Development of an Illustrated Guide to Techniques of Dressing Application in the Patient With Burns

Introduction. Burns are complex, difficult-to-treat wounds associated with high rates of morbidity and mortality. Objective. The aim of this study is to develop and validate an illustrated guide to techniques of dressing application for use in the initial management of the patient with burn wounds. Methods. The construction of the illustrated guide was based on a literature review conducted of publications between 2001 to 2017 in MEDLINE/PubMed, Scientific Electronic Library Online, Cochrane Library, and Google Scholar. No similar work was found in the literature. Standardized photographs were taken using a manikin to illustrate the step-by-step procedures. The content validity of the illustrated guide was assessed by a panel of 7 burn specialists through a questionnaire in the search for a consensus opinion according to the Delphi technique. The questionnaire assessed 3 main components: Objective, Structure and Presentation, and Relevance of the guide. Results. The final version of the illustrated guide showed an excellent overall content validity index (CVI) of 0.99. The CVI was 1.0 for the component Objective, 0.98 for Structure and Presentation, and 1.0 for Relevance. The guide has 79 pages, 86 illustrations, and 10 chapters on techniques of dressing application for patients with burn wounds. Topics including material preparation, gowning and gloving procedures, and techniques of dressing application for different parts of the body were addressed. Conclusions. An illustrated guide for dressing application in burn wounds was developed and validated for content by an expert panel. 

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Burn injury is a serious source of trauma, with social, economic, and public health repercussions that require the attention of government agencies.¹ Burns are complex, difficult-to-treat wounds associated with high rates of morbidity and mortality.² People with changes in the skin as a result of burn wounds, especially exposed scars, may have difficulty establishing or maintaining close interpersonal relationships, even among friends and relatives.³ 

Burns can be classified based on the wound depth as first-degree (epidermal), involving only the epidermis; second-degree (superficial and deep partial-thickness), involving the epidermis and superficial dermis; third-degree (full-thickness), involving the epidermis, dermis, and subcutaneous tissue; and fourth-degree, which are also full-thickness burns, but involve underlying structures such as muscles or bones.^4-6 The treatment of patients with burn wounds has been a great challenge worldwide because of their medical, surgical, and psychological complexity, requiring intensive multidisciplinary care.^7,8

About 300 000 burn victims die annually across the world.¹ In Brazil, it is estimated that 1 million burn cases occur per year, with only 100 000 victims seeking medical care, resulting in 30 000 hospitalizations per year and about 2500 deaths as a direct or indirect consequence of the burn injury, showing the importance of the topic in public health planning.⁹ Burns have various causes, such as chemical, radiation, thermal, electrical, and inhalation of smoke and chemical products.^1,2,8-10 The costs of care and modern specialized treatments are high.¹¹ Adequate human and technological resources for the treatment of patients with burns tend to decrease the length of hospital stay and mortality rate.¹² The quality of care provided to the burn patient is monitored constantly from admission to discharge in specialized burn facilities, representing a challenge for health care professionals and increasing their interest in patient recovery.^2-13 

Dressing applications in patients with burn injuries usually are performed by physicians and nursing professionals based on protocols from a specialized burn facility. Occlusive dressings are an alternative for burn treatment and may be applied to a clean surface of a burn injury within 24 hours after the accident.^4-14 Difficulties may occur at the time of application and removal of occlusive dressings, especially at the end of the procedure, when the correct positioning of the patient may be difficult to maintain due to the extent of the injury or prolonged duration of the procedure. Burns may result in functional disability due to sequelae such as hypertrophic scars, skin retraction, sensory changes, physical impairment, and anxiety, making it difficult for the patient to return to previous activities. A burn treatment should increase skin flexibility, because scars formed as a consequence of burn injuries are commonly inelastic and permanently restrict mobility of underlying tissue and joints.¹⁵ The use of occlusive dressings may facilitate physical therapy interventions, which aim to improve skin and muscle flexibility, joint mobility, and range of motion.

Guides and manuals with recommendations for health promotion and education provide important pedagogical support for the continuing education of health professionals. In addition to training, the educational material contributes to the standardization of protocols and empowers professionals to take action in patient care.¹⁶ Thus, the aim of this study was to develop and validate an illustrated guide of dressing application techniques for use in the initial management of the patient with burn wounds. This educational material may be used to standardize medical and hospital supplies and dressing procedures for burn injuries and serve as instructional tools for health care professionals. 

