Pediatrics Test 3 Burns

Second Degree Burns: Partial Thickness

A second-degree burn involves the entire epidermis. Sweat glands and hair follicles are left intact. The area appears very erythematous, blistered, and moist from exudate. It is extremely painful. Scalds can cause second-degree burns Such burns heal by regeneration of tissue but take 2 to 6 weeks to heal.

Nursing Diagnosis: Risk for impaired urinary elimination related to burn injury Outcome Evaluation: Child's urine output is greater than 1 mL/kg of body weight per hour.

Because the child's blood volume decreases immediately after a burn, renal function is threatened by kidney ischemia just when it is needed to rid the body of breakdown products from burned cells. If the child is burned over more than 10% of body surface, urinary output may decrease immediately. Blood volume must be maintained by IV fluid administration to establish good urinary output once more. Urine output should be 1 mL/kg of body weight per hour. The specific gravity of urine also should be monitored to determine whether the kidneys can concentrate urine to conserve body fluid (failing kidneys lose this ability rapidly). In the days after the burn, because products of necrotic tissue and toxic substances must be evacuated by the kidneys and antidiuretic hormone and aldosterone levels are increased in response to low blood pressure, kidney function may fail again. If free hemoglobin from destroyed red blood cells plugs kidney tubules (acute tubular necrosis), urine color will be red to black because of the hemoglobin present. An indwelling urinary (Foley) catheter should be inserted in the emergency department, and an immediate urine specimen should be obtained for analysis. A diuretic, such as mannitol, may be administered to flush hemoglobin from the kidneys. If this is effective, the urine returns to its usual straw color. Throughout the child's hospital stay, observing urinary output is a major nursing responsibility.

Emergency Management of Burns: Moderate Burns--- Second degree

Blisters, do not break If blisters broken, healthcare should cut away skin Application of silver sulfadiazine and bulky dressing to prevent skin damage. Follow up within 24 hours Monitor for pain control, treat with analgesics Moderate or second-degree burns may have blisters. - Do not rupture them, because doing so invites infection. The burn will be covered with a topical antibiotic such as silver sulfadiazine and a bulky dressing to prevent damage to the denuded skin. The child usually is asked to return in 24 hours to assess that pain control is adequate and there are no signs and symptoms of infection. Broken blisters may be débrided (cut away) to remove possible necrotic tissue as the burn heals.

Burns

Caused by excessive heat >104 Second greatest cause of unintentional injury in children 1-4yrs old Third greatest 5-14 yrs Toddlers burned by pulling hot pans off stove, grease, too hot bathwater. Bite electrical cords Older child- burns from flames from campfire, heater, fireplace, touch hot curling iron, play with matches, eye burns chemicals in science class Some burns particularly scalding caused by child abuse Burns more serious in child- covers more surface area.

Psychosocial Support of Child/ Parents

Children watch you as you care for them to see if you find them unattractive. As dressings are removed, children may expose parts of their body seemingly inappropriately, to see if you are shocked or revolted by them. Imagining how children feel, realizing that this mutilated skin is their skin, helps health care providers maintain a professional attitude. Returning to school can be difficult, old friends have new friends, so they may feel cut out of school activities, look different if they have burn scars, formal counseling. Some parents need formal counseling also, to help them accept their child's changed appearance.

Test Information

Circumferential dressing proximal to distal Severity of burn: by surface area burned, age of child and causative agent

Escharotomy

Cutting into eschar when circulation cut off. An eschar is the tough, leathery scab that forms over moderately or severely burned areas. Fluid accumulates rapidly under eschars, putting pressure on underlying blood vessels and nerves. If an extremity or the trunk has been burned so that both anterior and posterior surfaces have eschar formation, a tight band may form around the extremity or trunk, cutting off circulation to distal body portions. Distal parts feel cool to the touch and appear pale. The child notices tingling or numbness. Pulses are difficult to palpate, and capillary refill is slow (longer than 5 seconds). To alleviate this problem, an escharotomy (cut into the eschar) is performed Some bleeding will occur after escharotomy. Packing the wound and applying pressure usually relieves this.

Burns: Assessment

First question to ask is where is burn and what is extent and depth? Face and throat burns particularly hazardous because there may be unseen but accompanying burns in respiratory tract. Edema could lead to respiratory tract obstruction Hand burns are also hazardous because, if the fingers and thumb are not positioned properly during healing, adhesions will inhibit full range of motion in the future. Burns of the feet and genitalia carry a high risk for secondary infection. Genital burns are also hazardous because edema of the urinary meatus may prevent a child from voiding.

First Degree Burns: Partial Thickness

First-degree burn involves only the superficial epidermis. The area appears erythematous. It is painful to touch and blanches on pressure.Scalds and sunburn are examples of first-degree burns. Such burns heal by simple regeneration and take only 1 to 10 days to heal.

