Certified registered nurse anesthetist burnout related to moral distress: a replication study

Southern California CSU DNP Consortium California State University, Fullerton California State University, Long Beach California State University, Los Angeles POST BURN PRURITUS RELIEF PROTOCOL A DOCTORAL PROJECT Submitted in Partial Fulfillment of the Requirements For the degree of DOCTOR OF NURSING PRACTICE Doctoral Project Committee Approval: Gail Washington, DNS, RN, PHN, Project Chair Ayman Khalil Tailakh, PhD, RN, Committee Member Copyright Yeon Sook Kim 2015 Post burn pruritus is pervasive, occurring in over 90% of burn patients. Moreover, post burn pruritus continues in greater than 40% of patients for years even after burn wounds are healed. Post burn pruritus is a syndrome of stressful symptoms experienced by burn survivors that requires medical management with effective interventions. Unfortunately, many burn patients suffer from pruritus-related post burn injury regardless of current standard therapies. Therefore, in this Doctor of Nursing Practice project, published evidence including studies/reviews of post burn pruritus relief served as a basis for development of an advanced practice nurse (APN)-driven post burn pruritus relief protocol. A systematic review was conducted and relevant empiric articles from September 1, 2013 to November 17, 2014 were critically appraised. Initially, 79 articles were found; 38 articles were selected using pre-established inclusion criteria. Two frameworks were used to guide this project. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model was applied for the literature review and the Rosswurm and Larrabee's model for evidence-based practice change was used for clinical application. The newly developed APN driven post burn pruritus protocol is driven by burn healing phase (pre-healing, healing, post-healing), and emphasizes non-pharmacological interventions; it includes both non-pharmacological and pharmacological methods specifically intended for reducing burn associated pruritus. TABLE OF CONTENTS ABSTRACT . iii LIST OF TABLES . vi LIST OF FIGURES . vii ACKNOWLEDGMENTS . viii BACKGROUND . Problem Statement . Purpose Statement. Supporting Framework . REVIEW OF LITERATURE . Pharmacological Topical Interventions . Non-pharmacological Interventions . 14 Summary of Literature Review. 18 PRISMA Model . 20 The Model for Evidence-based Practice Change . 21 Search Strategy . 23 Data Extraction and Quality Assessment. 24 Eligibility Criteria . 24 Study Selection and Data Collection process . 24 PROJECT MANUSCRIPT . 35 DISCUSSION . 40 REFERENCES . 41 APPENDIX A: 5 – D ITCH SCALE . 49 APPENDIX B: VISUAL ANALOGUE SCALE . 50 APPENDIX C: ITCH MAN SCALE . 51 APPENDIX D: TABLE OF EVIDENCE FOR PROPOSAL . 52 1. Characteristics of Included Studies. 2. Post Burn Pruritus Relief Protocol guideline . 1. PRISMA 2009 flow diagram . 2. A model of evidence-based practice change . 3. Flow diagram for selection of studies .
4. Post burn pruritus relief protocol .
It is I gratefully acknowledge the absolute and unwavering support of my family, especially, my husband Harrison and my autistic son, Joon. Also, I truly appreciate the expertise of Dr. Mathew Reiss at Torrance Memorial Medical Center. BACKGROUND
In 1992, a Burn Nursing Delphi study classified pruritus as one of the highest priority areas in nursing research. However, there has been a lack of research examining the etiology and treatment of this highly distressing symptom (Goutos, 2010). Multiple studies (Carrougher et al., 2013; Goutos, Clarke, Upson, Richardson, & Ghosh, 2010; Goutos, Dziewulski, & Richardson, 2009) have examined post burn pruritus or itching and have varying findings. Each study, however, has consistently demonstrated a considerable level of pruritus in post burn populations. Casaer, Kums, Wouters, Van den Kerckhove and Van den Berghe (2008) reported that 49% of patients, even with small burn injury, experienced pruritus. Post burn pruritus can be defined as a severe itching sensation as a result of burn injury. Pruritus has been identified as one of the most general debilitating and stressful symptoms that post burn survivors experience (Bell & Gabriel, 2009; Goutos, 2010; Goutos, Dziewulski, & Richardson, 2009). The prevalence of post burn pruritus is seen in over 90% of burn patients and can persist in greater than 40% of those patients for 4 to 10 years after burn injury (Carrougher et al., 2013). According to Brooks et al. (2008), among patients with four years after burn injury, 79% reported intermittent problems with pruritus while 29% of patients reported persistent itching. However, twelve years after injury, these numbers decreased to 44% and 5%, respectively. According to Carrougher et al. (2013), itching prevalence is highly correlated with females, young age, large burn areas, more grafted areas, dry skin, and raised or thick scars. Casaer et al. (2008) more precisely reported that patients experienced more pruritus between the ages of 2 to 50 years old; if the burn area was large; and, the area of burn injury was on the trunk rather than the extremities. On the other hand, a study by Thompson et al. (2013) found no significant differences between age and gender regarding hypertrophic scars and pruritus. Thompson et al. (2013) reported burn size over 20% of total body surface area (TBSA) had increased risk of itching. Yang et al. (2014) found that patients with post burn pruritus had broader burned areas and more severe scars. According to Goutos et al. (2009), burn patients tend to have significant amount of itching within 1 month after burn injury with the highest at 6 months and a decline over the first year after the injury. They reported that the origin of a burn can affect associated pruritus. For example, scald injuries were most likely to provoke pruritus, followed by flame and contact injuries (Goutos et al., 2009). The reason for different findings from different studies was each study had different population characteristics regarding TBSA, ages, gender, and burn areas. However, larger size of burns are obviously more associated with post burn pruritus according to these studies (Carrougher et al., 2013; Casaer et al., 2008; Thompson et al., 2013). Post burn pruritus negatively impacts the quality of life in patients that included; sleep disturbances, decreased enjoyment with leisure activities, decreased ability to complete activities of daily living, and decreased school and work performance (Hettrick et al.,2004). In addition, about 60% of burn patients experienced difficulty falling asleep (Carrougher et al., 2013). According to Casaer et al. (2008), burn patients' daily life was impacted in 42% of those suffering from moderate pruritus and 92% of those suffering from severe pruritus. Parnell, Nedelec, Rachelska and LaSalle (2012) reported that pruritus was related to low concentration, agitation, anxiety, and flat mood. In general, researchers reported that pruritus triggered negative quality of life associated with dryness, heat, sweat, activity, stress, fatigue, physical effort, and special fabric. The problem of pruritus in post burn patients is well recognized. There are many potential treatments available for itching (Bell & Gabriel, 2009). However, none of the current standard therapies have been very effective (Otene & Onumaegbu, 2013). In addition, there is currently no accord on standardized treatment of post burn pruritus (Otene & Onumaegbu, 2013; Richardson, Upton & Rippon, 2014). Most often, therapies include pharmacological interventions that include a selective histamine receptor antagonist, but it is effective in only about 20% of patients (Brooks, Malic, & Judkins, 2008). This is because histamine is not the only element involved in the mechanism of itching, but also there are non-histamine dependent pathways involved in the pruritus mechanism according to the study by Schmelz (as cited in Brooks et al., 2008). Another treatment is emollients which also have limited usage. For example, a eutectic mixture of local anesthetic (EMLA) cream can be applied only to healed skin and the maximum zone treated is 600 cm2 for patients less than 19 kg and 2000 cm2 for patients greater than 20 kg (Brooks et al., 2008). This lack of effective care is further compounded by the absence of a standardized protocol. The Burn Nursing Delphi study (1992) identified the need for high impact potential antipruritic strategies to improve patient care (Goutos et Problem Statement
Post burn pruritus has been identified as one of the most general and stressful symptoms that burn survivors experience and should be aggressively managed (Bell & Gabriel, 2009; Goutos, 2010; Goutos, Dziewulski, & Richardson, 2009). Pruritus from post burn injury begins in the early stages of wound healing. Pruritus is usually prominent in patients who have second degree burns, but patients who experience third degree burns may also have partly second degree burns. Pruritus comes along with wound healing in the first two weeks after burn injury (Bell & Gabriel, 2009). Consistently research findings have strongly proposed that post burn pruritus management should be one of the top priorities for burn research (Bell & Gabriel, 2009; Brooks, Malic, & Judkins, 2008). Itching from associated burn injury that persists over a period of time leads to disabling symptoms such as sleep disturbance, anxiety, and interruption of daily activities (Goutos et al., 2009). Purpose Statement
The purpose of this project was to develop an advanced practice nurse (APN) driven post burn pruritus relief protocol that include pharmacological and non- pharmacological interventions in outpatient settings. This protocol would be used for patients experiencing post burn associated pruritus. Expected outcome of the protocol would be a reduction in post burn pruritus as determined by the 5 D Itch Scale and Visual Analogue Scale (VAS). This project has three objectives: 1) to conduct a systematic literature review; 2) identify non pharmacological and pharmacological relief interventions; and 3) identify an implementation change model for clinical practice. The target population for this project was all patients experiencing pruritus from second and third degree burns in various stages of wound healing. This project included post burn patients. The desired outcomes and benefits of this post burn pruritus protocol will improve the quality of life in patients with burn injuries (Casaer et al., 2008). Supporting Framework
This project used two supporting frameworks: the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model and the Rosswurm and Larrabee's model for evidence-based practice change. Further discussion of these models will be discussed in this paper. The purpose of this project was to construct a post burn pruritus relief protocol through a systemic literature review to develop a protocol in order to improve the quality of life in burn patients. The PRISMA model used to improve the reporting of systematic reviews and meta-analyses was used as the standard guideline for this systematic review (Liberati et al., 2009). The Rosswurm and Larrabee's model of evidence-based practice change was also used as an appropriate conceptual framework for evidence based practice in this project. The model incorporates principles of quality improvement, use of team work tools, and evidence-based translation strategies to support implementation of a new practice (Melnyk & Fineout-Overholt, 2011). In this project, developing a post burn pruritus protocol will promote quality care and improve patient outcomes. These frameworks were explained in the methods section of this project and is also integrated in reporting REVIEW OF LITERATURE
Bell and Gabriel (2009) reported the treatment of pruritus after burn injury by reviewing ten research articles that were clinical trials that included nine class II and one class III studies. Class II studies are reliable data that includes observational studies, cohort studies, prevalence studies, and case control studies. Class III studies, on the other hand, contain evidence provided by clinical series, comparative studies, case reviews, case reports, and expert opinion. According to their review, both pharmacologic and non-pharmacological methods significantly decreased post burn pruritus. Effective pharmacologic methods are selective antihistamine antagonists (cetirizine/cimetidine) in adult & pediatric population, Atarax and colloidal oatmeal (topical agent) in adult population, Gabapentin and EMLA (topical agent) in pediatric population. Effective non-pharmacologic methods contain pulsed dye laser and silicone gel sheeting in adult and pediatric patients, and massage and transcutaneous electrical nerve stimulation (TENS) in adult population. Bell and Gabriel (2009) suggested using moisturizing cream for all patients with post burn pruritus with different treatment plans based on the size of TBSA. According to the review by Goutos, Clarke, Upson, Richardson, and Ghosh (2010), a multidisciplinary approach is necessary in successful assessment and treatment. They recommended early use of centrally acting agents and peripherally acting agents as well as non-pharmacological interventions for the treatment of post burn pruritus in adult and pediatric populations. Rowley-Conwy (2014) also reported emollient cream, cool baths, pressure garments, and oral and topical antihistamines and analgesics were effective in decreasing burn associated pruritus. Rowley-Conwy (2014) also supported multidisciplinary team to manage burn patients' recovery for the best outcomes of physical, emotional, and psychological aspects. Goutos, Dziewulski, and Richardson (2009) suggested therapeutic strategies should be classified by interventions on peripheral & central aspects of the pruritic pathway. Interventions that focus on the peripheral aspects of burns are: cooling of the wound; antihistamines; topical Doxepin; local anesthetics; colloidal oatmeal; Capsaicin; Laser therapy; Aloe Vera; topical Dapsone; Unna boot; Compression garments; and, Ondansteron. Centralized interventions are Gabapentin; TENS; massage therapy; and, psychological support (Goutos et al., 2009; Zachariah et al., 2011). Findings for treatments to relieve post burn pruritus have been developed from several research studies and included diverse methods. However, there was only one suggested protocol found in the literature. This protocol focused on pharmacological methods and required physician orders. Therefore, this project has conducted a systemic review to develop a nurse driven post burn pruritus relief protocol. Pharmacological Topical Interventions
