Development of nursing care guideline for burned hands

Abstract Aim To develop an evidence‐based guideline to care for hand‐burned patients. Design An integrative review. Method The search was conducted of EMBASE, PubMed, Web of Science, SCOPUS, Clinical Key, Iranmedex, Magiran, Scientific Information Database (SID), Cochran, CINAHL and Google Scholar databases from January 2000–August 2019. Following the formation of the research team, two researchers independently selected the eligible studies. The initial search resulted in 2,230 records; ultimately, 40 articles were identified to be the review after screening the records based on the study's inclusion and exclusion criteria. Quality of selected studies was evaluated with the MMAT method. Results Data syntheses of selected studies, coded by highlighting the relevant parts of the text, and assigning code words to these areas were done. Following this, a constant comparison was used to develop categories by combining codes. Finally, hand burns nursing care guideline was developed by categorizing descriptive themes in two main phases. Conclusion This review results have shown that evidence‐based guidelines present high‐quality recommendations for the healthcare team, which improves the quality of clinical care. Due to a lack of established guidelines in our context, it seems to be helpful to use evidence‐based guidelines in managing burned hands.

By improvement in the management of patients with severe burns, including fluid resuscitation, pain management, modern dressing products, nutritional support, various surgical interventions, infection control and early rehabilitation programmes, the survival rate has been increasing in the last decades. But serious complications are still common among burn patients (Abu-Sittah et al., 2011;Deng et al., 2016;Kamolz, Kitzinger, Karle, & Frey, 2009;Soni et al., 2017).
Due to the differences in hand burn impairment nature from other injuries, hand burns are usually associated with numerous physical and psychological problems. Deformities, disabilities, wound infection, severe pain, contractures and hypertrophic scars are the most physical difficulties that a hand-burned survivor experiences (Abu-Sittah et al., 2011;Afifi et al., 2016). Simultaneously with physical difficulties, hand-burned patients confronted with multiple psychological challenges such as anxiety, post-trauma stress disorders, depression, sleep disorders, aesthetic problems, dependency, body image dissatisfaction and low self-esteem (Kornhaber, Wilson, Abu-Qamar, & McLean, 2014;Titscher, Lumenta, Kamolz, Mittlboeck, & Frey, 2010).
Multiple physical and psychosocial complications following hand burn injuries emphasize the need for proper management (Bayuo, Agbenorku, & Amankwa, 2016;Luce, 2000). It has been indicated repeatedly that the use of evidence-based guidelines by healthcare providers is a useful way of achieving optimal functional outcomes with fewer disabilities in hand burn patients (Brychta, 2012).
Clinical guidelines are specific and detailed plans that are used as a medical guide for daily clinical care. Guidelines have been designed for: (a) improving the quality of health care, (b) decreasing the use of unnecessary and ineffective procedures and (c) facilitating the patient management with high quality and fewer risk disabilities (Brychta, 2012).
According to reviews, several studies have been done in the development of clinical guidelines for the management of patients with hand burns; however, in most studies, the designed guidelines are not considered as clinical and comprehensive. This review was conducted to design and develop an evidence-based guideline for optimal hand burn care. Yet, the research question is how the nursing care guideline in burned hands is and can its effects improve the performance of burned hands?

| AIMS AND MATERIAL S
Clinical guidelines are systematically developed statements that help the healthcare team and their patients to make appropriate decisions about a special condition or treatment. As stated in studies (Butler, Hall, & Copnell, 2016;Gallery, Volunteers, & Login, 2007;Committee, 2018;Organization, 2014), it is necessary to design an integrative review (IR) for developing guidelines. Therefore, we designed an IR for developing a nursing care guideline for patients with burned hands; the IR method is an approach that, by combining different methods and examining all the findings of particular issues or subjects, provides useful and valuable information to the researcher or practitioners on that subject (Whittemore & Knafl, 2005). In this research, we used the Whittemore and Knafl's (2005) IR framework stages, which included Problem identification, Literature search, Data evaluation, Data analysis and Presentation.
Integrative reviews are the broadest type of research review methods permitting for the concurrent inclusion of experimental and non-experimental research to more fully understand a phenomenon of concern. These reviews include a wide range of purposes: to define concepts, to review theories, to review evidence and to analyse methodological issues of a particular topic (Broome, 2000).

