching. A reduction in itching can usually be seen within a few days of beginning treatment. 

Dosing 

Gabapentin is available in capsule/tablet form and for young children a liquid is also available. How much medicine your child requires depends on their age and weight and the dose will be decided by the doctor. Gabapentin is usually started slowly to help reduce the risk of side effects, for example:

• Day 1: given ONCE a day
• Day 2: given TWICE a day
• Day 3 onwards: given THREE times a day

Duration of treatment

Treatment with Gabapentin should continueuntil the scars heal and the sensation of itching reduces. When a decision is made to stop treatment, the Gabapentin will usually be withdrawn slowly to minimise the chance of any side effects such as restlessness. This may be done over several days and the doctor will advise on a plan as to how to reduce the dose. Side effects such as anxiety, trouble sleeping, nausea, pains and sweating have been reported with suddenly stopping the medicine, so parents and carers should ensure that they never run out of Gabapentin and that they have enough supplies to cover until the next prescription is due.

Common side effects

Most children experience only minor side effects. However, nausea and/or vomiting can occur. These symptoms normally occur in the first one or two days and usually disappear as treatment progresses. Giving the dose of Gabapentin with food (even a snack) can reduce the chance of your child feeling or being sick. Gabapentin can also cause drowsiness and dizziness but again this normally wears off after a few days. Sometimes Gabapentin can cause changes to mood and/or behaviour. If you notice or are concerned about any changes to the child’s mood or behaviour, please report this to your doctor. If you have any questions or concerns about the use of Gabapentin for itching or of the potential side effects below, please discuss with your doctor or pharmacist.

Potential side effects 

Common

Diarrhoea, dry mouth, dyspepsia, nausea, vomiting, constipation, abdominal pain, flatulence, appetite changes, gingivitis, weight gain; hypertension, vasodilation, oedema; dyspnoea, cough, rhinitis; confusion, depression, aggressive behaviour, sleep disturbances, headache, dizziness, anxiety, amnesia, ataxia, dysarthria, nystagmus, tremor, asthenia, paraesthesia, hyperkinesia; influenza-like symptoms; urinary incontinence; leucopenia; myalgia, arthralgia; diplopia, amblyopia, rash, purpura, pruritis, acne; convulsions; vertigo; palpitations.

Rare

Pancreatitis, hepatitis, jaundice, palpitation, hallucinations, movement disorders, thrombocytopaenia, blood-glucose fluctuations in patients with diabetes, tinnitus, acute renal failure, suicidal ideation, Steven-Johnson syndrome, alopecia.

Introduction

We have two nurse-led outpatient dressing clinics for children at Chelsea and Westminster Hospital and at Queen Mary’s Hospital, Roehampton. The same team of nurses work in both clinics.

At both clinics your child will be seen on a first come, first served basis. Please take a ticket from the ticket machine and take a seat in the waiting room.

The clinics tend to be very busy. We try to keep waiting times to a minimum but there is sometimes a short wait, depending on emergencies. We will give you a time slot for your appointment—please try and keep to it as much as possible.

What happens in the dressing clinic?

If this is the first time your child is attending, a full history will be taken—details of the accident, first aid etc. This assists in planning the most appropriate treatment.

Your child will have their dressings changed and the burn wound examined by an experienced Burns nurse. Occasionally we may ask one of the Burns surgeons to examine the wound but the majority of the time this is not necessary.

The burn wound will be redressed and you will be given a follow-up appointment in an outpatient clinic. Occasionally children will need to be admitted for treatment.

What do you do before the appointment?

Your child can eat and drink as normal. Please give your child some painkillers before the appointment—this usually means just as you are leaving home.

The recommended painkiller is paracetamol (Calpol®). Please follow the manufacturer’s instructions.

If your child is able to take ibuprofen (Nurofen®/Junifen®) you may administer this on its own instead of paracetamol, or together with the paracetamol. Please follow the manufacturer’s instructions.

Please remember ibuprofen must be taken with food.

General advice

Unless we advise otherwise, keep all your child’s dressings dry and intact until their appointment. This means avoiding baths, as it is very hard to keep dressings dry when bathing children.

Protein is very good for wound healing—we suggest high protein drinks and diet where possible. Examples of protein include milky drinks, cheese, fish, eggs, yoghurt and meat.

Often children do not feel like eating when they have a burn injury—do not worry, just continue with fluids.

You can give them regular painkillers (as described above) if you think they are in discomfort.

Concerns

If you child exhibits any of the following signs/symptoms, we may need to see them before your booked appointment:

• Fever (above 38°C)
• Diarrhoea
• Vomiting
• Rash
• Not drinking
• Not having wet nappies/not passing as much urine as normal
• ‘Not well’/‘not themselves’

The Burns Ward at Chelsea and Westminster is a 24-hour service, so you can call any time, day or night with any concerns on 0203 315 3707 / 0203 315 3706.

It is important that you call us, rather than attending your local A&E department or GP, as the symptoms may be related to the burn.

If you have any general enquiries regarding the treatment, you can call the dressing clinics directly during clinic hours.

Before you leave

The following items should be supplied to you:

• Discharge summary
• Medications (TTOs)
• Appointment Card
• Burns booklet
• Dressing supplies/sling

Caring for your new skin

Scarring

A scar is a mark that is left on the skin after a wound or an injury to the surface of the skin has healed. Scarring is unpredictable and varies from person to person.

Please contact your Burns Therapist immediately if your scar has any of the following signs:

• Increase in height
• Increase in size
• Increase in firmness
• Increase in colour
• Increase in itch

Scar massage

Following a burn injury the glands which produce the skin’s natural oils can be damaged and therefore your skin is likely to be very dry.

Once your wound has healed, it is important that your scar is washed with a mild soap 3-4 times a day. This is important to prevent a build-up of cream which in turn can block pores and cause spots.

A plain, non-perfumed moisturising cream should be used.

Initially you should apply light pressure as your newly healed skin will be fragile. This pressure should be increased so that when massaging you are applying enough pressure so that the tissues underneath becomes paler.

Scar massage should be performed across the scar, along the scar and in a circular motion over the scar for 5-10 minutes depending on the size of your scar.

Itch

It is common for your newly healed tissues to be itchy. It is very important that you don’t scratch as this may cause the skin to break. To ease the itch you may find it helpful to keep your moisturising cream in the fridge, bathe in cool (not cold) water, wear cotton clothes and sleep under cotton bed sheets. If you have been given one, your pressure garment should also help with the itch. If these do not help, please speak to your consultant or GP regarding medications for the itch.

Skin sensitivity

It is common for your scar to be very sensitive following a burn injury. To reduce sensitivity perform regular massage. It is also helpful to use different textures on your scar to get the new skin used to normal touch/textures such as towels and cotton wool. Returning to normal function as soon as possible will also help sensitivity.

Sun care

Your scar tissue does not have the same protection against the sun as it did previously and therefore is at very high risk of blistering or burning in the sun. It is therefore important that factor 50 sun cream is applied every time you go outside, even in the winter and that a hat is used to protect your face and neck.

Colour

Your skin may change colour with changes in temperature. This is normal due to changes in the blood flow through the scar tissue. This will improve as your scar matures.

Your new scar tissue is a different colour to the rest of your skin; this is due to the layer containing your skin’s natural pigment taking longer to recover. It may take many months for the pigment to change and in some cases the skin pigment may not always return to the original colour. If you have any concerns regarding this, your therapist will be happy to discuss these with you.