Pharmacological interventions are often used to relieve pruritus in burn patients. The first drug of choice for pruritus is antihistaminic drugs, especially, H1 antihistamines; approximately 90.91% of burn patients have had antihistamines prescribed for post burn pruritus (Goutos, 2010). According to Casaer et al. (2008), 23.3% of 258 adult and pediatric burn patients in clinical settings received antihistamines during their research study; and, those treated with antihistamines recalled that they felt reduced pruritus after the treatment. However, because participants also had ointments applied for pruritus, it was unclear how effective antihistamines alone were in decreasing pruritus. Ratcliff et al. (2005) evaluated the effectiveness of a pharmaco-therapeutic protocol for pain, anxiety, and itching among 286 acute pediatric burn patients in the hospital setting. They reported that 39.2% of participants received medication to control itching at the beginning, but eventually all the children took some type of oral itch medication because their burn wound itching intensity increased as the wound progressed. Ratcliff et al. (2005) accordingly recommended based on their research findings (1) moisturizing body shampoo, lotions, and topical ointments (not hydrocortisone creams); (2) Diphenhydramine 1.25mg/kg/dose orally every six hours; (3) if itch remains poorly controlled, subsequently add Hydroxyzine 0.6mg/kg/dose every 6hours, then Cyproheptadine 0.1mg/g/dose orally every six hours so that one of the medications could be given every two hours. Goutos (2010) stated that combination of H1 antihistamines and H2 antihistamines significantly decreased pruritus compared to using only H1 antihistamines. Goutos (2010) mentioned a combination of moisturization and three first generation H1 antihistamines was effective in 84% of acute burn inpatients. Second generation antihistamines are not used for pruritus because first generation antihistamines are commonly used for sedative effect as well as for pruritus relief. The study by Goutos (2010) demonstrated that 10 out of 22 burn units used additional pharmacological agent. Of the 10 units, 6 units used a second antihistamine, 1 used Ondansetron (serotonin receptor antagonist), and 3 used gabapentin with alone or combining with an antihistamine. Gabapentin has been more effective relieving pruritus in acutely burn patients than first generation antihistamines; especially, Chlorpheniramine Ahuja and Gupta (2012) compared the use of Pregabalin to other medicine in managing post burn pruritus for 80 adult patients in outpatient setting. They reported that the group using both antihistamine and Pregabalin and the group using Pregabalin only showed higher rates of remission of itching in post burn population compared to the group of using antihistamine only. However, in the population of mild itching, using both antihistamine and Pregabalin had a much higher rate (77.5%) than using only Pregabalin (23.3%) regarding reducing itching. Akhtar & Brooks (2012) explored the effect of botulinum toxin (Botox®) as a new agent in managing post burn pruritus and found that Botox® successfully decreased pruritus in 8 outpatient adult burn population who were resistant to conventional therapies. All eight post burn patients described itching as "0" out of 10 at 2weeks after Botox® injection. The average duration of no pruritus after the treatment was 9 months. The study of Baker et al. (2001) demonstrated the combination of histamine 1 (H1) receptor blocker and histamine 2 (H2) receptor blockers significantly reduced post burn pruritus than using H1 receptor blocker only during the first 4 days of treatment in 17 adult and pediatric patients. After 4days of treatment, there were no differences between two cases. Baker et al. (2001) also reported that programmed (scheduled) medication rather than medication on demand (PRN) contributed to the reduction of pruritus. The review by Goutos (2013) also reported that aggressive antihistamine was effective in the early phase, but in the later stages wounds appeared to be less effective to antihistamine therapy. Mendham's (2004) study was done to test the action of gabapentin on itching in healing wounds among 35 children admitted to the inpatient burn unit. The research sample was the population who had been treated with Chlorpheniramine and Trimeprazine, but still remained irritable and constantly itching wounds at the beginning of the research. Gabapentin was given starting as 5mg/kg three times a day and maximum dose increased up to 5mg/kg twice a day and 10mg/kg at night. Within 24 hours of gabapentin use, parents and nursing staff assessed the effects of the treatment and they stated that there was a remarkable reduction in itching and they had decreased or unused antihistamine intake. Ahuja, Gupta, Gupta, and Shrivastava (2010), studied the effectiveness of gabapentin in decreasing post burn pruritus comparing to using cetirizine alone and combination of gabapentin and cetirizine for 28days in 20 burn patients with ages of 12 to 70 years. The study showed that using gabapentin alone reduced itching in 95% of people in the group while cetirizine alone used group and combination of gabapentin and cetirizine used group reduced itching to 52% and 94%, respectively. In addition, the study demonstrated that the onset of action with gabapentin was significantly faster than the cetirizine. According to Ahuja et al. (2010), 74% in gabapentin group stated the relief of pruritus whereas 32% in the group with cetirizine alone stated pruritus relief on the third day after the treatment. Ahuja et al. (2010) suggested the need for pruritus relief protocol as well as the need for appropriate dosage of gabapentin treatment was needed to reduce post burn pruritus. Goutos, Eldardiri, Khan, Dziewulski, and Ricahrdson (2010) compared gabapentin treatment with antihistamine treatment in relieving acute post burn pruritus among 91 adult and pediatric burn population of inpatient setting. Gabapentin monotherapy was four times more effective than Chlorpheniramine monotherapy in acute burn pruritus (41.46% vs 10%). As an antipruritic polytherapy in acute burns, combination of gabapentin, cetirizine and Cyproheptadine was more effective than the combination of three antihistamines (Chlorpheniramine, Hydroxyzine, and Cyproheptadine) in relief rate of pruritus in post burn population. The outcome was 95.12% and 84%, respectively. Goutos et al. (2010) also suggested polytherapy in younger population and larger TBSA because monotherapy had higher failure rate in younger populations. Anand (2012) showed the effectiveness of gabapentin for pruritus in palliative care, too. According to the literature review by Anand (2012), gabapentin is safe and effective in uremic pruritus, cancer and hematologic causes, opioid-induced itch, brachioradial pruritus, burns pruritus, and pruritus of unknown origin. In the study by Goutos (2013), gabapentin had persistent therapeutic effect because of the ability to prevent central nervous system sensitization; Ondansetron was more effective in reducing pruritus than antihistamine; serotonin had pruritus relief effect; and TENS was more effective in reducing post burn pruritus during the remodeling phase. Warner, Coffee, and Yowler (2014) supported efficient outpatient burn management by using H-1 receptor blocking agent (cetirizine) during the early stage of pruritus as scheduled basis not as needed basis combined with frequent massage of moisturizers. In addition, neuro- inflammatory transmitter blockers (Gabapentin and Pregabalin) are effective because they prevent neuron transmitters from stimulating itch-specific neurons (Warner et al., The study by Otene and Onumaegbu (2013) revealed that 88.6% of 35 plastic surgeons had no assessment tool or method to evaluate post burn pruritus while only 11.4% believed they had a method of assessing the severity of post-burn pruritus. Otene and Onumaegbu (2013) also stated that "57.1% would use oral medications as first-line treatment, 22.9% would use injectables, 8.6% would use topical agents, 5.7% would only reassure the patients and another 5.7% would use a combination of oral and topical agents together. 85.7% of these plastic surgeons and burn care specialists did not have any form of anti-pruritic regimen, as only 14.3% indicated having this". Otene and Onumaegbu (2013) recommended Itch Man Scale as an assessment tool for pruritus and suggested rough guidelines as a pruritus relief management according to the score measured by Itch Man Scale. According to the review by Brooks et al. (2008), topical agents such as capsaicin and nanocrystalline silver ointment can be used to reduce pruritus. These drugs can also be used as part of a combination therapy. Topical steroid, Doxepin or Dothiepin cream (a tricyclic antidepressant), and EMLA can be used as part of a combination therapy in pharmacological interventions. One topical agent, Provase®, is a nonprescription moisturizer with a blend of protease enzymes. Nedelec, Rachelska, Parnell and LaSalle (2012) performed a prospective, double-blind, randomized, controlled, and pilot study to evaluate the effect of Provase® in reducing post burn pruritus in 18 burn patients. According to Nedelec et al. (2012), the application of Provase® to post burn population significantly reduced the duration and the frequency of pruritus, area of itch, and the presence of affective itch characteristics. For instance, treatment group reported the area of itch was decreased to half after four weeks of Provase® application. La Salle, Rachelska, and Nedelec (2007) evaluated the effect of naltrexone in managing post burn pruritus among 13 adult population in inpatient and outpatient settings. They reported research participants who had failed with H1 or H2 receptor antagonist and hydrating lotion demonstrated some satisfaction of naltrexone use in reducing post burn pruritus. Overall, 50% of research participants improved the frequency and duration of itching, 72% were satisfied with the itch relief provided by naltrexone, and 62% stated that quality of life improved by using naltrexone. Jung et al. (2009) did a study to determine the effects of naltrexone as a potential antipruritic medication for 19 adult burn population in the inpatient setting experiencing chronic refractory itching. All of the research subjects were population who had failed in reducing post burn pruritus with antihistamine, gabapentin, or both antihistamine and gabapentin before. However, researchers found out that 44.5% (9 patients) of research subjects reported decreased scratching activity two weeks after using naltrexone. Mugwort lotion seems to be effective in treating the itch associated with post burn pruritus who had hypertrophic scars (Ogawa & Hyakusoku, 2008). Mugwort lotion significantly decreased pruritus, sleep disturbance and redness after 2 months of treatment in 14 adult post burn patients of inpatient setting suffering from hypertrophic scars in the study by Ogawa & Hyakusoku (2008). Lewis et al. (2012) explored the efficacy of Medilixir (mixture of coconut, palm, castor, olive, hemp seed, wheat germ, and canola seed oil) compared to the standard treatment of aqueous cream (mixture of paraffin, heavy liquid, phenoxyethanol, and purified water) regarding relieving the post burn itch symptoms. Research findings indicate that Medilixir is more effective in minimizing post burn pruritus than aqueous cream in 52 adult burn population of inpatient setting. Campanati et al. (2013) evaluated the clinical effect of the topical application of Ozonated oil on second degree skin burns comparing to the treatment with hyaluronic acid gel. Thirty adult patients were applied Ozonated oil on half of the burn lesion and hyaluronic acid on the other half of the lesion once a day for 12weeks. Clinical features of each lesion (erythema, tension, height, itching, and burning sensation) were assessed at baseline, six, and twelve months after treatment. Ozonated oil had the same efficacy of hyaluronic acid in reducing symptoms related to burns (erythema, tension, height, itching, and burning sensation) after 12 weeks of topical application. Non-Pharmacological Interventions