| Stage 1: Problem identification
The first step in the review method is a clear identification of the problem; then, variables of interest are defined theoretically and practically.
Clinical guidelines are specified and extended guides with different variables in a specific field. According to studies, implementation of guidelines can improve the proficiency of the healthcare team in the management of patients, reduces mortality and morbidity rate and minimizes complications of the inappropriate treatment plans (Brychta, 2012;Gallery et al., 2007;Committee, 2018). Due to the importance of evidence-based guidelines in managing hand-burned patients and lack of these guidelines in our context, we aimed to design an IR for developing an evidence-based guideline for hand burn patients.

| Stage 2: Literature search
This research question was designed based on the Setting, Perspective, Intervention, Comparison and Evaluation (SPICE) framework that is more helpful than Population, Intervention, Comparison and Outcomes (PICO) framework with two important changes. These changes included dividing the population element into both "setting" and "perspective" and "evaluation" instead of outcomes (Cleyle & Booth, 2006;Crumley & Koufogiannakis, 2002).
These new concepts of the SPICE framework confirm that data practice is a social science and incorporates other concepts such as "outputs" and "impact" together with less tangible effects of a library or instructional intervention (Cleyle & Booth, 2006). SPICE framework is a more appropriate framework for health and social sciences (Cleyle & Booth, 2006;Eldredge, 2001) and helps practitioners to identify their practice-based questions. This framework was also used for matching the research design to the question, and inclusion and exclusion criteria, and guides the database search strategy (Cleyle & Booth, 2006). Eligible articles for this review include RCT, experimental, semi-experimental, descriptive and systematic review studies on guideline,   protocols or management of adult hand burns, dressing, wound healing, exercise, hand physiotherapy, burn pain and hand burn studies   available to the full-text article in English or Persian language,  Articles were excluded if studies were on animal burns or the study design was in pilot design studies, newsletters and case report.   : procedural pain,  background pain and breakthrough pain Pain management therapy at the emergency phase applies only to patients with burn greater than 10% (TBSA). Nevertheless, for patients with extensive hand burn pain, management is necessary Due to potential problems with medication absorption, from the IM and PO route at the emergency phase, the preferred route for the most medications is the intravenous route

| Designing the search strategy
The visual analogue scale (VSR) has shown to be a reliable method for measuring a patient's pain. - The main purpose of nutritional support in burn patients includes the following: • to accelerate good wound healing • to prevent and control infections • to prevent protein loss and body mass Initial nutrition assessment should do at admission day for developing baseline data to distinguish the progress made during the therapy The patient feeding should be initiated in the first 24-48 hr of postburn injury, and their diet should include a variety of micro-and micronutrients including proteins, vitamins, carbohydrates, fats and minerals.

TA
The visual analogue scale (VSR) has been shown to be a reliable method for measuring a patient's pain After the emergency phase has been completed, the patient may be tolerating oral pain medications Use of pain relief medications such as opioid agents, NSAIDs, lidocaine and acetaminophen to control procedural pain according to physician prescription, before and during wound manipulating Massage is considered as an effective method to reduce background and breakthrough pain, due to the prevention of muscle spasm Music can decrease the pain level by reducing sympathetic activities and releasing endorphin.   -If it is necessary, it should be coordinated by a nutritionist to evaluate the patient national requirements during the treatment period.