Oedema

Swelling is common after having a burn injury. Elevation, positioning, splints, exercise and pressure garments can assist with oedema. Please speak to your therapist if you are experiencing any swelling.

Stretches

As injured skin heals, the wound heals inwards from the edges to make the wound area smaller. This forms scar tissue which shrinks and tightens as it forms and can cause the movement of a joint to be limited. This can lead to a permanent loss of movement (contracture).

The first 6 months is the most important time to start to prevent contractures as the scars are more easily shaped and influenced in this time. If the scar is left without treatment, it can be extremely difficult to shape or move. Therefore, it is important to maintain movement and shape the scar tissue before it reaches this point. Joint contracture can be prevented or minimised through a therapy programme.

Your Therapist will give you advice and instruct you about ways to minimise the formation of a contracture. This may include:

• Positioning
• Exercises and stretches
• Splints
• Scar massage
• Pressure garments provided by your therapist

Please contact your therapist if you have any concerns or questions.

Contact information

T: 020 3315 5680

Patient Advice & Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception.

Alternatively, you can send us your comments or suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website www.chelwest.nhs.uk/pals.

We value your opinion and invite you to provide us with feedback.

T: 020 3315 6727
E: cwpals@chelwest.nhs.uk

How you might be affected

After any traumatic incident, it is normal to experience a number of stress reactions, which may continue for some weeks.

Traumatic events are shocking and emotionally overwhelming situations, and may arouse some powerful or upsetting feelings.

This leaflet is designed to give you some understanding of these common reactions and feelings, and to help you gain more control over them.

Overall people tend to be resilient and most people will recover without needing any professional help. However, this leaflet may be useful to you if you have recently experienced a traumatic event and are still trying to make sense of what has happened.

When traumatic events take place, our bodies react strongly. Because we are not calm or relaxed but feel under threat, our memory of events can be stored in a different way, and in a different place to other day-to-day memories. This can lead to trauma memories being easily triggered, and sometimes recalled in a way which makes it feel like the event is happening all over again (re-experiencing).

The team at Barts Hospital have made this short video, which explains this and is particularly relevant to those in hospital or who have recently left hospital after an injury.

Initial reactions

Reactions commonly experienced within the first few weeks of a traumatic incident include:

• Unpleasant thoughts or images about the event popping into your mind
• Nightmares about the event
• Not wanting to talk about what happened
• Sleep difficulties and tiredness
• Feeling helpless, angry or irritable
• Wanting to avoid people, places or activities that remind you of the event
• Feeling guilty or to blame for what happened
• Concentration and memory problems
• Headaches and bodily pain
• Tearfulness and sadness
• Fear and anxiety
• Feeling numb or detached

Re-experiencing

Re-experiencing (for example flashbacks, intrusive thoughts and nightmares) may:

• Be triggered by places, people, emotions, sounds, smells, tastes, physical sensations or images
• Disturb daily living by happening when you are not expecting them and cannot control them
• Make it feel like you are watching events as they happen to you

These reactions are normal, understandable and usually reduce gradually over time.

What can I do that might be helpful?

• Reminding yourself that re-experiencing is normal following a traumatic event
• Remember that the worst is over—the traumatic event happened in the past and is not happening to you now
• Breathe deeply, slowly and calmly in through your nose and out through your mouth
• Some people find it helpful to talk to those that they feel close to so that they can help when needed—they might be able to remind you of coping techniques, and that you are safe now
• Remember: ‘My mind is doing its best to make sense of what happened’
• Use grounding techniques (see below)

Coping skills

Grounding techniques

The main goal of grounding is to use your senses to focus your attention on your present surroundings. This give you a safe way to feel greater control of what you are thinking and feeling, and allow you to find a balance of feeling emotions too much or too little.

Grounding techniques can be used during a flashback or after a nightmare to help bring you back to the ‘here and now’.

• Explore the space around you using all your senses. Describe objects, sounds, textures, colours, smells, shapes, numbers and temperature. For example, do not just notice ‘the chair is green’, but look at it more closely. Is it textured? Is it fabric or plastics? What shade of green is it? How would you describe the shape?
• Switch on yours body’s relaxation response by swallowing your saliva. You can do this by eating a mint, sweet, or by sipping some water. Try describing the flavours to yourself in detail.
• Notice the sensations in your body as you tense and relax different parts.
• Pick out things in the room that are the same colour, or things that are spelt with the same first letter.
• Use your own grounding object – a small, comforting, physical object which you can carry with you. You can focus on the detail of this object when you are re-experiencing.
• Use a grounding phrase (or song) – a few words which are positive and remind you that you are surviving in the present. For example, ‘I am safe’ or ‘I am ok’.

Looking after yourself

• Be patient with yourself—it may take time to process what has happened
• Try to re-establish your usual routines
• Spend time with people who make your feel safe and supported during this time
• Take good care of yourself physically including exercising regularly, reducing alcohol/drug use and getting enough sleep—drugs and alcohol may briefly numb your feelings or give immediate relief, but will also stop you from processing what has happened and soon create further physical and psychological problems for you to deal with
• Talk to someone when you feel ready—this can help you piece together the event and understand things more clearly which may help in your recovery
• Self-compassion—a helpful question might be: ‘What would you say to a friend who was in your situation?’

Coping with the stress of a traumatic incident

Most people who have encountered a traumatic event find that their symptoms subside over time. However, reactions and recovery times vary for different people.

If your symptoms do not improve after 4-6 weeks, or If you feel like they are getting worse, please contact the Chelsea and Westminster Burns Psychology Team on 020 3315 2504 or chelwest.burnspsychology@nhs.net so that we can help.

Useful organisations

For information on understanding and coping with trauma visit the International Society for Traumatic Stress Studies and The Royal College of Psychiatrists, and Assist Trauma Care (link to http://assisttraumacare.org.uk)

The following organisations can also be called to support individuals and families affected by trauma in times of acute distress:

• Samaritans: 116 123

This is a patient and carers information leaflet designed to help patients and carers understand what Diphoterine® is, how it works and what to expect from the procedure.

Why do we need to irrigate chemical burns?

Our skin normal skin is mildly acidic with a typical PH being between 4.5 -5.5. When our skin comes in to contact with chemicals the PH of our skin is changed and this can cause significant tissue damage. Research shows irrigation decreases the PH change in the skin and limits the extent of the injury.

What is Diphoterine®?

Diphoterine® is a washing solution designed for eye and skin chemical splashes. Diphoterine® has amphoteric, chelating and hypertonic properties and as a result aims to minimise the development and severity of chemical burns.

Why use Diphoterine® instead of water?

The chelating and amphoteric properties of Diphoterine® allow it to bind chemically opposite compounds, limiting their ability to cause further damage. It is also hypertonic meaning it has a drawing out effect and can therefore assist to try and help remove some of the chemical that has already penetrated into the tissue.  Comparatively, water is hypotonic and has very little drawing effect on the chemical, limiting its ability to draw the chemical out of the deeper tissues.

Why is Diphoterine® hypertonic?

Diphoterine® is hypertonic to try and help limit the penetration of the chemicals in to deeper tissues. The hyperosmolar pressure creates a drawing effect from the inside to the outside tissues: as a result the chemicals are then pulled out from the deeper tissue to the surface of the skin or eye. Through this action, decontamination of the affected area is enhanced and accelerated.

Why is Diphoterine® Amphoteric?