Studies that have non-pharmacological interventions in relieving pruritus for burn population include: psychological interventions, massage therapy, silicone sheeting for burn wounds, hypnosis, TENS (transcutaneous electrical nerve stimulation), and Unna boot application (Brooks et al., 2008). Cold water, cold temperature, and rest also can relieve pruritus in some burn population (Parnell et al., 2012). The study by Goutos (2010) found that 2 out of 22 burn units utilized psychologists, 2 units used massage therapy, and 1 unit used silicone products for pruritic wounds and these methods were effective in reducing pruritus in burn patients. According to Upton, Penn, Richardson, and Rippon (2014), psychological approaches are effective in reducing wound itching. Upton et al. (2014) reviewed 12 published articles regarding psychological methods (habit reversal, suggestions, relaxation training, massage, and itch-coping programs) are used to treat wound associated pruritus. The study finding demonstrated psychological methods reduced itching but this approach was supported by only one article. Psychological interventions can be applied with consultation of a psychologist in conjunction with other therapies. Muscle relaxation methods decrease itching in burn populations. Farahanil, Hekmatpou, and Khani (2013) investigated the effect of muscle relaxation on pain, pruritus, and vital signs among 110 hospitalized adult and pediatric patients suffering from burns. They assessed pain, pruritus, and vital signs before and after the Benson relaxation method was applied. According to the study, muscle relaxation technique was effective in relieving the pain, pruritus, and vital signs of patients suffering from burns. Brooks, Phang, and Moazzam (2007) performed a case study with 5 cases including 7, 20, 40, 45, and 65% of TBSA having mixed-thickness burns from both inpatient and outpatient clinic and reported the effect of Acticoat® (Nanocrystalline silver) for itch relief in burn patients. Acticoat® was applied for 2 weeks and the intervals from original injury to application were 2, 3, 3, 6, and 8 months. Before and after 2 weeks of application, Visual Analog Scale (VAS) of itching was assessed and compared. VAS score was 7.4 before application and it decreased to 3.1 after application of Acticoat® (p = 0.002) which significantly reduced post burn pruritus. However, the study did not indicate the condition of wounds. For example, whether the burns were healed or unhealed was not stated. It is assumed they were unhealed or in the healing process because Acticoat® is used for unhealed wounds in current practice. Field et al. (2000) performed a randomized controlled trial (RCT) to evaluate the effect of massage therapy in reducing post burn itching, pain, and psychological symptoms of 20 adult burn patients in the outpatient setting suffering from pruritus. The research finding is massage therapy significantly decreases itching, pain, depression, and anxiety in post burn population with severe itching. According to Gurol, Polat, and Akcay (2010), massage therapy effectively alleviates pruritus in 63 burn adolescent inpatients even though this application is not commonly used. Pfab et al. (2013) reported in their review that 15 minute massage therapy twice a week over 5weeks reduced itching, pain, and anxiety levels in burn adolescents. The study by Cho et al. (2014) reported the effect of burn rehabilitation massage therapy on 146 adult inpatients with hypertrophic scars after acute burn care. Their findings indicated that burn massage therapy is effective in improving pain, pruritus, and scar characteristics in hypertrophic scars after burn (Cho et al, 2014). TENS is known as an ideal method of treating itching. The case study by Whitaker (2001) exhibited the effect of TENS in decreasing post burn pruritus. Whitaker (2001) applied TENS to a 19 year old patient at the inpatient setting who suffered from severe itching after being healed from 70% mixed thickness flame burns. After two weeks of using the TENS unit in the study, the patient did not need to continue the use of the TENS unit because post burn pruritus no longer existed. Hettrick (2004) evaluated the effect of TENS as the management of burn pruritus in a pilot study with RCT on 20 adult burn patients in the outpatient setting and reported TENS significantly reduced post burn pruritus in the population sampled. In the study, Hettrick applied one hours of TENS per day, 7 days a week for 3 weeks to the experimental group. It was suggested that TENS should be considered as a treatment option for burn survivors whose quality of life was negatively affected by itching (Hettrick, 2004). Silicone gel sheeting is considered effective in reducing scar pigmentation, pain, and itching as well as improving scar thickness and pliability (Li-Sang, Lau, Choi, Chan, & Jianan, 2006). The study by Li-Sang et al. (2006) demonstrated significant efficacy of silicone gel sheeting on severe post-traumatic hypertrophic scars among 45 Chinese adult outpatient burn population in their RCT. In a similar study, Li-Tsang, Zheng, and Lau (2010) investigated the effect of pressure therapy, silicone gel sheeting, and combined therapy on management of posttraumatic hypertrophic scar among 104 adult and pediatric burn population in the outpatient setting. All three methods significantly reduced itching but silicone gel sheeting had better results but was not statistically significant (Li-Sang et al., 2010). Laser therapy is one of ways to relieve pruritus. According to pretest and posttest designed study by Gaida et al. (2003), low level laser therapy (LLLT) was effectively decreased pain and pruritus in 19 adult post burn population of the outpatient setting. Likewise, Hultman, Edkins, Wu, Calvert, and Cairns (2013) reported that laser therapy on burn scars significantly improved pain, pruritus, pliability, and paresthesia among 147 outpatients (P < 0.0001). Waked, Nagib, and Ashm (2013) evaluated the effectiveness of triamcinolone acetonide phonophoresis (TAP) compared to TENS in the treatment of post burn pruritus for 40 adult inpatients. According to the researchers, there was a significant improvement in reducing pruritus in both group with TAP and the group with TENS (P<0.05). However, there was no significant difference between the two groups regarding the effect of pruritus reduction. Richardson, Upton and Rippon (2014) suggested an algorithm for the mechanism- based treatment of post burn pruritus based on the stages of healing. According to the algorithm by Richardson et al. (2014), there are four stages that include: inflammatory, inflammatory/proliferative, proliferative/remodeling, and remodeling. Each stage has different treatment methods. However, this algorithm is the only algorithm suggested and requires validation with further use in multiple studies. Summary of Literature Review
Summary of the literature review shows that Oral anti-pruritic medications are the first drug of choice and they can be given as a scheduled dose by combining with other anti-pruritic medications to be more effective in decreasing pruritus in post burn wounds regardless of wound healing stages. In addition, topical agents decrease post burn pruritus in healed wounds, especially, hypertrophic scars. These topical agents can be used with oral anti pruritic medications or after oral anti-pruritic medications have failed to relieve post burn pruritus. In addition, non-pharmacological interventions decreased post bun pruritus as effectively as pharmacological interventions. Effective non-pharmacological interventions were psychological intervention (habit reversal, suggestions, relaxation training, and itch-coping programs), pressure therapy, laser therapy, TAP, TENS, Massage, special dressing (silicone sheeting, Nanocrystallin [Acticoat®], and Unna boot), hypnosis, cold water, cold temperature, and rest. However, pharmacological interventions were suggested to augment non-pharmacological interventions to maximize This literature review analyzed 38 articles regarding post burn pruritus. 23 articles among them used VAS as a pruritus assessment tool, two articles used Itch man scale, two articles used both Itch man scale and VAS, and two articles used 5-D Itch scale. On the other hand, nine articles did not clearly state which pruritus assessment tool was used. Moreover, each treatment method was supported by less than five studies and most studies were relatively small sample size. Methods for this project included incorporating two models, the PRISMA model and the Rosswurm and Larrabee model of evidence-based practice change. Consistent with a systematic review, a table of evidence (TOE) was used for organization of the research studies (Appendix C). Methods contain: search strategy, eligibility criteria, study selection, data collection process, data extraction, quality assessment, and results. PRISMA Model
This project partly adopted the PRISMA flow diagram during the process of study selection and data collection. By using the PRISMA flow diagram, the selecting process of studies in this project was transparent. Steps for selecting research studies are identified in the PRISMA flow diagram (Figure 1), and includes: identification, screening, eligibility check, and inclusion of data. The PRISMA model for organizing and reporting systematic reviews includes an abstract, background, problem statement, purpose statement, methods, results, and discussion sections. These steps will be clearly delineated as headings throughout this paper. In the health sciences, 174 journals have used the PRISMA model for reporting systematic reviews and meta-analysis in their collections (Moher et al., 2009). The PRISMA model has also been considered as an assessment tool for research dissemination within the Enhancing the Quality and Transparency of Health Care Research (EQUATOR). The EQUATOR is an international initiative that seeks to improve reliability and value of health related research by promoting accurate and clear reporting of research studies (International Prospective Register of Systemic Reviews,

Figure 1. PRISMA 2009 flow diagram (Moher, Liberati, Tetzlaff, & Altman, 2009). The Model for Evidence-based Practice Change
Another framework for this project is the model for evidence-based practice change. This model, published by Rosswurm and Larrabee (1999), was a model used to change practice in an organization (Melnyk & Fineout-Overholt, 2011) and is closely related to the PRISMA model in that steps overlap. The Rosswurm and Larrabee model was based on theoretical and empirical literature related to evidence-based practice, research utilization, standardized language, and change theory. In this model, practitioners are guided through the entire process of developing and integrating an evidence-based practice change. The model supports evidence-based practice changes derived from a combination of quantitative and qualitative data, clinical expertise, and contextual evidence (Rosswurm & Larrabee, 1999). Because the purpose of this project was to develop a protocol to improve post burn pruritus and related symptoms, the model for evidence-based practice change was an appropriate framework for practice (Figure 2). In this model, step one included the background, problem statement, and literature review. In addition, step one assessed the need for change in practice by identifying the problem, inclusion of stakeholders, data collection of current practice, and development of a population-intervention-comparison-outcome- and time frame (PICOT). Step two was to locate the best evidence by identifying types and sources of evidence, reviewing research concepts, planning the search, and conducting the search (Table 1). Step three analyzed the evidence. This step included appraisal of the evidence, syntheses of the best evidence, and assessment of feasibility, benefits, and the risks of new practice. This project established incorporated step three under literature review and result. Step four was to design practice change and the development of a post burn pruritus relief protocol was the outcome of this step, and the protocol is contained in the results section. For the purposes of this time-limited DNP project steps five and six were not included and developing of a post burn pruritus relief protocol was sufficient, but this protocol will be tested in future research studies. Figure 2. A model of evidence-based practice change (Larrabee, 2009). Search Strategy
Four data bases: Cochrane Central Register of Controlled Trials, CINAHL the Cumulative Index of Nursing and Allied Health Literature, EBSCO, and PubMed were searched. In addition, The National Guideline Clearinghouse, and the following websites: Bandolier, The National Health Service (NHS) Center for Reviews and Dissemination, google scholar, and the American Burn Association (ABA) web site were used for searching data. Research articles were searched from September 1, 2013 to November 17, 2014. Key words linked with Boolean "AND" included burn(s), itch(ing), itch(es), pruritus, and pruritic. Data Extraction and Quality Assessment
In accordance with the PRISMA guidelines, articles were collected, studies reviewed for validity, potential bias, and threats. This review also included reviewing the articles for clarity of the clinical question, inclusion criteria, the relevance of the clinical question, study design, data collection, and analysis methods. Eligibility Criteria
According to the Iowa Model, systematic literature review was performed by formulating a focused clinical question about post burn pruritus (Holly, 2014). The question in the project is "In populations with burn injury, what measures are effective in minimizing post burn pruritus?" Initially, studies published within last five to seven years were inclusion criteria, but there were insufficient literature during the period. Therefore, the criteria for eligibility was expanded to all published studies written in English from 2000 to 2014 that performed on all second and third degree burn population suffering from burn related pruritus to collect sufficient data for the project. Study Selection and Data Collection Process