This descriptive study was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP; São Paulo, Brazil; approval no. CAAE 79468017.7.0000.5505) and performed in accordance with the ethical standards of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from all participants prior to their inclusion in the study, and anonymity was ensured. 

Literature search
Initially, a novelty search was performed on PubMed, Google Scholar, and the Scientific Electronic Library Online (SciELO), but no educational material similar to the guide proposed in this study was found.

The development of the illustrated guide was based on a literature review covering the period 2001 to 2017 and limited to publications in Portuguese, English, and Spanish. A literature search was carried out on the Cochrane Library, MEDLINE/PubMed, and SciELO databases, and on the Google Scholar search engine using the descriptors burns, occlusive dressings, epidemiology, patient care, dressings, and therapeutics.

Guide topics and images
The topics of the illustrated guide were selected. The content of the guide consisted of an informative text and sequences of photographs illustrating the techniques of dressing application in burn injuries.

The guide included Introduction and Reference sections and 10 chapters, categorized as follows: (1) wound dressing supplies; (2) positioning the patient on the bed; (3) gowning and gloving procedures; (4) dressing technique for the face, ears, and cervical region; (5) dressing technique for the upper limb (ie, upper arm, forearm, and axilla); (6) dressing technique for the hand; (7) dressing technique for the lower limb (ie, thigh, legs, and feet); (8) technique to prepare a vest-type garment dressing; (9) technique for placing the vest-type garment dressing in the trunk region; and (10) assessment of shoulder, elbow, wrist, knee, and ankle mobility and chest expansion.

The author created a draft of the guide and possible sequence of illustrations. Standardized photographs were taken using a manikin to illustrate the step-by-step procedures in a realistic setting. The most representative 86 photographs were used in the guide to illustrate the techniques of dressing application in burn injuries. Also, the authors chose colors that would make the figures and images most effective for communicating each technique. The layout of the illustrated guide followed the Brazilian Standard NBR-6029.¹⁷ 

Panel evaluation
A panel of burn specialists validated the content of the guide. Inclusion criteria for the health professionals on the panel were to have more than 3 years of experience in the field of burn care, be a nurse or a plastic surgeon, and agree to participate by providing written informed consent. Potential panelists who did not meet the inclusion criteria or did not return the completed questionnaire within 10 days of mailing were excluded.

Content validity of the illustrated guide was assessed by the expert panel through a questionnaire in the search for a consensus opinion among evaluators (Delphi technique).^16,17 The Delphi technique may be applied as a qualitative, quantitative, or mixed-methods approach.^16-21 There is no consensus in the literature as to the number of experts required to form a panel. The anonymity of the experts was ensured.¹⁸ Two to 3 rounds or cycles of consultation are usually necessary to reach a consensus among the experts, but more rounds may be needed.¹⁸ The experts were requested to return the completed questionnaire for each round of consultation within 10 days.

Questionnaire
The questionnaire evaluated 3 components of the illustrated guide: Objective (4 items), assessing the importance of the subject; Structure and Presentation (11 items), analyzing the overall organization, clarity of the text, number of images, educational content, and formatting; and Relevance (4 items), regarding the importance of the information provided on the different topics for the health care professional and whether the guide has the potential to be used as an educational tool. The questionnaire items had 5 alternative responses (ie, inadequate, partially adequate, adequate, very adequate, and not applicable [N/A]) and instructions for the experts to optionally express their personal opinion in the provided space.^22,23

Content validation
The content validity index (CVI) was used to measure the proportion of experts who considered certain aspects of the illustrated guide as adequate or very adequate. First, the CVI was calculated for each item by dividing the number of responses adequate and very adequate by the total number of responses for that item (Formula 1). The CVI of an item should be greater than or equal to 0.78 (ie, an agreement of at least 78% among experts) for content validation of the item when the panel is composed of 6 or more experts.²⁴ 

The overall CVI is given by the sum of the CVI values of all items divided by the number of items in the questionnaire (Formula 2). A minimum overall CVI of 0.90 (ie, an overall agreement of at least 90% among experts) is required for content validation of the instrument.²⁴

Only items rated as adequate and very adequate were entered into the CVI calculation. Items rated as inadequate, partially adequate, and NA carefully were revised according to the experts’ comments and suggestions, and if necessary, the guide was sent for another round of consultation until at least 78% consensus was reached for every item.