An amphoteric compound is a compound that is capable of binding opposing chemical substances such as acids, bases or oxidizers, reducing agents. As a result of the binding action, the chemicals are then ‘disabled’ and are unable to cause further damage.

The treatment process

To start decontamination, the affected area will need to be irrigated with Diphoterine® Solution.  This will wash away any harmful residues and help stop any further damage.

If there is no Diphoterine® Solution, immediately available, use water or normal saline solution and then wash with Diphoterine® as soon as possible.

The Doctor or Nurse will then spray the affected area with a canister of Diphoterine®; they will continue to spray the area until the canister is empty, this typically takes around 10-15 minutes. The spray can be likened to a cooling spray and feels like a light mist covering the affected area.

Typically one canister will be used to decontaminate the affected area however the Doctor or Nurse may use their clinical judgement and decide to use multiple cans; some examples of indications for this are delayed first aid/ prolonged contact time or a large surface area has been affected.

Post-treatment

The Doctor or Nurse will then clean your burn/s and then may apply Diphoterine® soaked gauze. This will stay in place for 24-48 hours and is designed to neutralise any residual chemical.

After 24-48 hours the soaks will be removed and the wounds dressed according to their presentation. 

The use of post-treatment soaks is at the discretion of the burns team and is dependent on the patient and burn injury.

Dressings

The dressings will be determined by the clinician’s interpretation of the wound. The possibility of surgery may be discussed with you and a plan made.

Contraindications

There are no known negative interactions with the different families of medicines or devices and more specifically with ophthalmic solutions used in chemical burn protocols. Diphoterine® is currently being tested for the treatment of chemical digestive burns but has not yet been validated. However, it has already been tested and classed as non-toxic if swallowed.

Do not use in cases of splashes due to white phosphorous.

Diphoterine® has a limited effect on hydrofluoric acid.

Side Effects

No side effects have been reported by the company’s vigilance system.

Washing with Diphoterine® may cause temporary ocular discomfort.

Further Information/Supportive Research

Diphoterine® was originally developed for use in chemical burns to the eyes with very strong, supportive research. It has since been adopted for the use in cutaneous burns in a wide variety of settings; the evidence is growing with some convincing results.

If you still have some questions about the product, treatment or procedures then please do not hesitate to ask one of the burns team.

Introduction

A major burn injury is usually classed as a burn of total body area of burn that is 20% or more (see glossary on page 1). If you have had a major burn injury, you may have been fed through a feeding tube for a while (see glossary on page 1). This enables us to meet your high nutritional needs during the early stages of your recovery. The reason for this is because having a major burn significantly increases your body’s metabolic rate for many months following your injury (see glossary on page 1). Your body’s need for protein and calories is much increased, even after your injury has first healed (see glossary below).

Even smaller burn injuries may require a higher protein and energy diet. In this case, eating and drinking can be done by mouth.

Changing from tube feeding to feeding by mouth

When changing from being tube fed to having food by mouth, sometimes you may have your tube removed to help with swallowing. You must be wide awake and be able to manage to cough up your saliva properly.

Start off with small amounts of pureed foods (see glossary below) and take sips of nutritional supplement drinks. These drinks can be prescribed by your dietitian (see ‘nutritional supplements’). A change in the sound of your voice or coughing when first drinking or eating indicates that you may not be ready to drink or eat yet.

However, if you find you have managed pureed textures well, trialling soft, mashable foods for your first meal would be recommended. It is important to chew more than you normally would. You may feel full very quickly when you first start to eat solid food again. You may start to feel more thirsty than usual. Drinking nutritional supplement drinks can provide a good source of nutrition at this time.

Poor appetite

A poor appetite is very common following a burn injury. This can be for many reasons some of which include: being in hospital, worrying, restrictive dressings, pain, pain on dressing changes, constipation, dislike of hospital food, feeling sick, feeling weak and taste changes. However, at this time in hospital after your injury, your body’s nutritional needs tend to be much higher. Therefore it is important to view food as an essential part of the healing process and make as much effort with your eating and drinking as you can. 

To help stimulate the appetite you can try:

• Eating more frequently; “little & often”, eg. 5-6 small meals or snacks, rather than 2-3 larger meals; try something every few hours. This is because not eating in itself can cause low appetite
• Eat what you want, whenever you want. Whilst in hospital, it can be useful to ask family and/or friends to bring in foods from outside the hospital
• If you’ve lost interest in food: Think of a food where the smell or sight of it usually makes you look forward to tasting it, then try a small portion
• Make eating easy; choose simple meals & snacks, and when at home, ensure cupboards/fridge are well stocked; choose favourite foods
• Choose nutritious fluids: do not fill up on water, tea, coffee; remember that drinking before a meal can fill you up
• If taking supplement drinks, only have these after a meal, otherwise they may fill you up

Nutritional supplements prescribed by dietitian

Sometimes high energy/high protein supplement drinks will be suggested by your dietitian. These are easy ways to take in a concentrated amount of energy and are available on prescription.

• Only use supplements when your appetite / weight is low
• Use to ‘supplement the diet’, not as meal replacements
• Try to take after or between meals, not before or with meals
• Juice based drinks(eg Ensure plus juice) can be made into jellies or sorbets/slushes.  If too thick, they can be diluted with fizzy drinks - lemonade, ginger ale, Fanta, tango (try not to dilute with water alone).
• Milk based drinks (eg Ensure Plus, Fortisip Extra) can be frozen to make ice cream or heated, (remove from packet if heating in a microwave).  They can be added to custards or yoghurts.  If too thick, they can be diluted with milk.
• Food Fortifiers (eg, Protifar powder) can be added to foods and drinks to increase protein.
• Supplements can be mixed with alcohol after you have been discharged from hospital (if alcohol allowed  and does not interfere with medication).

Drinks

Liquids are important but can be filling. Try to ensure drinks provide calories by possibly substituting water/coffee/tea with some of the following:

• Cocoa, drinking chocolate, coffee (made with all milk, i.e. latté or cappuccino, cream, evaporated milk)
•  Full fat milk (fortified) and milkshakes (fortified)
•  Lucozade or energy drinks
•  Fruit juices and full sugar squashes eg. Ribena / Robinsons
•  Drinking yoghurt
•  Fizzy drinks, include ginger ale (NB. can cause bloating)
•  Fruit smoothies (bought or homemade with fortified milk)

Food and fluid fortification

Choose high energy, high protein foods. Eating more of these will help you to gain/maintain weight. This means avoiding diet / slimline / low fat / no added sugar products.

Fats and oil have the highest amount of energy per gram compared with all other foods in our diet & are therefore invaluable in food fortification.  Fortify foods & fluids using the methods below whenever possible to add extra energy:

• Fortified milk - Add 3-4 tablespoons skimmed milk powder, (e.g. Marvel) to 1 pint full fat milk. Use this in soups, sauces, puddings, drinks, and on cereal
• Add butter or margarine spreads liberally on bread, toast, crackers, vegetables & potatoes
• Fry or add oil to dishes like rice and pasta
• Add yoghurt / fromage frais / cream cheese / crème fraîche / cream to stews, soups, drinks (use full fat products)
• Add grated cheese, cream / sour cream, fortified milk to soups & sauces. Have sauces on meats, potatoes and pasta
• Add evaporated milk to soup, sauces, milk & other puddings (eg jelly)

If you have been told by your Doctor / Dietitian that you have high cholesterol or heart problems, try using poly or mono-unsaturated oils/spreads whenever possible. This are better for heart health. High calorie foods good for heart health include:

• Oils & Spreads: olive, vegetable (rapeseed), sunflower, safflower, soya, corn. Olive oil based spread
• Oily Fish: Mackerel, salmon, sardines, herring, trout, tuna 
• Nuts: Walnuts, chestnuts, almonds, hazelnuts, peanuts, pistachio, pecans
• Avocado: use in salads, sandwiches or as a snack

Long Term Diet

With larger burns, your energy needs for healing continue to be very high, sometimes up until 12 months from the date of injury. Some people with very large burns have shown to have had high energy needs for up to 2 years after they have healed, however, this is quite rare.