Classification of Burns: Minor

First-degree burn or second-degree burn <10% of body surface or third-degree burn <2% of body surface; no area of the face, feet, hands, or genitalia burned

Emergency Management of Burns: Severe---Third degree

Fluid replacement Systemic antibiotic therapy Pain management Physical therapy The child with a severe burn is critically injured and needs swift, sure care, including fluid therapy, systemic antibiotic therapy, pain management, and physical therapy, to survive the injury without a disability caused by scarring, infection, or contracture

Grafting

Homografting (also called allografting) is the placement of skin (sterilized and frozen) from cadavers or a donor on the cleaned burn site. These grafts do not grow but provide a protective covering for the area. Autografting is a process in which a layer of skin of both epidermis and a part of the dermis (called a split-thickness graft) is removed from a distal, unburned portion of the child's body and placed at the prepared burn site, where it will grow and replace the burned skin. Cultured epithelium is derived from a full-thickness skin biopsy. This can be grown into a coherent sheet and supply an unlimited source for autografts. Larger areas may require mesh grafts (a strip of partial-thickness skin that is slit at intervals so that it can be stretched to cover a larger area;). The advantage of grafting is that it reduces fluid and electrolyte loss, pain, and the chance of infection. After the grafting procedure, the area is covered by a bulky dressing. So that the growth of the newly adhering cells will not be disrupted, this should not be removed or changed. The donor site on the child's body (often the anterior thigh or buttocks) is also covered by a gauze dressing. Both donor and graft dressings should be observed for fluid drainage and odor. Observe the child to determine whether there is pain at either site, which might indicate infection. Monitor the child's temperature every 4 hours. A rise in systemic temperature may be the first indication that there is infection at the graft or donor site. Autograft sites can be reused every 7 to 10 days, so any one site can provide a great deal of skin for grafting.

Partial Thickness

Includes first and second degree burns

Nursing Diagnosis: Disturbed body image related to changes in physical appearance with burn injury

Outcome Evaluation: Child expresses fears about physical appearance; demonstrates desire to resume age-appropriate activities. Children become extremely dependent on the nursing staff Respond to this forced dependence at first with gratitude then response may become less healthy. Young children may regress, older aggressive. Allow independent decision-making whenever possible.

Nursing Diagnosis: Deficient diversional activity related to restricted mobility after severe burn

Outcome Evaluation: Child expresses interest in obtaining school homework; child communicates with friends and relatives by way of telephone, letters, or e-mail. Remember that, even if a child's chest, abdomen, and hands are burned, he does not stop thinking so children who are burned need stimulation in their environment. It is important to make toys and play materials available.

Nursing Diagnosis: Social isolation related to infection control precautions necessary to control spread of microorganisms

Outcome Evaluation: Child states that he understands the reason for infection control precautions; child accepts it as a necessary part of therapy. Infection control measures ,Aseptic technique and appropriate barriers are necessary to reduce the risk of exposing the child to infection. Wear gowns, masks, caps, and sterile gloves. It is easy for children with burns to interpret confinement in a room as punishment, make the child's environment as warm and comforting as possible, keep near front of unit to see activity, decorate room with cards/ pictures Provide time for children to discuss their feelings about being kept in a room by themselves.

Nursing Diagnosis: Pain related to trauma to body cells

Outcome Evaluation: Child states that pain is at a tolerable level Morphine IV, Physical Therapy, Reduce stimuli Morphine sulfate is commonly the agent of choice. It can be administered IM, but, because circulation is impaired in children with shock, IV or epidural administration is most effective. Use of patient-controlled analgesia before performing any burn care such as débridement (the removal of necrotic tissue from a burned area) is also effective. Be sure to assess after administration that pain relief was adequate. In addition to the pain from the burn, children may be required to remain in awkward positions to keep joints overextended for most of every day. Doing so helps to prevent formation of contractures from scar tissue. It is difficult for children to watch television in this position or even to view activities on the unit so they need to be encouraged to maintain this position. If they have burns at extremity joints, they may have splints applied over burn dressings to maintain the joints in extension. Again, this makes activities very difficult and adds to their stress if they do not have adequate pain relief.