| Stage 3: Data evaluation
Mixed-studies review (MSR) can be more appropriate for decisionmakers and practitioners by providing a rich and practical understanding of complex health interventions and programmes (Pace et al., 2012).
The Mixed Methods Appraisal Tool (MMAT) seems to be a useful and unique tool for evaluating MSR (qualitative, quantitative and mixed methods) . This tool is recommended Besides, the MMAT permits the appraisal of the most common types of study methodologies and designs .
The MMAT contains five specific sets of criteria: (a) a "qualitative" set for qualitative studies; (b) a "randomized controlled" set for randomized controlled quantitative studies; (c) a "non-randomized" set for non-randomized quantitative studies; (d) an "observational descriptive" set for observational descriptive quantitative studies; and (e) a "mixed-methods" set for mixed-methods research studies, with design components of mixed-methods research. Each study type is reviewed and evaluated in its methodological domain (Pace et al., 2012).
The eligibility of articles was discussed in the research team; then, to appraise the selected papers in this study, two reviewers independently evaluated the quality of the papers with the MMAT method. We use this method to evaluate the quality of selected studies and to increase the validity of the study.
For evaluating the studies at first, we studied all relevant articles to identify their design. Then, we evaluated and scored them based on the MMAT checklist for a different type of studies. For example, we assessed the randomized control studies to see whether they have (a) an "appropriate sequence generation/randomization,"

Pre hospital
PaƟents & wound assessment -Be Sure of C-A-B is secure.
-Check the hand(s) pulse and movement in electrical burns

Hospital
IniƟal paƟent and wound assessment -Assess the paƟents about their demographic characterisƟcs, past medicaƟon history, burn percent, burn depth, burn type, immunizaƟon status; medicaƟon taken regularly and pain severity using the iniƟal hand burns wound assessment sheet.
Daily paƟent and wound assessment -Assess the paƟents wound characterisƟcs, hands range of moƟon, treatment plans, and pain and itchiness severity using the daily hand burns wound assessment sheet.

Cooling
-Cool the hand(s) with running cool water for 15-30 minutes and conƟnue it for more than 30 minutes in chemical burns. -Do not use ice or buƩer for cooling the hands.

Cooling
-ConƟnue irrigaƟng the hands with cool (not cold) water for paƟents who have passed the pre hospital phase.
-For paƟents who have not passed the pre-hospital phase start cooling burned hands immediately aŌer paƟents arrived at the emergency department.
Pain management -Evaluate pain severity using VAS or NRS different Ɵmes during day especially before and aŌer doing procedures, and manage the pain as presented in the hand burns acute phase diagram.
Pain control -Cooling the hand(S) can reduce the pain.
-If the pain is severe, administer the analgesics via the intravenous route (IV) with the physician ordered.
Pain management -Evaluate pain severity using the visual analogue scale (VAS) or numeric raƟng scale (NRS), and manage the pain as shown in the hand burns emergency phase diagram.
Wound cleansing -Clean and debride the hand burned wound as presented in the hand burned acute phase diagram.
Wound cleansing -Clean and debride the hand burned wound as presented in the hand burned emergency phase diagram.
Wound dressing -Cover the hands as guided in the hand burned emergency phase diagram Wound cleansing -Remove all jewelry, rings, and watches from burned hand immediately aŌer the burn injury. -Do not break any blisters; leave them intact as a biological dressing on the wound. -In the chemical burns, the first step is decontaminaƟng the offending agent. Therefore, you should start the wound lavage as soon as possible for limiƟng lower layers damage. -It should dust off any dry chemical agent such as lime, which may react with water exothermically and cause further thermal damage.
Wound dressing -Cover the hands as guided in the hand burned emergency phase diagram.
Wound dressing -Apply a thick coat of silver sulfadiazine, and cover the burned hands with a sterile gauge and bandage. Then wrap the fingers separately and loosely to avoid too much pressure.
-Be sure to check for sulfa allergy prior to applying silver Hand posiƟoning -Elevate burned extremiƟes (hands) above the level of heart on the pillows. -The paƟent should use resƟng hand splints during the day. -The paƟent with hand burns should not be encouraged to increase acƟvity during the first 24-48 hours aŌer injury.
Hand physiotherapy and paƟent educaƟon -The hand burned paƟents should encourage starƟng acƟvity and hand exercises within 72 hours aŌer injuries.
-Physiotherapy programs should be designed, based on paƟent's educaƟonal needs, hand burn severity, and their ability in doing exercises in 2 or 3 individual or group educaƟonal sessions. -It is recommended to educate easy exercises as presented below for the first session: 1. Make a fist 2. Claw stretch 3.Thumb extension 4.Thumb flexion 5.Thumb touch 6.Thumb stretches -It is suggested to educate the below exercises for the second session: Step 1