Purpose, design, sample, setting, findings of each study were recorded for the studies that were included in this review. Each paper was reviewed and analyzed descriptively. The systemic literature search of articles indicated that 38 studies met the inclusion criteria. A total of 79 articles were searched and 41 articles were excluded according to the flow diagram (Figure 3). First four articles were excluded; one was written in German, one was only response to the editor of the other article, and the other two articles were reviewed in other articles (duplication of research findings). Figure 3. Flow diagram for selection of studies. Next 22 studies were removed conforming to eligibility criteria: Seventeen articles were related only to scar, skin condition, and scar assessment; two studies were only regarding sleep quality in burn patients; and three articles stated general burns and their treatment only. Five articles were excluded because they were written about pruritus assessment tool development and evaluation only. Also, another study was not included because it stated general wound itching instead of writing specifically about post burn associated itching. Nine articles were excluded because they described only pruritus and did not write pruritus relief methods. Therefore, 38 articles were reviewed to develop a post burn pruritus relief protocol and significant findings of each study were shown in Table 1. Details of each publication was written in the Table of Evidence (TOE) under Appendix B. The TOE was constructed according to purpose, design, sample, setting, operational definition, findings, limitation of each study, and comments. A synthesis of each study was reported at the end of the review of literature. Table 1 Characteristics of Included Studies Characteristics of Ahuja & Outpatient TBSA > 5%, 2nd degree Pregabalin alone or combined antihistamine burns, & wound either in w/pregabalin → ↓ PBP Addition of antihistamines does not decrease epithelialized) or healed PBP Massage therapy can be used as adjunctive treatment TBSA > 5%, 2nd degree Gabapentin alone or combination of gabapentin burns, over 80% of wound & cetirizine → ↓ PBP epithelialized or healed Certirizine only does not decrease PBP Prospective& All healed areas after 2nd - Botox → ↓ PBP in the population who failed in 3rd degree burns managing PBP w/ conventional therapies/ 50% 8 pts w/ failure had no PBP within 2wks after Botox treatment/ free of itching up to average 9 months after Gabapentin → ↓ PBP & ↓ in morphine demand Zofran is second method for PBP. Other methods (cooling of wound, antihistamines, local anesthetics, topical doxepin, colloidal oatmeal, capsaicin, laser treatment, dapsone, unna boot, compression garments, & TENS) → ↓ PBP Characteristics of Baker et Setting not Partial thickness & any % Combination of H1 receptor antagonist (cetirizine) & H2 receptor antagonist Not specified in description (cimetidine) is more effective in decreasing PBP of wound healing stage than H1 receptor antagonist (diphenhydramine) during the first stage of treatment. It is more effective to treat PBP w/ scheduled medication than w/ as needed medication Burn associated wound w/ All PBP- Moisturizing cream, massage 10% TBSA or less- antihistamine, colloidal Not specified in the stage of oatmeal w/ liquid paraffin, topical antihistamine, silicone gel sheeting More than 10% TBSA- oral non selective antihistamine, oral selective antihistamine, oral gabapentin Not specified in the stage of Not Algorithm consisting of 4 steps of treatment 1st- oral antihistamine, topical emollient, 2nd – clinical psychologist, 3rd – massage, silicone sheeting, hypnosis, TENS, unna boot, topical nanocrystalline silver, capsaicin, 4th – 8topical antihistamines, H1&H2 a9ntagonists, topical steroid, doxepin, EMLA, gabapentin, dothiepin cream TBSA range 7-65% w/ 2weeks of Acticoat (Nanocrystalline silver) unhealed burn wound application is effective in PBP. Unclear setting/ 2nd degree burns in healing Ozonated oil & hyaluronic acid have the same effect in reducing PBP 12 weeks of topical Characteristics of Ozonated oil is more effective than hyaluronic acid in preventing post hyperpigmentation. All healed burn wound Massage therapy is effective in improving pain, hospital setting/ pruritus, & scar characteristics in hypertrophic scars after burn. hypertrophic scars Inpatient setting/ Quasi- 2nd degree burn wounds Twenty-minute Benson muscle relaxation is 110 hospitalized experimental Stage of wound healing not effective in relieving PBP. clear-possibly not healed wound considering Healed burn wound Massage therapy significantly decreased itching, pain, depression & anxiety in PB population w/ severe itching (30 min x 2days per week x Healed burn wound (scar) LLLT demonstrated improvement in pain & pruritus among all participants. All stages of healing in Aggressive antihistamine is effective in the early phase, but less effective in the later stage of Gabapentin is persistent in decreasing PBP. Ondansetron-more effective than antihistamine. Serotonin- antihistamine effect TENS-effective in remodeling phase Characteristics of Varied by methods of Peripheral & central aspects of pathway need to be included in decreasing PBP. Peripheral - cooling of the wound, antihistamines, topical Doxepin, local anesthetics, colloidal oatmeal, Laser tx, Aloe Vera, topical Dapsone, Unna boot, Compression garments, Ondansteron. Central - Gabapentin, TENS, Massage therapy, Psychological support Inpatient setting/ Cohort, Partial to full thickness Monotherapy in PBP: gabapentin monotherapy observational burn injury. has more effective than chlorpheniramine. Healing stages not Polytherapy in PBP: Combination of gabapentin, the study, 41-2nd Intervention cetirizine, & cyproheptadine is more effective than combination of 3 antihistamines (chlorpheniramine, hydroxyzine, & Inpatient setting/ Experimental 2nd to 3rd degree burn 15minute massage twice per week for 5weeks applied to healthy skin around the wounds & Healing stage not specified. surface of wound decreased PBP in adolescent 2nd to 3rd degree recently TENS significantly reduced PBP in the target healed burn wound All healed burn wounds Laser therapy decreased pain, pruritus, pliability, & paresthesia in population with hypertrophic Characteristics of Cairns (2013) Jung et Healed burn wounds With Naltrexone therapy,14 pts reported rehabilitation / improvement in experience of itching & 5 pts reported no change in itching. Experimental TBSA of 7-70% & all Participants stated satisfaction with Naltrexone grafted burn areas. in decreasing PBP & improved regarding Healing stages not specified frequency & duration of itching. Lewis et Inpatient setting Mean TBSA:7.2%, mostly Medilixir is more effective to minimize PBP partial thickness burn than aqueous cream. wound & newly healed scar Post traumatic hypertrophic VAS SGS was effective to reduce thickness, pain, itchiness, & pliability of the severe hypertrophic SGS showed more effective in decreasing pain and pruritus than the scar thickness. CTG & PG group showed significant improvement in scar thickness after 6 months of intervention (CTG>PG). Inpatient setting Experimental Burn wounds and skin loss Gabapentin reduced itching in healing wound & from meningitis. decreased antihistamine intake in pediatric Not healed wound Characteristics of Nedelec, Not clear / All healed burn wounds Provase decreased PBP in weekly frequency, daily episode of itch, & duration of itch episode. & La Salle (2012) Ogawa Inpatient setting/ Prospective, All healed burn wounds Mugwort lotion is effective for improving itching & sleep disturbance. (Two months of Mugwort treatment decreased symptoms) scars from burns PBP relief methods used by % of plastic surgeons - 57.1 (oral meds), 22.9 (Injections), 8.6 (topical agents), 5.7 (reassure pts), 5.7 (combination of oral & topical agents). 85.7 without anti-pruritus protocol. Any skin conditions that 15 minute massage therapy twice a week over 5weeks reduced itching, pain, & anxiety levels in burn adolescents. Inpatient setting Itching management protocol for children; : Various wound stages 1)Moisturizing body shampoo & lotions, topical ointments (not hydrocortisone creams) 2)Diphenhydramine 1.25mg/kg/dose po Q 6h 3)If itch remains poorly controlled, subsequently add hydroxyzine 0.6mg/kg/dose q 6h, then cyproheptadine 0.1mg/kg/dose po q6h so that one of the medications is given q2hrs Characteristics of Four different stages of PBP management algorithm per 4 healing Literature up to healing in burn wounds phases of wound suggested – inflammatory phase, inflammatory/proliferative phase, proliferative/remodeling phase, & remodeling Burn scars from partial or PBP significantly decreased by SRMT in burn full thickness burns on victims with scars from partial to full thickness on the forearm or hand. Double-blind All stages of burn wound PBP is reduced with massage w/ emollient cream, cool baths, pressure garments, & oral and topical antihistamines & analgesics. Any skin conditions Five psychological approaches to treat wound causing pruritus- atopic associated itching are suggested. dermatitis, burn wounds, (Habit reversal, Suggestions, Relaxation skin disorders, pruritic skin training, Massage, & Itch-coping programs) Inpatient setting 2nd & 3rd degree burn Triamcinolone acetonide phonophoresis is as wounds, 10-15% TBSA. – useful as TENS to reduce PBP & Ashm 40 burn pts All Healed scars All phases of burn wounds Early pruritus management: H-1 receptor blocker (cetirizine) on as scheduled basis not as needed basis combined with frequent massage of Neuro-inflammatory transmitter blockers (gabapentin & pregabalin) is effective because itch-specific neurons won't be stimulated by Characteristics of using this medicine. Inpatient setting Healed 70% TBSA flame 2 weeks of TENS is effective in decreasing PBP. burn wound (scar) Day #1: 62.5% decreased in itching within 4hrs Day #2: 88% decreased within 4hrs of application. Day #3: No itching within 4hrs of application. All burn wounds. Current tx options for PBP summarized; Healing stage not specified Antihistamines (H1 & H2 receptor antagonists), Topical alternatives over the healed burn wounds (colloidal oatmeal baths, EMLA, corticosteroids, massage therapy, Doxepin cream). Adjuncts (Biofeedback therapy, psychological support, combined w/pharmacological agents, TENS), Newer medicine: Ondansetron (5HT-3 receptor antagonist), Gabapentin (anti-epileptic drug), Pregabalin (anti-convulsant), Paroxetine (SSRI), & Naltrexone (opioid antagonist) Notes. CTG = combined pressure therapy and silicone gel sheeting group; EMLA = eutectic mixture of local anesthetic; h = hour; hrs = hours; H1 = histamine 1; H2 = histamine 2; LLLT = low level laser therapy; PBP = post burn pruritus; PG = pressure therapy group; pts = patients; RCT = randomized clinical trial; SGS = silicone gel sheeting; SRMT = skin rehabilitation massage therapy; SSRI = selective serotonin reuptake inhibitor; TBSA = total body surface area; TENS = transcutaneous electrical nerve stimulation; VAS = visual analog scale. PROJECT MANUSCRIPT
Thirty-eight articles were reviewed. Eighteen articles identified pharmacological effects on post burn pruritus that included single medicine use and two or three combined medicine. Effective pharmacological, both oral and topical, methods used in decreasing pruritus were antihistamines, Pregabalin, analgesics, corticosteroids, Gabapentin, Naltrexone, Botox, Provase, Capsaicin, colloidal oatmeal, Aloe Vera, topical Dapsone, Doxepin, Mugwort lotion, EMLA, Ozonated oil, and hyaluronic acid. Fifteen of the thirty eight articles stated positive non-pharmacological methods in relieving post burn pruritus. Examples of effective non-pharmacological methods included: cool bath, massage therapy, laser therapy, TENS, TAP, muscle relaxation, psychological approach, biofeedback therapy, silicone gel sheeting, Acticoat®, and pressure garment therapy. Of the studies, five supported combination of pharmacological and non-pharmacological methods to reduce post burn pruritus. The outcome of the systemic literature review regarding pruritus relief in post burn populations was synthesized and evaluated based on best outcomes which are pharmacological and non-pharmacological interventions. Accordingly, an advanced practice nurse (APN) driven post burn pruritus relief protocol was developed (Figure 4). This protocol was designed to apply to three different stages of wound healing such as: pre-healing (no granulation tissue); healing (partly granulated tissue); and healed stages (scar formation); and, recommended dosages per each intervention (Table2). Non- pharmacology interventions are recommended before pharmacological interventions based on established effectiveness. 1. Non-Pharmacological methods (Single or multiple options)
• Massage therapy to intact skin areas except wound (priority) • Benson Muscle Relaxation therapy 2. Pharmacological methods (Single option only: same priority)
• Pregabalin alone (if not effective)  Pregabalin + 2 H1 blockers • Gabapentin alone (if not effective)  Gabapentin + H1 blocker (if not effective)  Gabapentin + 2 H1 blockers • Combination of H1 & H2 blockers 3. Supplementary pharmacological method (additional option): Naltrexone
All methods for pre-healing wound stage
Topical agents (Ozonated oil or Hyaluronic acid gel 0.2%)
1. Non-pharmacological methods (single or multiple options)