Nursing Diagnosis: Risk for ineffective breathing patterns related to respiratory edema from burn injury

Outcome Evaluation: Child's respiratory rate remains within 16 to 20 breaths/minute; lung auscultation reveals no rales If a child inhaled smoke from a fire, the injury from the smoke inhalation can be more serious than the skin surface burns. If the trachea is burned, edema fluid will pass into the injured bronchioles and trachea, causing pulmonary edema or obstruction limiting air inflow. This can lead to dyspnea and stridor. About 1 week after the smoke inhalation, the child is at risk for the development of pneumonia because of denuded tracheal and bronchial tract areas. Assess for burns of the face, neck, or chest, which would indicate that the fire was near the nose and respiratory tract. Assess the quality of the child's voice (it will be hoarse if the throat is irritated from smoke). Carefully monitor the respiratory rate of all burned children, because respiratory rate increases with respiratory obstruction. A child also may become restless and thrash about because of lack of oxygen. Symptoms of smoke inhalation may not occur immediately but only 8 to 24 hours after the burn. A chest radiograph taken at this time will reveal collecting edematous fluid and decreased aeration. Continue to assess the child's temperature every 4 hours for the first week after the injury, to assess that lung infection is not developing. Bronchodilators and antibiotics may be prescribed.

Nursing Diagnosis: Risk for injury related to effects of burn, denuded skin surfaces, and lowered resistance to infection with burn injury

Outcome Evaluation: Child's temperature remains at 98.6° F (37° C); skin areas surrounding burned areas show no signs of erythema or warmth. There appears to be some defect in the ability of neutrophils to phagocytize bacteria after burn injury. The formation of immunoglobulin G antibodies also apparently fails. For these reasons, a child has reduced protection against infection. Staphylococcus aureus and group A β-hemolytic streptococci are the gram-positive organisms, and Pseudomonas aeruginosa is the gram-negative organism, that commonly invade burn tissue. Children are usually prescribed parenteral penicillin to prevent group A β-hemolytic streptococcal infection and tetanus toxoid to prevent tetanus. In addition to bacteria, fungi also may invade burns. Candida species are the most frequently seen (Madoff, 2008). Nose, throat, and wound cultures may be done immediately and then daily to detect offending organisms. Bacteria and fungi can penetrate the burn eschar readily, so this tissue offers little protection from infection. Fortunately, granulation tissue, which forms under the eschar 3 to 4 weeks after the burn, is resistant to microbial invasion. Systemic antibiotics are not very effective in controlling burn-wound infection, probably because the burned and constricted capillaries around the burn site cannot carry the antibiotic to the area. For this reason, any equipment used with the child must be sterile, to avoid introducing infection. Children are placed on a sterile sheet on the examining table. Personnel caring for the severely burned child should wear caps, masks, gowns, and gloves, even for emergency care. Although their burns may be covered by gauze dressings, children usually are cared for in private rooms to help reduce the possibility of infection. Helping children maintain their self-esteem and keeping them from withdrawing from social contacts can be difficult when infection control precautions are required.

Nursing Diagnosis: Risk for ineffective tissue perfusion related to cardiovascular adjustments after burn injury

Outcome Evaluation: Child's vital signs stay within normal limits; hourly urine output remains greater than 1 mL/kg. Take height, weight, and vital signs on admission, and continue to take vital signs every 15 minutes until they are stable, then every 24 hours. Another important period occurs at 48 hours after the injury, when fluid is returning to the bloodstream. Remember that gradual but persistent changes in blood pressure may be as informative as sudden changes. A complete blood cell count, blood typing and cross-matching, electrolyte and BUN determinations, and blood gas studies to ascertain blood levels of oxygen and carbon dioxide are important to obtain.

Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements, related to burn injury

Outcome Evaluation: Child's weight remains within normal age-appropriate growth percentiles; skin turgor remains normal; urine specific gravity remains between 1.003 and 1.030. After burns, the metabolic rate increases in children as the body begins to pool its resources to adjust to the insult. If children do not receive enough calories in IV fluid, their body will begin to break down protein. This is particularly dangerous because a child needs protein for burn healing. Additionally, breakdown of protein can lead to acidosis. An NG tube may be inserted and attached to low, intermittent suction as prophylactic therapy to prevent aspiration of vomitus, NG remains until bowel sounds heard. If a child has burns over more than 30% of the body surface, paralytic ileus may occur. Symptoms of intestinal obstruction, such as vomiting, abdominal distention, and colicky pain, will appear within hours of the burn. Children with severe burns usually are allowed nothing by mouth for 24 hours because of the danger of vomiting or paralytic ileus. After this, most children are able to eat, so oral feedings are begun as soon as possible. To supply adequate calories for increased metabolic needs and spare protein for repair of cells, the diet is high in calories and protein(protein shakes) Because adequate nutrition is important, it may be necessary to supplement the child's diet with IV or parenteral nutrition solutions or NG tube feeding.