Emergency Phase Acute Phase
Step 2 Step 3 Step 1 Step 1 Step 2 Step 3 Step 4 Step 4 Step 6 Step 2 Step 3 Step 4 Step 5 Step 5 Step 5 sulfadiazine cream, and consider using another anƟbioƟc ointment for the paƟents with past allergic history to sulfonamides.
Hand posiƟoning -Elevate burned extremiƟes (hands) above the level of heart on the pillows. -The paƟent should use resƟng hand splints during the day.
1. Finger liŌ 2.Finger stretch 3. Pinch strengthener 4.Grip strengthener 5.Moving wrist forward and back -Evaluate the paƟent's progression and hand range of moƟon (ROM) improvement. Then record it in the daily hand burns wound assessment sheet. NutriƟonal support -IniƟal nutriƟon assessment should do by a nutriƟonist team at admission day for developing baseline data to disƟnguish the progress made during the therapy.
-Hand burned paƟents without severe injuries should start orally (Po) diet in the first few hours aŌer the injury.
-The paƟents should encourage to drink enough fluids especially water and juice in the emergency phase due to fluids shiŌ.

NutriƟonal support
-If it's necessary, you should coordinate by a nutriƟonist to evaluate the paƟent naƟonal requirements Ɵll the treatment period.
-Following hypermetabolism aŌer burn injuries paƟents nutriƟonal needs increase. Therefore, their daily diet must contain various trace elements such as proteins, Micronutrients, carbohydrates, fluids, fiber, and lipids. -Its recommended that a burned paƟent daily diet should contain protein (1.5-2 g/kg/d), zinc, copper and selenium, as well as of vitamin B1, C, D and E.
Step 6 Step 7 Step 6 (b) an "allocation concealment and/or blind" and (c) "complete outcome data and low withdrawal." Finally, we selected the articles with a score of more than 50% for developing our guideline. The articles and scores of two reviewers were examined, and any disagreements were discussed until agreement was reached. According to the evaluation of studies based on MMAT, it was found that the quality of selected studies was moderate with the MMAT score of 50%-75%.
A total of 86 studies were excluded due to not meeting the study's inclusion criteria during the quality appraisal of the articles by the research team. The quality scores, study aim, design, data collection, conclusion and limitation of the studies are included in Table 1.

| Data synthesis
The data analysis stage is one of the most difficult aspects and potentially fraught with error. According to the main object of the study, free line-by-line coding of the findings from all studies in Persian and English language occurred. Then, the codes were examined and analysed for their meanings, and similar data were reorganized into two categories (emergency and acute phases) based on the guideline aim and best evidences (Herndon, 2012;Paul, Day, & Williams, 2015;Summer, Puntillo, Miaskowski, Green, & Levine, 2007). All data were examined for meaning and content during the coding process. All similar codes were interpreted and compared impartially in each category, specifically looking for similarities and differences, and then in each section, the best evidence was selected. Predetermined and relevant themes of each category were extracted from all selected studies and compiled into a matrix. The steps of data analysis in the study include data reduction, data display, data comparison, conclusion drawing and verification (Whittemore & Knafl, 2005).