The final version of the illustrated guide contains 79 pages, 10 chapters, and 86 illustrations showing step-by-step dressing application techniques for burn wounds. The cover image of the guide is shown in Figure 1. Examples of the layout of the illustrated guide can be seen in Figure 2 and of illustrations of a dressing technique in Figure 3, which show a rayon bandage impregnated with a topical agent that was applied over a simulated burn wound in a manikin. The placement of the bandage starts from the axilla, extends around the arm (always in the proximal-distal direction), and may involve the whole circumference, if necessary (Figure 3A, B). When a rayon bandage is wrapped circumferentially around the arm, the end of the bandage dressing should return to the starting point but leave 2 cm to 3 cm of bandage extending beyond this point to allow cutting with scissors (Figure 3C). 

Nine burn care specialists were invited to participate in the study; 7 accepted the invitation and returned the completed questionnaire within 10 days of mailing. The expert panel was composed of 2 plastic surgeons (1 male, 1 female) and 5 female nurses, of whom 2 had doctoral degrees, 2 had master’s degrees, and 3 had postgraduate qualifications. Additional characteristics of the participants are shown in Table 1.

The CVI was calculated to obtain the proportion/percentage of expert agreement on the illustrated guide. All items of the questionnaire achieved the minimum CVI per item of 0.78 required for validation in the first round of consultation, with no need for a second round.

The CVI was 1.0 for items (n = 4) in the Objective component, corresponding to 12 adequate and 16 very adequate responses (Table 2). All items of this component were validated, and no suggestion for changes was provided by the experts.

Structure and Presentation (11 items) was the component that received most of the suggestions for changes. Of the 11 items, 10 had a CVI of 1.0 (ie, rated as adequate or very adequate) as seen in Table 3. One expert rated 1 of the items partially adequate, resulting in a CVI of 0.85, and commented that the instructions for cutting a rayon bandage into strips and applying the strips to the wound in 1 of the procedures were not clear. The text was revised according to the suggestions of the expert, but the item was not sent for a second round of consultation because the required minimum CVI of 0.78 was achieved.

All items (n = 4) in the Relevance component had a CVI of 1.0, corresponding to 8 adequate and 20 very adequate responses, and therefore were validated for content (Table 4).

The final version of the guide showed an excellent overall CVI of 0.99 on the first round, above the required minimum overall CVI of 0.90, indicating a 99% consensus was reached among the experts. The authors applied for the International Standard Book Number (ISBN) after the expert panel validated the final version of the illustrated guide.

A summary table was prepared to contain the comments and suggestions provided by the experts. Some modifications were made to the illustrated guide based on relevant suggestions for improvement of the instrument. All chapters have a sequence of standardized photographs illustrating the described procedure (Figure 3).

The use of appropriate dressing techniques for burn injuries positively affects health-related quality of life and self-esteem, contributes to a rapid and safe intervention, and minimizes possible scar retractions.^3-13 The illustrated guide was created based on a review of the scientific literature and experience of experts in the field. The guide describes step-by-step burn wound dressing techniques independent of the total body surface area (TBSA) involved and provides information on prevention of complications and promotion of health and social reintegration. It also helps clarify some aspects of burn care and contributes to the management of patients’ burns using locally available resources. Manuals and guides have been used to disseminate best practices and as educational and training materials for health professionals working in different fields.^22,25,26 Such standardized guides are expected to reduce morbidity and mortality rates, improve treatment quality, and reduce treatment costs in private and public health care systems.^22,25,26

Well-written and easy-to-understand information facilitates learning; thus, the illustrated guide was developed to provide relevant information with clear and simple language. The most representative illustrations were included in the guide.

Because of the large amount of dressing supplies needed in the treatment of burn injuries, the authors suggest using an auxiliary table top to place the closed packages of dressings and another table to place the packages in use, which are opened on a sterile field. The patient should to be positioned properly for the dressing application procedure. The supine position is considered best because it allows an easy visualization of the burned areas and facilitates the work. After the dressing procedure, elevating the limbs improves venous return and prevents edema.