Generally, you will need to eat a diet high in protein and energy up until your burn is fully healed or as advised by your burns dietitian.

Once your burn is fully healed and your weight is stable, then you can switch to a healthier balanced diet that the general population are advised to follow. Please refer to pages 14 and 15 for guidance regarding this.

Vitamin and Mineral Supplementation

You may be prescribed vitamin and mineral supplements or a nutritional supplement whilst you are in hospital and after discharge from hospital.  Copper, selenium, zinc, vitamin C are regularly given to patients with a larger burn injury. This is because they help with wound healing. Please ask your Dietitian how long you need to take them after you are discharged from hospital.  Generally, supplements are no longer necessary when your burns have healed and you start to maintain your weight. 

Breakfast Ideas

• Cereals – Use fortified milk (see recipe). Porridge/Ready Brek, made with fortified milk, cream, evaporated milk, yoghurt. Try adding dried fruit, fresh fruit or nuts. Try adding honey, brown sugar, golden syrup or maple syrup to add taste to muesli or sugar coated cereals. Try cereal with fruit juice if milk is not tolerated. Remember cereals can be eaten any time of the day, hot or cold. NB: Scandishake, Build-up or Complan sachets & ‘Procal’ can be added to porridge
• Eggs (poached, boiled, scrambled with salmon, omelette); try bread ‘fingers’ dipped into beaten egg & fried. Ensure eggs are well cooked.
• Cooked breakfasts (bacon, sausage, ham & baked beans).
• Bread/toasts (sweet or savoury toppings).
• Croissants, muffins, scones, pitta bread (sweet or savoury toppings).
• Waffles or crumpets (with maple syrup, honey, savoury spreads).
• Yoghurts, fromage frais (full fat), flavoured or plain (try adding dried / fresh fruit, nuts, honey, spices etc).
• If you find that eating in the morning makes you feel sick, try dry toast or crackers.

Easy Small Meal Ideas

Eating several small meals and snacks can be much easier than facing a large meal.

• Scrambled eggs, omelette, with added cheese, avocado, bacon, herbs etc
• Baked beans on toast (well buttered/spread), topped with melted cheese
• Cheese on toast (try spreading cream cheese & top with Cheddar/hard cheese)
• Bacon buttie—bacon with onions, mushrooms on bread or toast
• Mini pizzas—bought or homemade (can use bagel, muffin or crumpet as a base)
• Sausage rolls, pork pies, scotch eggs, Falafel
• Soups (canned/packet/homemade)—add full fat milk, cream or cheese, croutons
• Flans, quiches, pies, pasties
• Sausages (or hotdogs), bacon, egg with baked beans
• Pancakes/kievs stuffed with vegetables/meats in cheese sauce
• Spaghetti, macaroni cheese (sold in small or large tins)
• Oily fish—eg tinned mackerel, sardines or salmon on toast
• Takeaways—burgers, fish and chips, Chinese, Indian, Kentucky Fried Chicken
• Instant, frozen and microwave meals—can be very nutritious

High Energy Snack Ideas

• Cereals (see breakfast section)—can be eaten any time of the day
• Small sandwiches (see sandwich section) or toast with topping
• Muffins and scones (cheese or sweet), crumpets, croissants (filled), waffles, flapjacks
• Nuts (peanuts, pecan, cashew, pistachio, brazil, walnuts, almonds,), dried fruit, olives, Bombay mix
• Avocado (with oil or seafood dressing)
• Milkshakes, ‘Fruit Smoothies’
• Tortilla crisps, breadsticks, pitta bread with dips such as taramasalata, humus, cream cheese, satay, peanut butter, avocado/guacamole, soured cream
• Desserts (see next section) such as yoghurts, rice pudding can be taken at any time

If high cholesterol isn’t a problem for you, the following snacks may also be useful, as long as they are used as part of a balanced diet:

• Doughnuts (large or mini), pastries, fruit strudels
• Crisps
• Mini pork pies, scotch eggs, sausage rolls, mini sausages
• Cheese and biscuits (remember to also use butter or spread)
• Samosas, bhajis

Puddings and desserts

Fruit is an easy dessert, but quite low in energy, so try to combine it with other higher calorie ingredients.

Other dessert ideas can be used as snacks between meals.

• Fruit, served with full-fat yoghurt, cream, ice cream, custard, condensed/evaporated milk, tinned fruit in syrup, dried fruit and nuts (soaked in juices or alcohol, if allowed)
• Fruit yoghurts (full fat), Greek yoghurt and honey, fromage frais, crème fraîche (add extra dried/fresh fruit, nuts (flaked/chopped), honey, syrups, crunchy cereals, spices)
• Custards, mousse, fools, whips, crème caramel, blancmange
• Mini trifles, cheesecakes, banoffee pie
• Rice pudding, milk puddings (semolina, tapioca)—can add sugar, syrups, jam
• Ice-cream (including ready bought on stick)
• Jelly (make with evaporated milk or fruit-juice supplement drinks)
• Fruit crumbles, fruit pancakes or fritters, fruit pasties, pies
• Flour based—sticky toffee pudding, spotted dick, bread and butter pudding served with cream, ice cream or custard
• Cakes—chocolate, lemon drizzle, fruit sponge, Victoria sponge, carrot

Sandwich ideas

For variety and greater flavour, try using different breads (fresh, hot, toasted)—rolls (eg with seeds), baps, French bread/baguettes, focaccia, naan, ciabatta, bagels, pitta bread, muffins, crumpets, scones, croissants. Always have at least two fillings such as ham and cheese.

Remember:

• White breads can be less filling/bulky than wholemeal types
• Try an ‘open sandwich’, ie only one slice of bread, with plenty of filling
• Ensure bread/roll is well spread with butter or margarine (not low fat varieties!)
• Use plenty of mayonnaise or salad cream (if enjoyed)—a dash of mustard or tomato puree adds flavour
• Try adding chopped herbs (fresh or dried) to add extra flavour.

Fillings:

• Fish—tuna, salmon, pilchards, sardines (tinned in oil), smoked/peppered mackerel
• Cheese, hard or soft, try different varieties; try a layer of cream cheese & topping with grated hard cheese
• Avocado and/or bacon
• Pastes eg olive, pesto, smoked mackerel, pate
• Meats—corned beef, cold meats, hams, chicken, spam
• Egg mayonnaise (ensure egg is well cooked)
• Peanut butter, tahini
• Taramasalata, houmous, falafel
• Sweet spreads: jam, marmalade, banana and honey, chocolate/nut spreads

Pastas & Rice

Pasta provides a good base to meals; try to use sauces that provide additional energy & protein:

• Try creamy sauces eg use cream, full fat milk, yoghurt/fromage frais
• Macaroni or cauliflower cheese; add croutons or cubes of ham/bacon/pancetta/salami/pepperoni
• Use grated cheese or sour cream to top tomato or vegetable based sauces
• Pesto or oil-based sauces
• Add avocado, nuts, bacon, olives, mackerel, hard boiled egg, prawns
• If appetite is poor, use less pasta and more sauce

Salads and vegetables

Although full of vitamins and minerals, salads and vegetables can be filling, while providing little energy. The following ideas help increase calories.