| Data reduction and display
To manage data for a better understanding and enhance the visualization of patterns and show the relationships between primary TA B L E 5 Hand burn emergency phase cleansing, dressing and pain management Immediately, after burn injuries keep the hands under running water to prevent more injuries and minimize pain Continue hand lavage for more than 30 min in chemical burns In solid chemical burns, such as lime, first dust off the agent and then start to lavage Use polyethylene glycol in the burns with phenol like agents.
In the second-degree burns with blisters, it is suggested: • Don't break blisters with less than 2cm diameter except those are on the joints • Aspirate the blisters with more than 2cm diameter Aloe vera gel Vaseline Polyethylene (PE) sheets Olive oil Daily dressing in 1% silver sulphadiazine or mafenide ointment and vaseline for wounds with high amount of exudate Daily dressing with 2% mupirocin or bacitracin and vaseline for wounds with low amount of exudate Dressing in silver aqua gloves and changing herring 14-7 days Daily dressing with antibiotic ointment and polyethylene gloves Third Immediately, after burn injuries keep the hands under running water to prevent more injuries and minimize pain Continue hand lavage for more than 30 min in chemical burns In solid chemical burns, such as lime, first dust off the agent and then start to lavage Use polyethylene glycol in the burns with phenol like agents -Use 1% silver sulphadiazine ointment or 2% mupirocin Daily dressing in 1% silver sulphadiazine or mafenide ointment and vaseline for wounds with high amount of exudate Daily dressing with 2% mupirocin or bacitracin and vaseline for wounds with low amount of exudate Dressing in silver aqua gloves and changing herring 14-7 days -Daily dressing with antibiotic ointment and polyethylene gloves data sources, the following data are considered as the initial subgroups: author, country, year, study design, data collection and results ( Table 1). The extracted themes are displayed as an algorithm, and emergency and acute phases are described in Tables 5 and 6.

| Data comparison
In the third step of data analysis, data were compared with each other to identify the specific patterns of studies and the precise and important themes in them. Data synthesis from the selected studies was coded by highlighting the relevant parts of the text and assigning code words to these areas. All similar codes were interpreted and compared impartially in each category, specifically looking for similarities and differences, and then, in each section, the best evidence was selected. Following this, a constant comparison was used to develop categories by combining codes. Descriptive themes were attached to each category.

| RE SULTS
The papers studied were mainly quantity papers, eighteen articles were conducted using the descriptive design, eleven articles used the experimental or quasi-experimental or RCT research design, and eleven articles were the Review articles.

| Stage 4: Presentation
In the final stage of the framework, more precise details of the primary sources and evidence as a logical chain to provide a result consistent with the findings were given to the reader of the review (Whittemore & Knafl, 2005).

| Development of hand burns wound care guideline
Based on two valid and comprehensive references (Herndon, 2012;Paul et al., 2015) in burn care field, the descriptive statements/ themes were extracted from our IR and categorized in two main phases (emergency and acute phases), and then, bunt hand management steps were classified based on their priority and importance in caring (Alsbjörn et al., 2007;Brychta, 2012;Yastı et al., 2015). Hand burn management steps, study design, number of related studies and most important descriptive themes depending on each section were included in Tables 2 and 3. Generally, the designed guideline was classified as below:

Emergency phase
The emergency phase was also referred to as resuscitative phase, which begins with the onset of burn injury and may be completely bypassed in the first 24-48 hr postburn injury. The most important themes that are noticed at this phase are initial patient and wound assessment, cooling, pain control, wound cleansing, wound dressing, physiotherapy and nutritional support.
The key themes included in the emergency phase are as follows: assessment of patients ABC (Soni et al., 2017), assessment of patient for any secondary traumatic injuries (Barillo & Paulsen, 2003), keeping hands under cool water for minimizing deeper injuries (Abu-Sittah et al., 2011) and removing all foreign bodies from the wound (Robinson & Chhabra, 2015). It is important to debride any loose or thin blisters and remove any foreign material from the wounds before applying dressings (Alsbjörn et al., 2007;McKee, 2010;Soni et al., 2017), covering the hand wound with sterile gauze and bandages(McKee, 2010) and elevating hands for first 48 hr (Barillo & Paulsen, 2003;Paul et al., 2015).

Acute phase
The acute phase starts as soon as the emergency phase completely bypassed, and it will continue until wound closure. Duration of this  The key themes included in the acute phase are as follows: daily assessment of the patient (Curtis, 2001;Herndon, 2012;Kamolz et al., 2009;Paul et al., 2015), physical examination that should be implemented during the daily assessment (Arnoldo, Klein, & Gibran, 2006;Paul et al., 2015), use of pain relievers to control burn-related pain as physician description (Sterling, Gibran, & Klein, 2009), use of dressing choices as wound bed characteristics and keeping it as thin as possible (Barillo & Paulsen, 2003), early excision and grafting that increases wound healing with better functional and aesthetic outcomes (Alsbjörn et al., 2007;Omar & Hassan, 2011) and hand rehabilitation, which is an essential principle ineffective care of handburned patients (Amini, 2011;Mohaddes Ardebili et al., 2014). If it is necessary, it should be coordinated by a nutritionist to evaluate the patient national requirements during the treatment period (Berger, 2009;Jafari et al., 2018).
Among 40 articles identified in this review, 23 (52%) focused on the emergency phase, 30 (68%) focused on the acute phase, and 15 (34%) focused on both emergency and acute phases. We have presented a summary of our guideline as an algorithm (Tables 4-8).
Knowing that, five of the studies were in Persian language and 35 in English language.