• Moisturizing body shampoo • Benson muscle relaxation • Massage therapy applied to healed wound • Acticoat® (Nanocrystalline Silver) • Silicone Gel Sheeting • Pressure garments (Unna boot®) 2. Topical agents (Select one opti on)
• Mugwort lotion • Ozonated oil • Hyaluronic acid gel 0.2% 3. Supplemental Intervention (single or multiple options)
• LLLT or regular laser th erapy Above methods failed Oral: Zofran® (ondansetron), Serotonin, SSRI (Paroxetine), Tricyclic
antidepressant (Doxepin), Gabapentin, Naltrexone. Topical: Antihistamines, H1 & H2 antagonists, Botox®, Topical Steroid,
EMLA® Cream (lidocaine 2.5% & prilocaine 2.5%), Dothiepin (Tricyclic agent) Figure 4. Post Burn Pruritus Relief Protocol. Table 2 Post Burn Pruritus Relief Protocol Guideline (Recommended Dosage) Recommended Dosage (refer to article No. in Table 1) Massage therapy to intact skin 15 minutes/day, 2 days/week, 5 weeks or as needed. Benson Muscle Relaxation therapy 20 minutes daily for 1 month or as needed (11) Pharmacological treatment (1, 2, 5, 6, 16, 25) - Pregabalin alone - 150-300mg/day (divided by 2 or 3 times) - Pregabalin & two antihistamines - Pregabalin (same dose), Cetirizine 10-20mg/day (one or twice a day), & Pheniramine 25mg/day before sleep - Gabapentin alone - 300-900mg/day (adult), 5-10mg/kg/day (child) - Gabapentin & H1 blocker - Gabapentin (same dose) & Cetirizine 10-20mg/day - Gabapentin & Cetirizine (same doses) & - Gabapentin & two H1 blockers Cyproheptadine 4mg every 6hours - Cetirizine: 20mg/day (adult) & 10mg/day (pediatric - Combination of H1 & H2 Cimetidine: 1200mg/day, divided by 4 (adult), 30mg/kg/day, divided by 4 (child) Naltrexone (supplemental 25-50mg/day before sleep for 2weeks (20, 21) pharmacological treatment) All treatments for pre-healing stage Ozonated oil 2drops/cm²once a day or & Topical agents (Ozonated oil or Hyaluronic acid gel ½ finger tip/cm²daily Hyaluronic acid gel 0.2%) For 12 weeks or as needed (9) Benson muscle relaxation Same dose as above (11) Massage therapy applied to healed 15-30minutes, 1-3times/week for 5-12weeks (10, 12, 29, 32) Apply for 2weeks (8) LLLT or regular Laser Therapy LLLT: 2 times/week for 8weeks (13) Regular laser therapy: once per month for 6 month (19) Once a day for 2-3weeks (14, 18, 37) 3 times/week for 1 month (35) Silicone Gel Sheeting Wear 12-24hours/day for 6 months (8, 23, 24) Apply as needed (7, 15) - Once a day for 2 weeks (22) - Mugwort lotion - 2 times/day for 2 months (27) - 3 times/day for 4 weeks (26) - 2drops/cm² once a day (9) - Hyaluronic acid gel 0.2% - ½finger tip/cm² daily (9) Moisturizing body shampoo Use as needed (30) Apply as needed (7) Each stage of wound healing can be managed by both non-pharmacological and pharmacological interventions. Non-pharmacological methods are less invasive interventions and are considered the primary intervention. On the other hand, Pharmacological methods are more invasive interventions and are most times used as a supplement to potentiate the effect of non-pharmacological interventions or to decrease possible adverse effects of combination medications. Non-pharmacological interventions are versatile and can be combined with any other non-pharmacological interventions as well as pharmacological interventions. Choice for non-pharmacological interventions will be considered by the facility's resources and patients' preferences. However, only one option from pharmacological interventions should be used with any non-pharmacological interventions only when non- pharmacological methods are not effective. Also, single medicine can be started when adding pharmacological methods. For example, in pre-healing stage, they can use all of non-pharmacological methods (both massage and Benson muscle relaxation therapy) and only one of pharmacological methods (either Pregabalin alone, Pregabalin & two antihistamines, Gabapentin alone, Gabapentin & H1 blocker, or Gabapentin & two H1 blockers, or Combination of H1 & H2 blockers). In this case, only Pregabalin needs to be initiated, but if Pregabalin alone does not effectively relieve pruritus two antihistamines can be added (Figure 4). Moreover, if pruritus persists regardless of interventions used, the following medications can be added to reduce symptoms: Zofran® (ondansetron), Serotonin, SSRI (selective serotonin reuptake inhibitor: Paroxetine), Doxepin® (tricyclic antidepressant), Gabapentin, Naltrexone, Topical Antihistamines, Topical Steroid, EMLA® Cream (lidocaine 2.5% & prilocaine 2.5%), Dothiepin (Tricyclic agent) cream, and Botox® (botulinum toxin). This post burn pruritus relief protocol was developed after a comprehensive systematic review of the literature with best practices identified. APNs can also use this evidence based protocol as standardized procedure for prescriptive authority. DISCUSSION
This protocol, the second of any post burn pruritus protocols is the first APN driven evidence based protocol that uses non-pharmacological interventions as a primary method of choice to reduce post burn pruritus. This protocol can be implemented in practice by APNs or RNs depending on the choice of interventions used. In addition, this protocol has recommended dosage and period for each intervention to clearly guide APNs and RNs. Using the Rosswurm and Larrabee model the nurse in clinical practice can assess the efficacy of this post burn pruritus protocol to ascertain if the protocol: 1) relieved discomfort from pruritus; 2) lessened disturbances on daily life that can include low concentration, agitation, anxiety, and a flat affect; 3) and increased quality of life. The 5-D Itch Scale (Appendix A) and/or the Visual Analogue Scale (Appendix B) are both valid and reliable and can be used before and then after the treatment method to quantify patient outcomes. The results from this systematic literature review and the model for implementing practice change, significantly contribute to the treatment of post burn pruritus. Non-pharmacological and Pharmacological interventions for post burn pruritus have been identified and presented in an easily identified protocol to improve patient outcomes and clinical practice. The findings of this systematic literature review and proposed protocol will help to advance the DNP role in research and translational inquiry. This protocol will be utilized in the future to develop interventional studies to enhance post burn pruritus management as well as to relieve patient suffering. REFERENCES
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Journal of Burn Care & Rehabilitation, 22, 274-276. Zachariah, J. R., Rao, A. L., Prabha, R., Gupta, A. K., Paul, M. K., & Lamba, S. (2011). Post burn pruritus-A review of current treatment options. Burns, 38, 621-629. APPENDIX A
(Adapted from Elman, Hyman, Gabriel, & Mayo, 2010) APPENDIX B
(Adapted from Elman et al., 2010)

(Adapted from Morris et al., 2012) APPENDIX D
Summary of Studies Including Pruritus in Burn Patients Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes 4 groups divided from A to For mild itching pts (VAS 2-5): Pregabalin alone & outpatients from D. They were asked at 3, 7, combined antihistamine the department of 14, 21, 28 days after tx B & D group showed 77.5% & 23.3% w/pregabalin showed To compare the Key variables: Burns & Plastic regarding VAS scores of remission of itching, respectively on significant effect in decreasing itching All groups received B & D group showed 100% & 96.7% of remission of itching, respectively on A: Antihistamine (cetirizine 28days after tx antihistamines does not + pheniramine) use seem to be beneficial to B: Combination of For moderate itching pts (VAS 6-8): decrease pruritus antihistamine & pregabalin 60yrs, TBSA > C: Placebo (Vitamin B) use B & D group showed 64.8% & 61.4% Also, massage therapy D: Pregabalin use of remission of itching, respectively on effectiveness within 2- 2nd degree burns, B & D group showed 92.6% & 92.8% 4wks after tx that of remission of itching, respectively on showed it can be used 10mg QD or bid + 25mg as adjunctive tx epithelialized) or healed < 3month B: Pregabalin + Cetirizine For severe itching pts (VAS: 9-10): Limits: the study did not define end point of 75 mg bid, tid, or 150mg B & D group showed 56.9% & 52.7% anti-pruritic therapy of remission of itching, respectively on C: Vitamin B 1 capsule Both B & D group showed 78.9% of QD, bid or 2 capsules bid remission of itching on 28days after tx. D: Pregabalin 75mg bid, Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes tid, or 150mg bid GA – cetirizine tx only GA: pruritus reduction in 52% GB – gabapentin tx only GB: pruritus reduction in 95% centrally acting drugs & patients per each GC – gabapentin & GC: pruritus reduction in 94% peripherally acting drugs did not show Onset of action with gabapentin better effect in reducing cetirizine tx, & VAS used for antipruritic significantly faster than the cetirizine: PB pruritus compared effect at baseline, 3, 7, 14, 32% in GA vs 74% in GB on the 3rd to using centrally acting 21, & 28days after tx for day of the treatment drugs (gabapentin) Different drug dose used Need for larger sample based on the VAS (2-5, 6-8, size to generalize, > 1% graft were cetirizine tx in IC:12–70yrs old, Limited period of data burn area > 5% Single site study suggested PB pruritus relief protocol and the epithelialized or gabapentin in the future completely < 1 month back 10 pts who failed During the study, only 8 pts All 8pts stated severe itching before tx – Botox can successfully included due to 2 pts 2pts10/10, 1 pt-9/10, 4 pts-8/10, 1pt- be used to treat PB excluded for language pruritus that is resistant barrier & not a burn scar. Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes Key variables: therapies All 8 pts described symptoms as "0" out therapies (silicone gel tx, F/u done before tx, 1wk, of 10 at 2wks after tx 2wks after tx and b/w3- 23months after tx. Three pts labeled the score as 1, 2, & 3 at 6, 4, & 3 months after tx VAS used to assess itching 5 others had no itching since 2wks after :11.3 months f/u period. 2-3rd degree burns All scarred areas Reviewed studies Classification of pruritus: Gabapentin is safe & effective in uremic Well-designed placebo- regarding use of pruritus, cancer/hematologic causes, controlled randomized (prurioreceptive), central opioid-induced itch, brachioradial trials are needed to effectiveness of Key variables: pruritus (cause, (neuropathic, neurogenic, pruritus, burns pruritus, & pruritus of show the effectiveness of gabapentin in & classification pruritus not responsive Causes of pruritus: uremic, Recommended doses: to other modalities of tx cancer (solid tumors or Uremic pruritus-100mg after each HD, hematologic), opioid- Opioid-induced itch-1200mg before induced, cholestasis, spinal anesthesia w/morphine use brachioradial, burns r/t itch Started w/32 pts, A1: Cetirizine + Cimetidine During days 1-16, no significant Use as scheduled meds differences b/w A1 (A1B1, A1B2) & instead of prn meds to A2 (A2B1, A2B2) even with some Key variables: study B1: Revive lotion improvement in both tx B2: Corrective concepts Each group had 4tx options During days 1-4, A1 had significant (A1B1, A1B2, A2B1, improvement compared to A2 A2B2) in different time different period frame of 1-4, 5-8, 9-12, & During days 5-16, no significant Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes differences b/w A1 &A2 possibly from the residual effect of previously used tx Pts completed itch score (VAS) before tx, at 1, 6, & Also, no difference b/w B1 & B2 noted. 12hr intervals after tx Class II: studies where Pharmacologic methods (w/ specific The study suggested tx certainly reliable data are dose) below decreased PB pruritus plan according to TBSA collected (observational studies, cohort studies, Selective antihistamine antagonists To all PB pruritus; prevalence studies & case- (cetirizine/cimetidine) in adult & Moisturizing cream, control studies) pediatric population, Atarax in adult population, Specified b/w TBSA Class III: evidence Gabapentin in pediatric population, <10% & >10% provided by clinical series, Colloidal Oatmeal (topical) in adults, comparative studies, case & EMLA (topical) in pediatric reviews, case reports, & Non-pharmacologic methods decreased The classified literature was PB pruritus significantly; determined to support Pulsed dye laser in adult & pediatric pts, guideline status as outlined Silicone gel sheeting in adult & by the Practice Guideline for Burn care 2006 Massage in adult population, & TENS in adult population VAS used for itching (Brooks, Malic, Literature Current standard tx: oral antihistamines Literature evidence on PB pruritus tx: 1.Combination of colloidal oatmeal & paraffin bath emollient + antihistamines 2.Combination of different antihistamines 3.Combination of H1 Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes &H2 antagonists 4.Gabapentin use 5.TENS, massage tx, Laser tx, Unna boot, Doxepin cream, EMLA cream, silicone gel sheets, Acticoat dressing. Algorithm for PB pruritus management suggested w/ 4 steps

5 subjects w/ 7, Acticoat applied for 2 wks VAS score: 7.4 before tx decreased to and the intervals from 3.1 after tx (p = 0.0022). This report did not Key variables: 65% of TBSA original injury to indicate the condition of application were 2, 3, 3, 6, Ex) Pt w/ excoriation of the skin due to wounds whether they itching showed absence of excoriation following acticoat tx unhealed. However, it is Before & after 2 wks of assumed they were outpatient clinic application, VAS assessed unhealed or in the healing process because acticoat is used for unhealed wounds in current practice patients

(Campanati et