• Serve with coleslaw, pasta, rice & potato salads
• Use mayonnaise & salad cream or oil-based dressings (not low-fat versions)
• Try adding chopped nuts, seeds, pinenuts, olives, dried fruit
• Add avocado, hard-boiled egg, bacon, ham, cubes of cheese
• Add pieces of sausage / hotdogs, chicken, fish (tinned or fresh)
• Try croutons (bought or homemade - cubes of bread fried in oil, herbs, garlic)
• Stirfrys: add nuts, tofu / quorn, chicken, fish; use oil in dressings 

Potatoes

Potatoes can provide easy and economical meals—try these:

• Filled jacket potatoes (see below) & potato skins (deep-fried)
• Chips, bought, oven cooked or deep-fried (can use unsaturated oils)
• Mashed potato (packet or homemade) - add butter / marg, milk, cream or cheese
• Potato fritters - mash & fry with onion, cheese, bacon, ham etc.
• Potato layers - bake sliced potato with onion, cheese sauce, egg & milk
• Croquettes, bread crumbed potatoes, wedges, hash browns.
• Add potato to soups to thicken
• Use crisps (crushed) & grated cheese for toppings.

Jacket/Baked potatoes (See sandwich fillings for other ideas):        

• Tuna mayonnaise, sweetcorn and cheese
• Baked beans and cheese
• Bolognaise or chilli sauce, topped with grated cheese or sour cream
• Ratatouille, topped with grated cheese or sour cream
• Coleslaw
• Egg mayonnaise
• Sausage and baked beans
• Pizza sauce and grated mozzarella
• Scrambled egg, tomato and green pepper
• Prawn mayonnaise / prawn cocktail
• Brie and cranberry sauce
• Sauteed mushrooms, garlic and grated cheese

Glossary

Total Body Surface Area of Burn or TBSA) – Refers to the area or percentage of the body that has been affected by a burn injury.

Metabolic Rate – The amount of energy used by the body when at rest.

Tube fed – A way of giving artificial food through a tube into the stomach, sometimes it is placed after the stomach at the top of the small intestine.

NG tube – Shortened way of writing or saying a Nasogastric feeding tube. This is a type of feeding tube that is inserted via the nose, through the food pipe into the stomach.

Calories – Unit of energy that comes from breaking down food from the digestive tract.

Protein – A type of essential nutrient that act as building block in the human body. Protein is an important source of fuel / energy for the body. Proteins are also involved in healing burn injuries.

Pureed foods – Foods with a similar consistency to baby food or apple sauce containing no lumps or stringy pieces.

Soft foods – Foods that can be mashed easily with a fork.

Flamazine cream for burns

What is Flamazine™?

FLAMAZINE™ is a topical antibacterial cream with an active ingredient which belongs to the group of antibiotic medicines called sulphonamides.

Flamazine™ contains Silver Sulfadiazine.

What is it used for?

FLAMAZINE™ is used to prevent infection in severe burns and might be used to help removing burnt dead tissue. 

It is soothing when applied and has proven activity against a broad range of organisms including both Gram-positive and Gram-negative bacteria and some viruses and fungi

Don’t use Flamazine™:

• If the tube is expired or has been opened for more than 7 days.
• If you are allergic to Silver Sulfadiazine or any other of the ingredients in Flamazine.
• In children <1 month old.
• If you are pregnant or breast feeding
• If you suffer from: Glucose-6- phosphate deficient, low white cell count, problem with your liver or kidneys
• Use Flamazine™ in or near the eyes.
• Give Flamazine™ to anyone else, even if they have similar problems to yours.

How to use Flamazine™?

Remember to take analgesia before changing your dressings

1. Wash your hands.
2. Remove the previous dressing/bandages.
3. Mix 5mls (teaspoon) of the antiseptic soap provided spoonful into 200mls (about ½ a pint) of tap water. You can soak the affected area if possible.
4. Clean with the gauze provided using a wiping motion to ensure the old cream is removed.
5. Dry gently with a clean towel.
6. Reapply cream generously (3-5mm thick) and cover.
7. Renew every 24 hours unless instructed otherwise.

* If you using Flamazine™ on the genitalia reapply every time you go to the toilet/change nappy.

How long should I use it for?

The Burns team will advise you when to stop using Flamazine™. If in doubt contact the Burns Team

Stop using Flamazine™:

If you experience any of the following:

• Increased pain, burning or itching
• Nausea, vomiting or diahorrea
• Skin reactions or rashes.

Please contact the Burns Team or attend the Emergency Department if unwell.

Storage

Keep Flamazine™ in cool place and out of the reach of children.

Any doubts?

If you have any doubts, concerns or questions about how to use Flamazine™, please contact the burn team.

Adult: 020 3315 2500

Children: 020 3315 3707

Please discuss with the burns team if you are not happy to change the dressing yourself.

Healed wounds

Now that your wounds have healed it is very important that you start looking after your new skin.

Proper after care of your skin is very important to restore your skins function, reduce pain and swelling as well as minimise any scarring that may form.

It is important that you keep your new skin clean and hydrated. When you are no longer in dressings you can begin to bath again initially with a mild baby soap.

Moisturisers can be used to soften the skin, prevent dryness and reduce feelings of tightness.

Do’s and Don’ts

Avoid creams that are aqueous based for massage as these are designed for bathing.

It is important to moisturise shortly after contact with water as this can have a drying effect e.g bathing or swimming.

There are many different products on the market that advertise they treat “scarring”. Whist everybody’s skin is different there is no evidence that any of these products are any more beneficial than simple moisturiser for hydration and massage.

It is important to wash your skin daily to avoid an accumulation of cream.

How to massage your healed skin

Massage the affected area with moisturiser 4-5 times daily for several minutes over each area. If you have dry skin then this can be increased.

Massage initially with moderate pressure and move the skin in all different directions. As your skin heals you can increase the pressure you use to massage.

Use a simple unperfumed moisturiser e.g E45, Diprobase or Nivea. Everybody’s skin is different; you may find that you need to trial a number of different moisturisers to find the right one for you.

Sometimes different massage techniques are required to mobilise the scar tissue effectively. This will be advised by you therapist during review and you will be advised to perform with or without moisturiser.

1. Zig-Zag Mobility

2. Circular mobility

3. Pinch and roll

Please contact your therapist if you have any concerns or questions.

Contact information

chelwest.burnstherapy.cw@nhs.net

Patient Advice & Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception.

Alternatively, you can send us your comments or suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website www.chelwest.nhs.uk/pals.

We value your opinion and invite you to provide us with feedback.

T: 020 3315 6727
E: cwpals@chelwest.nhs.uk

P

What is a pressure garment?

A Pressure Garment is a tight lycra piece of clothing made to your measurements, to provide constant pressure over an area of your body.

Why do I have to wear it?

Pressure Garments limit the growth of scar tissue by exerting constant pressure over the scar. The pressure helps to keep collagen fibres in the scar flat. You have been given a pressure garment to treat your raised or firm scar.

How long will I have to wear it for?

A Pressure Garment can be used until a scar has matured, this may take between 18-24 months but this can be longer, or shorter. Your Therapist will discuss when it is time to start reducing the use of your Pressure Garment.