| D ISCUSS I ON
The latest studies indicate that using evidence-based guidelines by the healthcare providers is a useful way for presenting proper management for patients with hand burns; therefore, this review aimed to design an integrated and evidence-based guideline for hand burn management (Esmailian & Golestani, 2016 There are few studies that have considered nursing care for patients with hand burns. In a study of Ashwin Sony (Soni et al., 2017), exhaustive management of hand burns has provided an initial evaluation of the patient, escharotomy, excision, grafting of hand burns, wound management and amputation, but less attention has been paid to nursing care in hand-burned patients. In the presented study, we aimed to show the importance of nursing care in the management of hand-burned patients; moreover, in the guideline, a multidisciplinary team consists of a physician, nurses, nutritionist and physiotherapist considered for hand burn management. In addition, we provided the nursing cares in two phases, respectively, according to their importance in the management of hand-burned patients: in the emergency phase, initial patient and wound assessment, cooling, pain control, cleansing, dressing, hand positioning, and nutritional support are presented; and in the acute phase, daily wound and patient assessment, pain control, wound cleansing, wound dressing, hand physiotherapy and nutritional support are presented.
Accordingly, it is clear that our systematic review results are largely in line with other studies (Arnoldo et al., 2006;Young et al., 2017) that show implementation of evidence-based guidelines increases the quality of nursing care, reduces burn injury complications, reduces the distance between the theoretical and clinical aspects and helps the decision-making of the multidisciplinary burn teams and patients in specific clinical conditions. In this interest, the results in a retrospective cohort study conducted by Clark, Lowman, Griffin, Matthews, and Reiff (2013) indicate that implementation of early mobilization guideline on burn patients collaborates the multidisciplinary team (physician, nurses, physiotherapist) in early patients' mobility and reduces burn injury complications such as airway, cardiovascular, gastrointestinal, musculoskeletal and deep vein thrombosis, while no adverse events were reported related to the early mobility guideline. In another study by Ratcliff, Stephen (English, Ratcliffe, & Williams, 1999) with the aim of evaluating the effect of pain and anxiety guideline in children with burns shows that implementation of pain control guidelines such as music therapy guidelines is more effective than routine pain management on procedural pain control in burn patients.
The other advantage of this study is that all types of study including randomized control trials, descriptive studies, reviews and books, selected in the systematic review, were used for the development of nursing care guidelines after their quality was evaluated by the MMAT method. So studies with unclear methodology and results, case reports and pilot studies were not used in designing the guideline.
In conclusion, the unique property of this study is that it is evidence-based. In other words, a strong systematic review was conducted to design a guideline that presents all aspects of management for patients with hand burns.

| Limitation
This study has some limitations that should be taken into consideration when analysing the results. One of the limitations of this study is that on the one hand, some of the selected quantitative studies did not include enough population to do generalization and that on the other hand, some of the qualitative studies were originated from very different contexts also that we did not have access to the full text of all selected studies. In addition, the inability to use original language studies is another limitation of our study.

ACK N OWLED G EM ENTS
This research was based on the Master of Science thesis approved by the School of Nursing and Midwifery, Tabriz University of Medical Sciences. The author would like to acknowledge all Chancellor of

Research of School of Nursing and Midwifery for their cooperation
in the execution of the project.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflicts of interest.

E TH I C A L A PPROVA L
The ethics committee of Tabriz University of Medical Sciences authorized the permission to conduct this study (Ethical No: IR.TBZMED. REC.1396.975). All authors have full control of all primary data, and they agree to allow the journal to review their data if requested.