30 pts w/partial Pts applied ozonated oil on Ozonated oil had the same efficacy of Limit: lack of a to full thickness half of the burn lesion and hyaluronic acid in reducing symptoms histological comparison 2nd degree burns hyaluronic acid on the other r/t burns (erythema, tension, height, half of the lesion once a itching & burning sensation) after 12
wks of topical application and controlled 01/2012 Ozonated oil was more effective than Clinical features of each hyaluronic acid in preventing post- Key variables: stage of re- lesion (erythema, tension, lesional hyperpigmentation Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes height, itching & burning comparing with hyaluronic sensation) assessed w/ IVCP at baseline, 6monthes & 12 months after tx. scars, photo type > III, allergy or Pts completed survey intolerance to the focusing on "what part of the treated lesion had improves more?", which thyroid diseases, topical tx is more comfortable?", & "what tx corticosteroid or Burn patient age G1(w/in 24months PB More than 73% of adult burn survivors suffered from pruritus episodes during Questionnaire for burn r/t the first 2 yrs following injury; responses regarding study (N = 930). pruritus provided at D/C, 6, wound condition d/t 12 & 24 months PB In 75.7% of long-term burn survivors, self-report based data & Key variables: patients injured pruritus existed <6hrs/ day from mild to no P/E information; G2 (over 2yrs PB injury): moderate for the intensity; Limited control ability 2010. –no more 2-yr f/u & long-term f/u in for question variability 5yrs (172subjects) & in In more than ½ of long-term burn & question confusion 10yrs (164subjects) PB survivor, pruritus still impacted their d/t various data leisure, household, vocational activities collection methods; No current tx method 43 out of 930subjects in for PB attained; provided 5 or 10 common to both G1 & G2 Predictors of PB pruritus include female Future study needed to gender, younger age, %TBSA-burn, assess tx methods for Group 2 (LTF) – f/u at 5 depth of injury, %TBSA grafted, dry &10 yrs after burn injury & skin, & thick or raised scars; 43 subjects completed from Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes care facility at No differences in PB pruritus noted Note: Since the data D/C & thereafter regarding ethnicity/race, scar collection method was discoloration, & open/closed wounds self-report only, experts' objective data, especially for wounds are needed Questionnaire was made in No difference in time b/w injury & First study on pruritus patients treated in Dutch w/ collaboration of a interview in patients reporting pruritus in a large population Retrospective, the university of burn surgeon, a child & no pruritus (P = 0.3); w/small burns (TBSA psychiatrist, a registered Similar pruritus incidence obtained nurse, a specialized from patients or a relative (P = 0.2) Injury Clinic in physiotherapist & an intensive care physician (no Pruritus incidence 50%; High P values for the detail info on the ¼ of the moderate pruritus group had info obtained methods %TBSA-burn, A relative who questionnaire noted) negative impact on daily life (P = & the time b/w injury & lived in the same .0002) & sleep pattern (P = .002) factors in small Questionnaire is not Patients had less pruritus when the age psychometrically at burn injury was < than 2yrs, %TBSA- validated, not age burn was < 2%, & wound healing was < 3 weeks, but more pruritus when the specified in races, burn areas were trunk or lower limbs opioid intake & burn (P<0.001) Age < 50yrs & %TBSA-burn had Notes: Further studies expectation for severe pruritus in needed for impact on QoL, development of pathologic scarring, Half of patient having pruritus received early consultation in the treatment & 25% of them reported plastic surgery clinic, a distinct effect; No association b/w formal referral to wearing of garments & application of general practitioner f/u, Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes & a preventive tx Before & after massage No significant differences b/w EG & Burn massage therapy therapy, EG & CG assessed CG for gender, age, TBSA, interval b/w burn injury & rehabilitation therapy, Key variables: scars after acute pain(VAS), Pruritus, & period of rehabilitation therapy, VAS, pruritus, & scar Scar characteristics pruritus, & scar characteristics before characteristics in (thickness, melanin, hypertrophic scars after erythema, TEWL, sebum, elasticity) b/w 2 groups Results after burn rehabilitation massage therapy; standard therapy Measurement tools: EG showed significant improvement in Massage given only for Thickness, melanin & pain, itching, scar thickness short period (average: erythema, TEWL, sebum, (↓thickness), melanin (↓melanin), 34.7days), so long-term & elasticity assessed by erythema (↓erythema), scar TEWL effects not identified. (↓TEWL), & sebum (↑sebum) in addition to the Tewameter, Sebumeter, & hypertrophic scar not Cutometer, respectively However, for scar elasticity, EG showed considered significant improvement only in  Future study Burn rehabilitation massage immediate distension & gross skin therapy given 30min a day for 3times a week, average 12.5 times by specialized burn rehabilitation massage Demographic info obtained. Muscle relaxation technique is effective Pain VAS, Pruritus in relieving the pain, pruritus & v/s of No explanation for hospitalized 2nd assessment scale, & v/s pts suffering from burns. Its use as a other methods to reduce degree burn pts, assessed before & after 20 therapeutic & alleviative method to be pain or pruritus used or min Benson relaxation suggested for patients suffering from allocated to case method to control group. A No explanation of & control groups. month later, these 4 frequency of relaxation assessments performed Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes group: control & before & after 20 min Benson verbal & muscle relaxation technique to case hospital in Iran Chi-square, independent t- test, paired t-test & Mann-Whitney test were used CG received standard There was significant reduction in itching, pain, depression & anxiety in significantly decreased Key variables: (EG:10, CG:10) EG received standard medical care & massage depression & anxiety in Inclusion criteria: therapy on the wound for PB population w/ A closed, oderate 30min, twice a week for c/o severe itching After massage therapy, Limits: needs larger Itching, pain, depression & sample & long term use anxiety compared b/w two of massage therapy VAS used for itching VSS (for ht, pliability, 17 out of 19 lesions showed Selecting other side of pigmentation & vascularity macroscopic improvement while 2 skin in the same pt is of scar), VAS (for pruritus lesions did not improve. possible weakness of All pts suffered & pain), digital :Scar < 12months improved better than Key variables: from burn scars scar > 12months before the study macroscopic evaluation Need more studies that and none of them were performed before & LLLT demonstrated improvement in have higher number of pain & pruritus among 19 PB sample and control site from different people corticosteroids, rather than the same group w/ different sites Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes excision before LLLT In each pt, 1 burn scar was given by LLLT & 1 similar burn scar was defined as a control area(no tx) Phone questionnaire The median of postburn pruritus is 80% The first study to specialists from distributed to inquire burn explore the knowledge 22 burn units in relevant pruritus on burn pruritus among Key variables: the UK (12 questions in 21 burn units (95.45%) have no daily physicians, reporting a assessment on pruritus in a quantitative lack of consensus on manner; 1unit uses Itch Man Scale on a Protocols for burn 1. % of burn patients 12 units (54.55%) reported more intense pruritus needed; affected by pruritus, pruritus in the evening; The reasons for lack of 2. differences in adult & 34.36%, 34.09% & 20.45% felt more protocols include low pediatric burn patients for pruritus during the wound healing, remodeling & acute phase, respectively; 3. assessment tool 40.91% felt more pruritus in superficial consideration of pt availability for pruritus in partial thickness burns; preferences, & poor pt daily care plans, 40.91% & 31.82% felt more pruritus in resource allocation 4. diurnal variation of wounds treated w/ dressings & w/grafts, January, 2008 – 5. effect stage of healing & 90.91% used antihistamines as a 1st line Low Sample size. for pruritus:1unit used ondansetron, & 6. effect of burn depth & 3units used gabapentin alone or with an Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes pruritus, healing method & 5 units used additional pruritic relief The study showed methods: 2 units utilized psychologists, relevant research pharmacological agents, other 2 units used massage therapy, & 1 according to question other supplement in used silicone products for pruritic contents & suggested pruritus management, more research on each 8. protocols in postburn Only one unit has a specified protocol content to relieve pruritus in the unit for pruritus management PB Pruritus lasts longer than wound Neuropathic element is healing period (inflammatory, cause of PB Pruritus proliferative, & remodeling phase) and neuropeptide- mediated selective Pruritus classification (by Twycross et hyper innervation Pruritoceptive, Neuropathic, excitement to develop Neurogenic, & Psychogenic pruritus) longstanding symptoms Aggressive antihistamine is effective in the early phase, but in the later stages Needs more study wounds appear to be less effective to antihistamine therapy Evidence from the effectiveness of therapeutic approaches acting on the Gabapentin-persistent therapeutic effect of gabapentin is due to the ability of preventing CNS sensitization Ondansetron-more effective than antihistamine. Serotonin- antihistamine effect Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes TENS-effective in remodeling phase Multidisciplinary approach is needed in The study advocates the successful assessment & treatment. early employment of centrally acting agents Key variables: agents in the Employment of a tool to assess severity & peripherally acting Pruritus, burn, burns literature of pruritus is critical because sever agents as well as non- pruritus needs a combination of agents- Itch man scale is recommended for burn interventions for the tx Use of topical emollients & cooling agents is included in the protocol due to positive clinical experience even w/o supportive studies classification to Agents acting on the central part of the pruritic pathway-gabapentin, ondasetron Agents acting on the peripheral part of the pruritic pathway-H1 partial agonist & H2 receptor antagonist Non-pharmacological adjunct-TENS, laser, pressure garment, massage therapy Therapeutic strategies are classified by interventions on peripheral & central aspects of the pruritic pathway Peripheral aspects: cooling of the wound, antihistamines, topical Doxepin, local anesthetics, colloidal oatmeal, Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes Capsaicin, Laser tx, Aloe Vera, topical Dapsone, Unna boot, Compression garments, Ondansteron Central aspects: Gabapentin, TENS, Massage therapy, Psychological support Study #1 & #2 pts assessed Antipruritic monotherapy in acute Gabapentin is more 50 PB pts applied for pruritic symptoms using burns: gabapentin monotherapy had 4 "itch man scale" & VAS times more effective than monotherapy by acting chlorpheniramine tx (41.46% vs 10%) directly on the central Antipruritic Polytherapy in acute burns: Combination of gabapentin, cetirizine, It is important to use 41 PB pts applied 1: little itch not interfering & cyproheptadine was more effective Key variables: to revised St. than combination of 3 antihistamines peripheral aspects of the 2: more itch sometimes (chlorpheniramine, hydroxyzine, & pruritic pathway in interfering w/activity cyproheptadine) in symptomatic relief managing burns itching 3: a lot of itch, which of pruritus in PB population antihistamines EC: burn makes lying still & concentration difficulty Needs further studies 4: most terrible itch making Factors for failure in monotherapy are incorporating long term hypersensitivity it impossible to sit still & younger age and larger TBSA f/u of comparing peripherally & centrally Pts w/ higher initial itch scores needed acting agents in late more pharmacologic escalation hepatic impairment (Gu¨rol, Polat, EG showed significant improvement in Limits: small sample admitted for burn Demographically & burn reducing itching, pain, & anxiety characteristically no compared to CG (p < 0.001) The study did not Key variables: university differences b/w EG & CG specify the condition of Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes wound whether it is 2/2008 to 6/2009 EG got 15minute massage healed or not. – it is tx 2x/wk for 5wks as well assumed that not all as standard care wound are healed 2nd or 3rd degree according to the fact pain, itching, & Massage tx done by trained some pts were getting massage therapists, applied standard tx including to healthy skin around the pain & they were wounds & surface of enrolled in the study right after admission Itching rating, VAS for pain, & STAI assessed on the 1st day & last day of 5-wk study period VAS used by sample before TENS significantly reduced PB pruritus & after tx and data were in the population sampled generalized to children standard of care. compared b/w 2 groups <18 or pts> 75yrs of Therefore, TENS should be considered received standard as a tx option for burn survivors whose The mode of TENS was quality of life is negatively affected by high frequency & low- 7days per wk for Additional parameters for TENS need to be IC: age of 18-75 w/ partial or full- thickness burns, proliferative