When should I wear it?

A Pressure Garment is more effective the more it is worn. You can wear your Pressure Garment during the day and at night time. Take it off when you are treating your scar with massage or to apply silicone and when you are washing.

How do I wash it?

Pressure Garments should be hand washed. Pressure garments can be cool washed (400 or less) with mild, non-biological detergent once a week. Hand washing makes them last longer. Air dry the garment, do not put it in a tumble dryer or on a radiator as this breaks the elastic in the material and makes the garment ineffective. Clean your garments regularly to prevent build-up of cream/silicone.

Can I have another one?

You will be fitted with one Pressure Garment at your hospital appointment. A spare garment will then be posted to you. Adults will be issued with new garments after 3 months, children after 2 months (occasionally sooner if the child grows out of the garment). If you do not have a review booked for 3 months you will need to contact Burns Therapy to request replacement garments.

Please contact the therapy department if you do not receive garments in the post within one month or if there is a problem with the garment.

What should I do if the seams of my pressure garment have broken, the elastic has stretched or my pressure garment no longer fits?

Contact Burns Therapy for advice. You will need to return the garment to Burns Therapy for mending. DO NOT alter your garments yourself, the pressure has been carefully calculated by specially trained Pressure Garment Technicians.

Will my Pressure Garment protect me from the sun?

No. Your Pressure Garment has no UV protection in it. You will need to protect your scar if you are outside in direct sunlight by covering it or applying factor 50+ sun cream.

Further details

Please bring your pressure garments with you when you attend burns therapy appointments so they can be reviewed and altered if needed.

If you experience any of the following after putting on your Pressure Garment contact the Burns Therapy Team:

• Increased soreness or breakdown of skin
• Change in circulation such as blueness or swelling
• Abnormal sensation or pins and needles.

If this is out of hours remove your garment until you have received advice.

This leaflet is intended as a guide to answer some of the questions you may have about Pressure Garments. Please follow the specific advice given to you by your Burns Therapist. This will occasionally be different to the standard advice given here.

Frequently asked questions

What is a skin graft?

A skin graft is the transfer of healthy skin from one part of the body to cover the burn wound. The skin graft must be taken from the same person as the graft is applied to as skin donated from friends or family will be rejected by your body.

The skin integrity is very important to provide a protective barrier from infection and water loss. When the skin is damaged by a burn or scald the protection is lost.

If the burn is deeper than the top layer of the skin (i.e. following a second or third degree burn, also called partial or full thickness burn) a skin graft might be needed as the wound will be unable to heal by itself. A skin graft is necessary when the cells needed to repair the skin have been lost or damaged and new tissues are needed. This is because the burn extends into the deeper layers of the dermis and has destroyed the tissues that can heal the wound. Without a skin graft the risk of infection is higher and the wound could take a long time to heal resulting in abnormal scarring or delayed healing.

How is the skin graft taken?

This is a surgical procedure, which will usually require a general anaesthetic. The surgeon will take a thin shaving of healthy skin and put it on the cleaned burn wound. This new wound is called the ‘donor site’ and will have a dressing on it. The skin graft may have small perforations in it to enable better contouring and adhesion of the skin graft. This is called a meshed skin graft.

How does the skin graft stay in place?

The skin graft may be stapled, stitched or glued, depending on the size and depth of the graft and the site of the wound. The graft will then have a dressing over it for protection. If the graft is on or near a joint, a splint may be used to reduce movement to protect the graft.

How long do these wounds take to heal?

The healing time of the graft will depend on the size and depth of the wound. The aim is to get the wound healed in about 7 - 10 days, but healing may take longer. Infection, comorbidities and some medications can slow down healing.

Are there any risks?

The risks will be explained by the surgeon when they ask you to sign the consent form for the operation. These include bleeding (in some cases a blood transfusion may be required and if anticipated this will be discussed with you), infection and partial or complete loss of graft. Re-grafting may be required if some or all the graft is lost. Please ask your doctor or nurse if you would like further information about any of these points.

What dressings will be used?

Both the donor site and skin grafts will be covered by dressings. The dressings might be different each time they are changed but this will be explained by your nurse/doctor. The type of dressings may also change as the wounds heal.

When can I start walking/ moving around after a skin graft?

This will depend on where the grafted area is. If the graft is not on the legs, you can walk as soon as you feel able; if the graft is on the legs the doctor may want you to be on bed rest for a few days, or to walk with the help of crutches. Protecting the skin graft in the first few days is important to allow the healing to progress and the graft stick down. Please ask your nurse if you have questions.

What can help the wounds heal?

It is important that the care instructions given by the surgeons and nurses are followed, to give the graft a good chance of healing. A healthy balanced diet that includes plenty of protein is important. Protein foods include: milk, cheese, yoghurts, eggs, meat, fish. Smoking and passive smoking slows down the healing by reducing the amount of oxygen reaching the skin.

Will there be dressings on my wounds when I go home?

Probably yes. These will require changing once you have gone home. Arrangements for this will be made before discharge: you may be able to have dressings changed locally by the practice nurse, paediatric community nurses or the burns outreach nurses. You will have to return to the hospital for some appointments to see the doctors.

What will my skin graft look like?

With any skin graft there will be scarring. The appearance of the graft will change over the weeks and months and will take up to 2 years to fully mature. Once the graft is healed you will be referred to the scar management team.

Small areas of wound breakdown and blisters are common on the newly healed skin as it is thinner and more sensitive. This may occur due to irritation from clothing or accidental bumps and bruises. If this happens these areas can be protected with small dressings to prevent further damage and help healing. If you have any problems with the wound after discharge please contact the dressing’s clinic or the ward.

How do I care for my skin graft?

Once the graft has healed and the dressings are removed you/your child will be able to wash and bath the area gently. Make sure the water is not too hot. Avoid using highly perfumed soaps and bubbles. After bathing gently pat the grafts dry and then massage the area with non-perfumed moisturising cream. It is important to cream and massage the new skin at least twice daily to moisturise the graft and help flatten the scars.

It is very important that both the graft is protected from the sun and is covered using high factor (>SPF30) sun  cream (for both UVA and UVB) and protective clothing as the new skin may burn very quickly and blister. If it becomes tanned this can be a permanent tan that can be blotchy and irregular. It is important to protect all newly healed areas from sun damage for at least 2 years.

The skin graft tends to become dry and flaky due to the lack of sweat and oil glands. You will be given advice on this prior to discharge and by the scar management team.

Will I be in pain?

During the surgery you will have had local anaesthetic injected into your wound so that it is numb will the operation takes place. This will also help reduce the pain fro a short time after the operation. Once the local anaesthetic wears off it is expected that you will feel sore. You should take simple pain relief such as paracetamol before the effects of the local anaesthetic wear off. If you find that the pain is not managed by taking regular paracetamol you should speak to your GP or a pharmacist for advice on additional pain tablets.

Do I need to have the dressing(s) changed?

It is common for the dressing to be left in place for up to a week. The frequency of your dressing changes will be determined by your surgeon and the location of your wound and or the presence of infection.

Do I need to come back to the burns unit to have the dressing(s) changed?

Some direct closures can be managed appropriately by your local practice nurse. You will be advised to make an appointment with your practice nurse if it is deemed safe to do so. Otherwise you will be given a follow up appointment for the Burns Dressing Clinic to have you dressing changed.

Do I need to have the stitches removed?