Lack of knowledge and difficulty with memorization are some of the factors that justify the development of educational materials on gowning and gloving procedures, which not only protect the professional against biological hazards, but also ensure the dressing is applied under aseptic conditions to minimize the risk of infection. Prevention of complications focused on patient education improves patient quality of life and may be a simple and cost-effective strategy.²⁷

Second- and third-degree burns require debridement to remove devitalized tissues and daily dressing changes. This requires the use of sterile techniques and may be performed in a surgical center, intensive care unit, or wound dressing room, determined by available facilities in various health care settings.^4-7 Topical antiseptic solutions, typically composed of alcohol, triclosan, iodine, or other detergents, are utilized to reduce the levels of pathogenic microorganisms.²⁸ Chlorhexidine detergent solution, a chlorhexidine-alcohol solution, and alcohols are among the most efficient and widely used agents for skin antisepsis in sterile and surgical procedures. Chlorhexidine is not absorbed through the skin, and allergic reactions are rare; however, contact of chlorhexidine with the eyes or auditory canal should be prevented to avoid conjunctivitis, corneal injury, and damage to the cochlea and middle ear.²⁶ Polyhexanide is also an antiseptic that combines a broad antimicrobial spectrum with low toxicity, high tissue compatibility, good applicability, and no systemic absorption.²⁹ Nonocclusive dressings should be used on the face, ears, and neck, because those areas are difficult to treat and require special attention to prevent complications such as infections, edema, and hypertrophic scar retractions.³⁰

For the upper and lower limbs, the guide suggests using occlusive dressings with rayon bandages, gauze-cotton pads, and crepe tape. Occlusive dressings are a proven alternative to nonocclusive dressings in burn treatment.^4,7,27

The description of techniques for preparing and placing a vest-type garment dressing on the trunk is relevant for health care professionals who lack the skills to apply a dressing to the shoulders, back, chest, abdomen, and gluteus. These techniques reduce procedure time and decrease stress for members of the health care team, relieve the patient’s pain, and optimize the use of dressing supplies for specific body regions.

Assessment of shoulder, elbow, wrist, knee, and ankle mobility and chest expansion is essential to patient rehabilitation. Occlusive dressings should maintain joint mobility. The assessment of chest expansion in conscious patients and in those receiving mechanical ventilation is of vital importance because excessive compression commonly is applied to the dressings, resulting in decreased chest expansion.^15,31

In this study, it was not possible to delve into products developed for the treatment of wounds. Instead, the study focused on dressing application technique, but it would be interesting and useful to explore the possibilities of technologies that could be recommended for treating these complex wounds by optimizing treatment.

The authors developed an illustrated guide of step-by-step dressing application procedures that was validated by an expert panel. The cliché that a picture is worth a thousand words drove the guide’s development, as illustrations facilitate comprehension of written text.³² Guides and manuals for health education must be validated by an expert panel of health care professionals with master’s or doctoral degrees and experience in education and patient care to ensure the usefulness of the instrument for the intended application.^25,26,33 

The illustrated guide may be used in burn care services, including specialized centers, intensive care units, hospitals, burn units, burn treatment centers, and emergency services. It also may be utilized in the application of wound dressings in patients with extensive, difficult-to-treat skin lesions, such as pemphigus and epidermolysis bullosa. Health institutions may use the illustrated guide to disseminate best practices and as an educational and training tool for the application of dressings in burns and extensive skin lesions. The guide provides information on wound dressing supplies, positioning of the patient, gowning and gloving procedures, techniques for applying dressings to different anatomical regions, instructions to prepare and place a vest-type garment dressing in the trunk region, and assessing joint mobility and chest expansion, always focusing on patient safety and the safety of the clinicians applying the dressings.

Further studies on the development of instructional and educational materials with information on types of secondary dressings used in the treatment of burn injuries of various degrees for different regions of the body are needed. 

Authors: Susana Rodrigues de Melo Pieroni, RN, MS^1,2; Leila Blanes, RN, PhD^1,3; Christiane Steponavicius Sobral, MD, PhD^1,2; and Lydia Masako Ferreira, MD, PhD^1,4

Affiliations: ¹Professional Master's Program in Science, Technology and Management Applied to Tissue Regeneration, Federal University of São Paulo (UNIFESP), São Paulo, Brazil; ²Red Cross Hospital, São Paulo, Brazil; ³São Paulo Hospital (HSP), São Paulo, Brazil; and ⁴Division of Plastic Surgery, Department of Surgery, UNIFESP

Correspondence: Susana Rodrigues de Melo Pieroni, MS, RN, Division of Plastic Surgery, UNIFESP; Rua Botucatu 740, 2o. andar; CEP 04023-062 São Paulo, SP, Brazil; susanapieroni@uol.com.br 

Disclosure: The authors disclose no financial or other conflicts of interest.