stage of >5, remodeling Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes phase of wd healing w/ recent re-epithelialization. EC: pregnancy, hx of epilepsy, pacemaker Sample: mean age-26.9, Within the 12months of the study mean TBSA-16.1%, period, VSS & UNC4P (pain, pruritus, 1.unaware of long-term average 2.8sessions/pt, pliability, & paresthesia) decreased (P < including pulsed dye laser 2.not specified in scar & CO2 laser at 16months Key variables: treated at the (median) & 48months 3.evaluator bias not effects of laser (mean) after burn injury. VSS & UNC scar scale 4.no control group assessed right before the 5.order of different first session, 4-6wks later, lasers not examined & at the time of the next Recommendation: RCT w/ long-term period & objective data (elasticity, hardness, & redness) & subjective data (QoL) Retrospective, 19 pts treated for Total 19pts (9-treated 14 pts reported improvement in Not sure of naltrexone w/antihistamine only, 9- experience of itching & 5 pts reported as the first line of PB w/antihistamine & no change in itching pruritus, but the study gabapentin, 1-w/gabapentin suggests naltrexone Key variables: Hangyang Sacred only) who are dissatisfied 44.5% (9pts) reported ↓ scratching warrants further studies Heart Hospital in w/ current tx received using RCT to examine naltrexone for 2wks. its potential role as a tx After 2wks, participants However, 7 pts reported side effects for chronic itching in Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes answered for itching on (headaches, nausea, vomiting, & abdominal cramps). w/retrospective rating of the severity of itching. No laboratory tests after tx noted (Tx: began w/25mg, then ↑ to 50mg the following day) 15 pts who traditionally Participants demonstrated some treated w/antihistamines satisfaction of Naltrexone use in Need a larger sample, traditional tx for (H1 or H2 receptor reducing PB pruritus; Key variables: PB pruritus. antagonist) & hydrating measurement of itch lotion, but still w/ pruritus Overall, 50% (4pts) improved regarding recruited for naltrexone tx- frequency & duration of itching qualification of 1pt dropped for allergic according to Frech-Canadian VAS scratching activity, reaction, 1pt dropped for recruitment of a broader intolerable dizziness range of burn pts, long Regarding additional 6 questions, term f/u, & a placebo 8 pts completed French- 72% (9pts) satisfied with the itch relief controlled tx group Canadian version of the provided by naltrexone itch VAS before tx & 2wks 62% (8pts) stated that QoL improved after naltrexone tx, then compared the result. 5pts completed only after tx All pts answered 6 additional questions regarding naltrexone, too Components of Medilixir- 1.Medilixir reduced itch after Medilixir is more coconut, palm, castor, application more frequently than effective to minimize olive, hemp seed, wheat PB pruritus than germ, & canola seed oil 2.By using Medilixir, pts felt itch Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes Key variables: Mean recurrence later than CG w/tx of Components of aqueous Limits: small sample cream- paraffin, heavy 3.EG required less antipruritic liquid, phenoxyethanol, & medications than CG did direct admission, Meaning: a larger size study can be warranted No significant difference in any demographics Mean time in seconds required for cream application & mean days before the 1st cream application b/w two groups not significantly different. VAS used for itching Spectrocolorimeter & EG showed significant improvement The study indicated that w/ post-traumatic TUPS used for regarding scar thickness & scar silicone gel sheeting pigmentation measurement was effective to reduce thickness, pain, Vancouver Scar Scale for For scar pigmentation, pain & itching, itchiness, & pliability of Post traumatic EG (24pts) wore the scar thickness EG showed better outcomes but not the severe hypertrophic scar among the Chinese day and received 15minute lanolin VAS used for pain & Moisturization effect of the scar twice a the tough & hard scar day for 6months. Digital image of each scar may contribute to the was recorded by using a reduction of the skin thickness after 6 months only massage for ‘s intervention Two-way repeated Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes ANOVA used to analyze Limit: population is above 4 measures & limited to Chinese Turkey test for post hoc people- generalization to long traveling comparison analysis used for difference over time(2 Small size of sample & 6months after beginning) Study had only 16 burn scars out of 45 scars – can be applied to specifically to burn scar pts? 4 groups of PG (n=30), Scar Thickness: CTG showed SGS (n=24), combined w/ significant improvement at 2, 4, 6 showed significant PG & SGS (CTG, n=29), & months after tx. PG showed significant improvement in scar Jiangsu People's control group (CG, n=21) improvement 6 months after tx. thickness after 6months First Affiliated Drip-out: 20 pts Scar Pigmentation: CTG showed more 4 groups assessed before, 2, improvement than other groups & all 4, & 6months after other groups showed significant SGS showed more
improvement regarding pigmentation effective in decreasing
pain and pruritus than
Assessment tools: the scar thickness
Subjective feedback from Scar Pliability: significant improvement pts regarding their in all groups showed at each Limits: high drop-rate perception on the scar assessment. CTG had the most injuries, & scar < condition (cosmesis, pain, improvement in softness of scar among & pruritus) by VAS. all groups at 2 & 4 months after tx Objective tools for scar- spectrocolorimeter (for Pain: 3 EG showed significantly less color), TUPS (for pain over time & CTG & PG had thickness), & VSS (for significant effect on pain Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes Pruritus: all groups reported VSS > 5 & each significantly less itchy but SGS seemed better result (no significance) Questionnaires were Itching complaints at 3months, 1yr & The study shows the completed by PB pts at 2yrs PB show 87%, 70% & 67%, necessity to approach 3months, 1yr, & 2yrs after itching from multiple perspectives, such as The frequency of moderate to severe psychological state of Key variables: Netherlands & The questionnaire has a 7- itching is 34% & 23% at 1 & 2 yrs PB, pts, because chronic point Likert scale for itching occurs in a itching & the Impact of group of different Event Scale (IES) for Risk factors for itching are surgical operations, PTS, gender (F>M) & symptoms of PTSD Limit: the questionnaire of the study is based on However, TBSA is not a factor at 1 & a single question. 2yrs PB & gender is not a factor at 2yrs Answers were scored differently from VAS/ The study excluded pts In conclusion, PTS symptoms & surgical operations (more grafted skin) psychiatric problems. are risk factors for itching at 2yrs PB The study may underestimate the prevalence rate of itching Gabapentin given starting Nurses and parents reported a Total 35 children as 5mg/kg tid. & maximum remarkable reduction in itching & behavioral difficulties, dose up to 5mg/kg bid & antihistamine intake was decreased or the tx needs to be Key variables: 23≤3yrs). 10mg/kg at night. 3 out of 23 kids having skin loss from meningitis. Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes -maximum dose for One child w/ ADHD showed disruptive RCTs are necessary epilepsy:40mg/kg/day behavior as a side effect-only one case chlorpheniramine Parents & nursing staff assessed the effects of the tx (gabapentin use) remained irritable & constantly rubbing wounds A total of 23 post Duration, frequency, & Duration of itch episodes in minutes at numbers of itch episode per baseline & wks 1, 2, 3, & 4. Tx group significantly reduced who were itching day, itch TBSA & affective has shown significantly reduced burn associated pruritus from burn injury itch characteristics duration of pruritus compared to the compared to using other treated in Villa measured at baseline, 1,2,3, & 4th wk after tx b/t control Frequency of itch was described as the number of days a wk at baseline, wks 1, Small pilot study, single - 12 for tx group, 4 Measurement used: 2, 3, & 4 showed that tx group had center & convenience Description of Pruritus significantly low frequency at wks 2,3, population, short period Experienced During & 4 compared to the control group of data collection Previous Week for Duration of episode – Number of daily itch episodes was classification b/w acute <5, ≥5 & <30, ≥30 & <60, significantly lower in the tx group & chronic pruritus in compared to the control group at wk 2 post burn population IC: experiencing Daily frequency – after the treatment postburn pruritus Wkly frequency – Itch TBSA measurement over time for tx & control groups: Tx group had Questionnaire for Pruritus significantly smaller itch TBSA compared to the control group at wks 1, Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes Modified Vancouver Scar lasting more than Scale; Mexameter Presence or absence of affective itch characteristics: Tx group significantly Descriptive statistics & a felt less bothersome from burn epithelialized test Wilcoxon rank-sum test associated pruritus at wks 1, 2, 3, & 4, area, &18 yrs or less annoyed at wks 4, & less unbearable from pruritus at wks 2, 3, & 4 compared to the control group 15 pts (M5, F10; 15pts received mugwort No significant improvement after 1 wk Mugwort lotion is 24-74yrs old) w/ lotion twice a day, then 1 effective for improving wk later survey completed. subjective symptoms Key variables: scars who ; one pt was dropped for a Significant improvement in pruritus, suffered from 2nd cold sensation to the site of sleep disturbance & redness noted 2months after tx (P = 0.027) Need to continue to treating the itch scars 2 months after the same tx, evaluate effects & 14 pts completed survey mechanism of mugwort. regarding improvement of Need to conduct more studies to evaluate this Study subjects answered Q1: 54.3%(night), 28.6% (afternoon), Itch man scale (0-4) attended for 5day for: Q1. Time of the day 2.9% (no difference), 14.3% (no when itching is most assessment tool for Q2: 34.3% (kids), 25.7% (adults), pruritus & anti-pruritus Q2. Ages of experiencing 25.7%(no difference), 14.3% (no regimen to be applied more itch (adults or kids), according to the scale Q3. Itch assessment tools Q3: 88.6% (no assessment tool to use), Q4. Types of burns resulted 11.4% (vague methods used) joint scientific in the greatest levels of Q4: 37.1% (deep dermal burns), 20% The recommendation burn specialists (partial thickness burns), 17.1% (full needs to be supported Q5. Treatment methods, thickness burns), 11.4% (full thickness by evidence based Goutos (2010) general meetings usage of any form of anti- & deep dermal burns), 2.9% (partial research. Sample size Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes pruritic regimen thickness & deep dermal burns), 11.4% too small & limited to a (no answer). 85.7% (conservative tx > country (Nigeria) to generalize to the world Q5: 57.1% (oral meds), 22.9% ( Injections), 8.6% (topical agents), 5.7% (reassure pts), 5.7% (combination Surgeons and the of oral & topical agents). 85.7% (no any form of anti-pruritic regimen). 23 subjects aged Demographic findings: Frequency if pruritus: daily (87%) & 2-3x/wk (96%). Duration characterize nonstop PB PB pruritus with of pruritus per incidence: 5-30 minutes Mean years postburn (52%)-No significant difference b/w Pruritus reported as (0.95), Range (0.1-3.21), acute & chronic pruritus groups unbearable, bothersome Mean burn % TBSA Description of accompanying Sensation: & annoying; (35.35), Mean pruritus Stinging (74%), pinching (48%), Acute group reported %TBSA (6.22)-1 subject more severe pruritus & Crawling & burning pruritus sensation it possibly expects that were perceived as more severe in spite patients recover, Scales & questionnaires in of low frequencies improve coping skills & English & French; pain, Affective aspects of pruritus: experience w/pruritus & pruritus, & QoL scales Unbearable (91%), bothersome (91%), scar maturation over Parameter for acute pruritus Acute group has less pruritus episodes Acute pruritus group & chronic pruritus d/f as but more influence from the pruritus persistent pruritus in PB than chronic group pruritoceptive pruritus subjects: PB 6months Mean VAS Scores for Itch: 2.65. Worst whereas chronic group pruritus score: 7 (acute group) & 9.07 Primary variable analyzed neuropathic pruritus. as a single category Best score for pruritus: 1.38 Therefore pruritic There was a significant difference treatment can be more between the pruritus & pain sensations effective when pruritus Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes A severity index for (general pain, P = .0003; local pain, P = characteristics are sensation was calculated by Sleep problems associated with pruritus Pruritus triggering & were not significantly reported relieving QoL activities Pruritus caused low concentration (N = reported, which can be 8), agitation (8), anxiety (4) & no applied to teach burn change in the mood (6) survivors to reduce Pruritus triggering QoL activities were pruritus episodes dryness(83%), heat(70%), Limitations: ↓ power fatigue(57%), physical effort(52%), & analysis d/t ↓sample special fabric(48%) Cold temperature (30%), cold water Acute pruritus period is (26%) & rest (22%) were pruritus relieving activities The age of burn scars Sleep, lying down, sitting, eating & hot water did not affect pruritus. Regulating the central The severity scores of pruritus b/w scars sensitivity of pruritus were similar explored incompletely- The natural lubrication of the skin b/w pruritus