This will depend on what stitches were used during your operation. If you have dissolvable stitches they do not usually need to be removed. Dissolvable stitches take approximately 6-8 weeks to fully dissolve. Occasionally the stitches on the surface of the wound do not dissolve and do have to be removed. If you have dissolvable stitches and they have not dissolved in two weeks you can arrange and appointment with your GP practice to have them removed. If you have non-dissolvable stitches or staples, these will have to be removed.

Who removes the stitches?

The surgeon will advise you about when the stitches need to be removed. This will range from 5-21 days depending on the area.

After the operation what do I need to look out for?

Complications are not common but the ones to look out for are:

Bleeding

after 48hours you may notice some bleeding on your dressing. This is completely normal straight after your surgery. However if the wound continues to bleed or leak fluid, an appointment will need to be made for a registered nurse to review the wound. You can do either of the following:

• Make an appointment with your practice nurse at your local GP
• Make an appointment with the nurses at the Burns Dressing Clinic

If bleeding is continuous you should seek medical attention via an emergency department immediately.

Pain

If your wound is causing you significant discomfort and an the pain is increasing, this could indicate the following:

• putting too much strain on the wound, you need to rest the area to allow the damaged skin to heal.
• a sign of infection

If pain is continuous you should seek medical attention via your GP or an ED

Infection

It is important to look out for signs of infection. If you develop any of the following symptoms, please seek medical advice straight away:

• Redness and heat surrounding the wound
• An increase in pain
• Discharge from the wound
• Generally feeling unwell in yourself
• Nausea or vomiting
• Fever (temperature anove 38C)

If any of the above symptoms occur, please seek medical attention immediately. You can contact the nurses in the Burns Dressing Clinic first as they may have a space to see you. However, if this is not possible we recommend that you arrange an appointment with your GP or attend an ED

How will it look after the scar is healed?

A scar will be left once the wound has healed. How visible the scar is differs from person to person and will continue to change over time.

After all dressings, and any stitches or staples have been removed or have dissolved from your wound, the scar will begin to remodel to look more like the surrounding skin and get stronger. It will always be more fragile than it was before the operation so needs protection.

Scarred skin can become thick, lumpy, dry and itchy. To combat this, scar massage and moisturising can be started as soon as the wound is healed. It is recommended that you massage the scar 2-3 times a day for 5-10 minutes each time to help soften it, to prevent skin breakdown and improve appearance. Consider wearing sun protection (>spf30) at all times. 

When can I return to normal activities?

This will differ between individual circumstances, the type of operation, and your level of pain. Most wounds take a minimum of two weeks to begin to heal and get stronger so you are advised to avoid activities that could put strain on your wound. However, some areas need further restrictions. For example, if you have had surgery on a limb it is advised that you elevate to reduce any swelling, do not drive, avoid exercise and avoid heavy lifting. The type and size of your wound and the extent of your injury will determine how long these restrictions should be followed. The Burns Dressing Clinic Nurse of Therapists will discuss this with you.

What is oedema?

Oedema is the medical name for ‘swelling’. This leaflet will help you understand why you may have oedema following your burn injury and give you some advice about how to reduce swelling and prevent complications.

Why do I have oedema?

Depending on the size of the burn, you may experience swelling immediately around the injured area or it may involve other parts of the body. For example, if your burn is on your arm, then your hand can also become swollen, due to the effects of gravity.

The swelling is caused by fluid leaking from blood vessels and collecting around damaged areas. Swelling tends to occur soon after injury and generally decreases after 48–72 hours, although this timescale can vary. The extent and location of the swelling will depend on how the burn was caused and the location and depth of the burn injury.

It is very important that the swelling is reduced as soon as possible. Otherwise it can increase pain, make it difficult to move, cause stiffness or deformity of joints, interfere with the normal functioning of your muscles, nerves and blood vessels and can cause a superficial burn to deepen.

If you have had a skin graft, tissue fluid and bleeding can affect the healing and in some cases, may cause the graft to fail. In this instance it is even more important to follow the advice below to minimise the negative effects of fluid.

What can I do to reduce oedema?

There are steps that you can take to reduce the amount of swelling you have and to prevent it from getting worse.

Elevation

Elevation will encourage drainage of fluid and allow it to be reabsorbed by the body. The swollen part should be higher than the rest of the limb so that gravity can assist. Slings, pillows, tables and sometimes splints may be used to position your limb.

Movement

Movement encourages drainage of fluid. Muscles act as a pump, pushing fluid away from the swollen area. Your therapist may show you specific exercises to help with this. Sometimes movement is not encouraged (e.g. recent skin graft). Please ask your therapist if you are unsure.

Upright position (for face, head or neck burns)

If you have facial swelling it is extremely important to maintain an upright position. You should avoid lying flat as this encourages fluid collection in your face and head which can lead to difficulty opening your eyes and may also affect your breathing.

Compression

Your therapist may bandage your hand with a stretchy bandage called ‘coban’ which helps to push the oedema out of the swollen area. If your burn has healed, you may also be given a compression glove.

What is it?

A silicone gel sheet is a soft, flexible, self-adhesive dressing that is applied over scars. It contains silicone. Silicone can help to improve the colour, height and texture of a scar.  Silicone can also relieve itching and discomfort caused by a scar.

How does it work?

It is not clear exactly how Silicone works on a scar. Some research suggests that the silicone creates a protective barrier over the scar which allows it to mature while helping to prevent production of excess scar tissue. The silicone layer also assists with hydration of the scar.

Where can I get silicone gel sheets?

There are different brands of silicone gel sheet available. Your therapist will assess which one is most suitable for your scar and demonstrate how to use it by providing you with a small sample. We request that your GP provide an ongoing supply. You will be given a letter to give to your GP requesting this.

How do I use a silicone gel sheet?

• Ensure that the affected area is clean and dry.
• Wipe off any excess cream if you have been using cream to massage.
• Remove the protective backing on the sheet and place the sticky side on your skin.

• Build up your skin tolerance. Wear the sheet for 4 hours daily for two days. Then increase gradually up to the amount of time advised by your therapist.
• Wash the gel sheet daily using lukewarm soapy water, rinse well and dry by patting it with a non-fluffy towel.
• Wear the same piece of silicone until it starts to deteriorate, then replace it with a new piece.

Precautions

• Do not use the gel sheet on open wounds. If you develop a wound in your scar, remove the gel sheet and keep it safe until the wound is healed.
• Don’t forget to wash the gel sheet. A buildup of dirt or bacteria may irritate the scar.
• Do not throw the gel sheet away if you develop any irritation or redness in response to using it. Remove the sheet, wash and dry your skin. Leave the sheet off until the symptoms resolve, then try it again, building up the skin tolerance slowly.

How long should I continue to use a silicone gel sheet on my scar?

90 days is the recommended initial treatment period. However, you may be advised to continue to use it for longer than this by your therapist depending on the appearance and age of the scar.

My GP/Pharmacy cannot order Silicone Gel Sheets—Is there anything I can do?

Inform your therapist and they may be able to assist in resolving the problem.

If this is not possible, you can purchase silicone gel sheets yourself by ordering them on-line.

www.amazon.co.uk

www.farmaline.uk

Please contact your therapy department if you have any concerns or questions.

Contact information

chelwest.burnstherapy.cw@nhs.net

Patient Advice & Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception.

Alternatively, you can send us your comments or suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website www.chelwest.nhs.uk/pals.

We value your opinion and invite you to provide us with feedback.

What is it?

Silicone spray is a clear, self-drying spray. It is made from silicone. Research has shown that silicone can help to reduce the colour, height and texture of scar tissue. Silicone can also relieve itching and discomfort from your scar.

How does it work?

It is not clear exactly how silicone works. Some research suggests that silicone forms a waterproof protective barrier over the scar. This allows the scar to mature while helping to prevent production of excess scar tissue. The silicone layer also assists with hydration of the scar.

Where can I get silicone spray?

Your therapist will demonstrate how to apply the spray by using a department sample but cannot provide a full bottle. We request that your GP writes a prescription for an ongoing supply. You will be given a letter to give to your GP requesting this.

How do I apply silicone spray?

• Ensure that the affected area is clean and dry.
• Wipe off any excess cream if you have been using cream to massage.
• Apply a very thin layer of spray, gently wiping over the scar twice to spread it evenly.
• Allow to dry for 4-5 minutes before putting on clothes or pressure garments.
• Once dry, you can apply cosmetics or sunblock on top of the spray.
• If it takes longer than 4-5 minutes to dry, you have used too much. Wipe off the excess and allow to dry.

How often should I apply silicone spray?

Apply the spray as frequently as your therapist instructs you to during the day after massaging with cream.

Precautions

• Do not use on open wounds.
• Avoid contact with eyes and mucous membranes.
• Do not apply over other skin products.
• Discuss any dermatological conditions (e.g. eczema, psoriasis) you have with your
• Silicone spray may stain clothes if not allowed to dry completely before dressing.
• If the spray causes any redness or irritation, wash it off and contact your therapist.

How long should I continue to use silicone spray on my scar?

90 days is the recommended initial treatment period. However, you may be advised to continue to use it for longer than this by your therapist depending on the appearance and age of the scar.

My GP/pharmacy cannot order silicone spray. Is there anything I can do?

Inform your therapist and they may be able to assist in resolving the problem. If this is not possible, you can purchase silicone spray yourself by ordering it on-line. Search for ‘SilDerm Scar Spray’.

Please contact your therapist if you have any concerns or questions.

Contact information

Chelwest.burnstherapy.cw@nhs.net

Patient Advice & Liaison Service (PALS)

If you have concerns or wish to give feedback about services, your care or treatment, you can contact the PALS office on the Ground Floor of the hospital just behind the main reception.

Alternatively, you can send us your comments or suggestions on one of our comment cards, available at the PALS office, or on a feedback form on our website www.chelwest.nhs.uk/pals.

We value your opinion and invite you to provide us with feedback.

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:

• Changing Faces—www.changingfaces.org.uk
• Dan’s Fund—www.dansfundforburns.org
• The Katie Piper Foundation—www.katiepiperfoundation.org.uk

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

What is a splint?

A splint is a hard piece of plastic material measured and moulded to your exact size to hold a particular body part in a specific position for a period of time (your Burns Therapist will advise you on how long you need to wear it)

Why do I have to wear it?

There are a number of different reasons people are provided with splints. These include:

• After an operation to apply skin grafts. These grafts need to be kept very still while they are healing so a splint is provided to stop a joint from moving and disrupting this.
• To improve the range of movement at a joint by providing a long stretch at rest.
• To prevent or reduce pain by resting a joint.
• To prevent or reduce deformity during a period of healing.
• To assist function
• Swelling

What is my splint made out of?

A material called Thermoplastic which softens when it is warm allowing moulding and hardens when cold to keep its shape.

When do I need to wear my splint?

The different reasons for needing a splint mean when they should be worn changes depending on the circumstance.

Your Burns Therapist will instruct you on when to wear your splint, if you are unsure please ask.

If you experience any of the following when wearing your splint contact the burns therapy team:

• Swelling or pain from the splint
• Different sensation in the limb or pins and needles.
• Rubbing from the edges of the splint.

Splint use:

• DO wear your splint as instructed
• DO contact Burns Therapy if your splint breaks or no longer fits exactly
• DO clean your splint as needed with cool soapy water. Rinse the soap off well and dry thoroughly before putting the splint back on.
• DO bring your splint to appointments as it will need to be reviewed regularly.
• DO NOT put your splint in hot water or on/near a radiator as it will cause it to lose its shape.
• DO NOT try to alter your splint yourself.
• DO NOT remove your splint if you have been advised to wear it 24 hours a day.

This leaflet is intended as a guide to answer some of the questions you may have about splints. Please follow the specific advice given to you by your Burns Therapist. This will occasionally be different to the standard advice given here.

Splints

Please contact your therapist if you have any concerns or questions.

Contact information

Mobility aids

You have been issued with a crutch/crutches or a walking frame to help you move around after your burn injury. Please only use these as you have been shown and follow the instructions in this leaflet.

Crutches

Crutches are used for either Non Weight Bearing (where no weight is put through affected leg) or Partial Weight Bearing (where a small amount of weight is put through the affected leg)

Your Burns Therapist will instruct you which weight bearing type you should use and it is important you follow these instructions for your optimal recovery.

Safe use of crutches

• Always remove crutches from your arms before sitting down or standing up.
• Hold onto a rail where possible when going up or down stairs.
• Lead with your non affected leg when going up stairs, lead with your affected foot when going down stairs.
• Limit your amount of mobility to necessary trips only and be aware you will be slower than normal.

Walking sticks

If you are provided with a walking stick it will be measured and cut to the correct height for you. If the ferrule (the rubber stopper on the end which is put on the floor) gets worn down, please speak to your therapist.

Walking frames

Walking frames are usually used to assist with balance when walking if this has been affected by a burn injury. Occasionally it is necessary to be Non Weight Bearing (where no weight is put through affected leg) or Partial Weight Bearing (where a small amount of weight is put through affected leg) when using a walking frame.

Your Burns Therapist will instruct you on how to use your frame, it is important you follow these instructions carefully.

Safe use of walking frames

• Walking frames are for indoor use only.
• Do not pull on your frame to stand up. Stand first using arm rests to assist you then use your frame for balance.
• Limit your amount of mobility to necessary trips only and be aware you will be slower than normal.

All mobility aids are issued in good order. Please notify us if your aid needs replacement ferrules (the rubber stoppers on the bottom which are put on the floor)

If you are not sure how you should be using your walking aid please ask your Burns Therapist or contact the Burns Therapy Team (0203 315 5680)

All mobility aids (crutches and walking frames) remain the property of Chelsea and Westminster Hospital.

Please return them to the Burns Therapy Team when they are no longer required.

How to access skin camouflage

Chelsea and Westminster Hospital

A referral can be made by your burns therapist to a health care professional in the hospital. The health care professional will trial skin camouflage on your scars and advise you on the most suited shade for your skin type and scar.

Charities

A charity called Changing Faces runs the Skin Camouflage Service where you can have a free consultation using prescription products in order to find the best product and shades for you. In some areas of the UK you may need a healthcare professional to refer you to this service—learn more.

The Katie Piper Foundation is a charity that offers a free consultation in order to find the best product and they also provide make-up & lip and eye shaping. Referrals can be made by your burns therapist or independently by contacting the Katie Piper Foundation.

Skin camouflage products

There are a number of camouflage creams available on prescription (at the GP's discretion):

• Veil
• Covermark
• Dermacolour
• Dermablend
• Keromask

There are many cosmetic products (not on prescription) which can be used to cover scarring. These are not the same as camouflage products and may not provide the same level of coverage or staying power. For example: CoverFX.

Products can be bought online at:

• The Doublewear range from Estee Lauder
• Various products from Mac