mechanisms & acute & chronic group was similar, but tx to be more studied acute pruritus scars have more rough skin texture & higher mean level of Needs more pts from erythema despite no significant various areas, races, differences b/w groups TBSA, & time after burn & research period to ↑ for generalizability The article addressed CAM Regarding pruritus in burns, 15 minute This result is written application and its massage therapy twice a week over just per two other effectiveness for atopic 5weeks reduced itching, pain, & anxiety articles that are dermatitis, chronic levels in burn adolescents included in the project urticaria, uremic itch, Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes postoperative itch, pruritus in burns, & intractable neuropathic itch mechanisms, & acupuncture, clinical treating pruritus w/ CAM techniques (Ratcliff et al., The review done in terms Findings only Relevant to itching Itching in children of pain medication & TBSA, pain scales & age, considerable problem medication given for Performed per itching management as and involves both effectiveness of pain, burn, PTSD, anxiety, itch & grafted & non-grafted procedural pain, anxiety For itching > 2 of 4, give skin at a prevalence of medication & TBSA, and 1) Moisturizing body shampoo & up to 100% for the itch medication & TBSA lotions, topical ointments (not hydrocortisone creams) The review divided into 3 2) Diphenhydramine Diphenhydramine was groups according to ages: 1.25mg/kg/dose po Q 6h effective as a primary <3, ≥3 to <10, & ≥10 3) If itch remains poorly protocol medication for controlled, subsequently add Itch Man Scale used for hydroxyzine 0.6mg/kg/dose q 6h, then cyproheptadine Other studies showed average hospital 0.1mg/g/dose po q6h so that shower & bath oil stay days 11.1 + one of the medications is given containing liquid paraffin with 5% colloidal oatmeal, 39.2% received medication to control topically applied itching at the beginning, but eventually doxepin cream, & Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes all the children took some type of itch medication because their burn wounds combination with got more itching as the course Objectives of the Literature review regarding Below as effective txs for PB pruritus Good study due to the PB pruritus relief mgt & 1.Topical txs (cooling agents, colloidal approach according to synthesized findings oatmeal, topical emollients, mixture of the phase of healing beeswax & herbal oil, silicone gel sheeting, & EMLA). No significant evidence base for difference for Capsaicin use algorithm needs to be 2.Oral txs (oral histamnes, gabapentin, tried & evaluated naltrexone, some antidepressants, & effects of tx to doxepin). Oral chemotherapy & topical generalize to all burn on best available immunosuppressants used for tx- resistant pruritus 3.Other txs (TENS, botulinum toxin, Unna's boot dressing, & nanocrystalline silver) 4.Psychological therapies Algorithm shown based on the stage of healing along with the algorithm by Brooks et al. (2008) Pretest-posttest 2 skin 18 pts– SRMT group, SRMT significantly affected on burn scar The study is meaningful 17 pts- control group healing positively because massage therapy clinics in Seoul, SRMT significantly decreased depression can have positive effects Before SRMT & 3months among burn patients on pruritus, scar status, 11/2004 & 2/2005 after SRMT, survey for SRMT significantly decreased pruritus in and depression among on pruritus, skin itching was completed. Burn Inclusion criteria: scar & depression assessed There is a significant positive relationship 18yrs and older, among depression, objective skin status, Limit: small sample size, and pruritus, too needs more reliable & thickness burn on objective burn-scar Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes forearm or hand, Certified rehabilitation assessment tools nurses applied SRMT 30 min/wk for 3months & primary caregivers gave it 10min per day for 3 months For wound management: massage & Limited exploration on latest evidence in emollients, topical silicone therapy, post-burn pruritus Key variables: burn care by pressure garment therapy, low pulsed management.-showing ultrasound, serial intralesional corticosteroid injections, laser therapy pruritus management recent evidence management, w/o specific doses or rehabilitation & For chronic pain: analgesia For psychosocial care: long-term psychosocial follow up needed for For nutrition support: high calorie & protein with vitamins & minerals Burn pruritus: massage w/ emollient
cream, cool baths, pressure garments,
& oral and topical antihistamines &

Χ 2 analysis was used. Native American/Alaskan Native race, facial burns, & ≥ 20% TBSA burns are Relatively small cohort HTS is considered of VSS associated w/ ↑ risk of HTS No differences b/w VSS & itch scores in the Key variables: from pts & Pts VSS: Pigmentation(0-2), However, risk for itching is only subgroup while there is seen 2 times (one Vascularity (0-3), Pliability associated with burn size ≥ 20% TBSA. differences for the Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes (0-5), Height (0-3) There is no significant differences entire population, after burn, one at among ages and genders for both HTS There is no consensus 6-12months after in the literature as to constitute hypertrophic scarring even if a VSS score of >7 was itch scores were determined as a way of identifying HTS. Five psychological Habit reversal: itching is replaced by approaches to treat wound alternative behaviors using assessment, psychological tx can be associated itching (Habit education & behavior analysis, and used for pts w/ pruritus reversal, Suggestions, stimulation awareness training –Habit reversal, Relaxation training, Suggestions, Relaxation 11/2013, written Massage, & Itch-coping Suggestion: placebo effects have been training, Massage, & programs) reviewed from effective in reducing itching & pain Itch-coping programs contains itching published literature Relaxation training: many relaxation Limit: researches are Key variables: w/wounds or techniques have been effective to reduce relatively weak from mgt/tx of itching, itching (progressive muscle, low sample sizes, lack biofeedback-assisted relaxation & heart of control groups & rate variability biofeedback) Massage: massage techniques significantly decreased itching, pain, anxiety, skin status, remaining, depression, skin pigmentation, pliability, vascularity, & height 5-D Itch scale used to There is a significant difference b/w pre assess five domains of and post tx in both group1 & group2 Key variables: Group2:20pts degree, duration, direction, regarding pruritus (P<0.05) phonophoresis is as disability, and distribution useful as TENS to Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes There is no significant differences b/w reduce PB pruritus 2groups regarding effect of pruritus effectiveness of s, TENS, PB Mann-Whiney U test used Limits: No control to assess b/w 2 groups group in the study & small sample noted Wilcoxon test used to IC:age:18-50yrs, assess parameters within Suggestion: further 2nd & 3rd degree studies to compare control group with both Student t-test used to assess tx (Triamcinolone itching>5min & the difference in the origin pruritus, All P values < 0.05 liver, thyroid, & kidney disease, DM, pregnancy, open wound, sensitivity to cortisone, pacemakers, skin malignancy, taking glucocorticoids, phototoxic or immunosuppressive medicine Early pruritus management: histamine
Not mentioned specific burn wound, pain H-1 receptor blocking agent
dosages or frequency of Key variables: management, (cetirizine) on as scheduled basis not as tx for PB pruritus, but
pruritus, burn, home car needed basis combined with frequent
scheduled use of massage of moisturizers
antihistamine is notable Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes outpatient clinic In addition, neuro-inflammatory
transmitter blockers (gabapentin &
pregabalin) is effective because itch- specific neurons won't be stimulated by these transmitters by using this (pain, pruritus, Pt received TENS 9hrs a Day#1: 62.5% reduction in itching A larger case study or within 4hrs of application full-scale study needed Key variables: thickness flame Day#2: 88% reduction within 4hrs of Assessment for itching done daily for 5days, at 9th Day#3 – the end of study (DAY#16): severe itching & day, & 16th day after tx No itching within 4hrs of application relieve pruritus Pt did not receive TENS after 2wks d/t no itching Group A: 33pts w/pruritus, Histopathological analysis result: Patient with post burn Group B: 18pts w/o Group A has less elastic fibers (density) pruritus had broader burned areas & more Key variables: ages ranging 8 - burn, pruritus, 60yrs Differences b/w groups: Immunoreactivity of TRP channels in Group A has thicker burn burn scar & normal skin result: They also had elevated scars, more TBSA, more TRPV3, TRPV4, & TRPA1 elevated in male population, & higher Group A's scar tissue TPRA1 in the skin numbers in scar assessment TRPV4 becomes more active at temperature > 25°C & by arachidonic Treatment w/ antagonist of TRPA1 & TRPV4 Measurements, Operational Conclusions, Study Sample & Setting Definitions of Variables Results or Findings Limitations, & Notes for this population will be meaningful in the Current tx options for PB pruritus: Use of gabapentin Antihistamines (H1 & H2 receptor showed excellent relief antagonists), Topical alternatives over the healed burn wounds (colloidal especially tolerated well oatmeal baths, EMLA, corticosteroids, massage therapy, Doxepin cream), significant side effects, Adjuncts (Biofeedback therapy, which can be the 2nd psychological support, combined choice for the case of w/pharmacological agents, TENS), antihistamine resistant Newer medicine: Ondansetron (5HT-3 receptor antagonist), Gabapentin (anti- epileptic drug), Pregabalin (anti-convulsant), Paroxetine (SSRI), & Naltrexone (opioid antagonist) ABSHS = Abbreviated Burn Specific Health Scale; ACD = allergic contact dermatitis; AD = atopic dermatitis; ADHD = attention deficit hyperactivity disorder; BDISF = Beck Depression Inventory-Short Form; bid = twice a day; b/w = between; CAM = complementary and alternative medicine; CG = control group; CLD = cholestatic liver diseases; c/o = complain of; CTD = connetive tissue disease; CU = chronic urticaria; CV = confounding variable; CVD = cardiovascular disease; D/C = Discharge; d/f = defined; DFS = Dutch Fatigue Scale; DM = diabetes mellitus; d/t = due to; DV(s) = dependent variable(s); EC = exclusion criteria; EG = experimental group; EMLA = eutectic mixture of local anesthetic; F = female; f/u = follow up; G = group; GRADE = Grading of Recommendations, Assessment, Development and Evaluation; HD = hemodialysis; HS = hypertrophic scar; ht = height; HTP = hypertrophic scar; hx = history; IC = inclusion criteria; IF = itch frequency; II = itch intensity; info = information; IV(s) = independent variable(s); LAS = Linear Analog Scale; LIS = Leuven Itch Scale; LTF = Long-Term Follow up; M = male; meds = medications; Mexameter = a tristimulus colorimeter device used to measure scar; mgt = management; MRI = magnetic resonance image; MVLR = multivariate logistic regression analysis; mVSS = modified Vancouver Scar Scale; N = Number; NIDRR BMS = National Institute on Disability & Rehabilitation Research Burn Model System; NRS = Numeric Rating Scale; P1 = initial version; P2 = second version; P3 = third version; P4 = fourth version; PB = postburn; PBD = post burn days; P/E = physical examination; PET = positron emission tomography; PG = pressure therapy; PS = plastic surgeon; PSS = Perceived Stress Scale; pt = patient; PTS = post-traumatic stress; PTSD = post-traumatic stress disorder; QD = daily; QoL = quality of life; RCT = randomized clinical trial; r/t = related to; SC = skin condition; SGS = silicone gel sheeting; SLS = Satisfaction with Life Scale; SSRI = selective serotonin reuptake inhibitor; STAI = State Trait Anxiety Inventory; SWL = satisfaction with life; TBSA = total body surface area; TENS = transcutaneous electrical nerve stimulation; TEWL = transepidermal water loss; tid = three times a day; TRP = transient receptor potential; TRPA = transient receptor potential ankyrin; TRPV = transient receptor potential vanilloid; TUPS = tissue ultrasound palpation system; tx = treatment; UNC = University of North Carolina; USG = ultrasonography; VAS = visual analog scale; vs = versus; v/s = vital signs; VSS = Vancouver Scar Scale; Wd = wound; wks = weeks; w/ = with; w/o = without; yrs = years. • Articles are organized by the last name of the first author of each article.

Source: http://nursing.fullerton.edu/programs/pdf/dnp/finalprojects/2015/Kim_YeonSook_DNP_Final_Project_2015.pdf

Rx only

LEVETIRACETAM - levetiracetam tablet, film coated Solco Healthecare US, LLC DESCRIPTIONLevetiracetam is an antiepileptic drug available as 250 mg (pink), 500 mg (pink), 750 mg (pink), and 1000 mg (white) tablets for oraladministration.The chemical name of Levetiracetam, a single enantiomer, is (-)-(S)-α-ethyl-2-oxo-1-pyrrolidine acetamide, its molecular formula isC8H14N2O2 and its molecular weight is 170.21. Levetiracetam is chemically unrelated to existing antiepileptic drugs (AEDs). It hasthe following structural formula:

Mouth preparations

Preparation of mouth for removable partial dentures MOUTH PREPARATIONS One of the greatest challenges facing the dentist is the provision of the partially edentulous arch with a successful removable partial denture. To ensure this success, the hard and soft tissues of the particular arch being restored and the associated tissues must be in an acceptable biologic state.