Nursing Diagnosis: Interrupted family processes related to the effects of severe burns in family member

Outcome Evaluation: Family members state that they are able to cope effectively with the degree of stress to which they are subjected; family demonstrates positive coping mechanisms. Children with severe burns always have a difficult hospitalization because of the pain, restrictions, and (at some point) awareness of the disfigurement that accompanies major burns. They may need help in establishing priorities and may feel guilty

Nursing Diagnosis: Deficient fluid volume related to fluid shifts from severe burn

Outcome Evaluation: Skin turgor remains good; hourly urine output is greater than 1 mL/kg, with specific gravity between 1.003 and 1.030; vital signs are within acceptable parameters. Immediately after a severe burn, the child's circulatory system becomes hypovolemic, because of a loss of plasma, which oozes from blood vessels into the burn site and then sequesters in edematous tissue surrounding the site. This outpouring of plasma is caused by an increased permeability of capillaries (or damage to capillaries). It is most marked during the first 6 hours after a burn. It continues to some extent for the first 24 hours. A primary response of the myocardium to the shock of burn injury and hypovolemia can lead to a marked reduction in cardiac output and decreased blood pressure. Therefore, even with relatively minor burns, monitor vital signs closely to allow early detection of this event. A child may be severely anemic because of injury to red blood cells caused by heat and loss of blood at the wound site. The large amount of sodium lost with the edematous burn fluid and the release of potassium from damaged cells can lead to an immediate hyponatremia and hyperkalemia Lactated Ringer's , child may also need plasma replacement and additional fluid, such as 5% dextrose in water. Do not administer potassium immediately after a burn until kidney function is evaluated, to be certain that extra potassium can be eliminated.

Emergency Management of Burns: First Degree: Minor Burns

Relatively easy to treat: application of cool/cold wet cloths to cool the skin and prevent furthur burns. Application of analgesic- antiobiotic and wrap with gauze to prevent secondary infection NO BUTTER, bathing or swimming for at least a week. Follow up with physician within 48 hours Although minor burns (typically first-degree partial-thickness burns) are the simplest type of burn, they involve pain and death of skin cells, so they must be treated seriously. Immediately apply cold compresses to cool the skin and prevent further burning. Application of an analgesic-antibiotic ointment and a gauze bandage to prevent infection is usually the only additional treatment required. The child should have a follow-up visit in (48 hours) 2 days to have the area inspected for a secondary infection and to have the dressing changed. Caution parents to keep the dressing dry (no swimming or getting the area wet while bathing for 1 week). A first-degree burn heals in about that time.

Debridement

Removal of necrotic tissue from a burned area. Débridement reduces the possibility of infection, because it reduces the amount of dead tissue present on which microorganisms could thrive. Children usually have 20 minutes of hydrotherapy before débridement to soften and loosen eschar, which then can be gently removed with forceps and scissors. Débridement is painful, and some bleeding occurs with it. Premedicate the child with a prescribed analgesic, and help the child use a distraction technique during the procedure to reduce the level of pain. Transcutaneous electrical nerve stimulation (TENS) therapy or patient-controlled analgesia may also be helpful. Praise any degree of cooperation. Plan an enjoyable activity afterward to aid in pain relief and also to help re-establish some sense of control over the situation. Children need to have a "helping" person with them, to hold their hand, to stroke their head, and to offer some verbal comfort during débridement: "It's all right to cry; we know that hurts. We don't like to do this, but it's one of the things that makes burns heal" Nursing personnel need a great deal of talk time to voice their feelings about assisting with or doing débridement procedures. Be careful when serving as the "helping" person that you do not project yourself as the healer and comforter and a fellow nurse as the hurter or "bad guy." It helps if people alternate this chore so that, on alternate days, each serves as the protector or the comforter. If eschar tissue is débrided in this manner day after day, granulation tissue forms underneath. When a full bed of granulation tissue is present (about 2 weeks after the injury), the area is ready for skin grafting. In some burn centers, this waiting period is avoided by immediate surgical excision of eschar and placement of skin grafts. Another trend in débridement is the use of collagenase (Santyl), an enzyme that dissolves devitalized tissue.

Therapy for Burns

Second- and third-degree burns may receive open treatment, leaving the burned area exposed to the air, or a closed treatment, in which the burned area is covered with an antibacterial cream and many layers of gauze. A synthetic skin covering (Biobrane), artificial skin (Integra), or amniotic membrane from placentas can be used to help decrease infection and protect granulation tissue. As a rule, burn dressings are applied loosely for the first 24 hours to prevent interference with circulation as edema forms. Be certain not to allow two burned body surfaces, such as the sides of fingers or the back of the ears and the scalp, to touch, because, as healing takes place, a webbing will form between these surfaces. Do not use adhesive tape to anchor dressings to the skin; it is painful to remove and can leave excoriated areas, which provide additional entry for infection. Netting is useful to hold dressings in place, because it expands easily and needs no additional tape.

Classification of Burns: Severe

Second-degree burn >20% of body surface or third-degree burn <10% of body surface

Classification of Burns: Moderate

Second-degree burn between 10% to 20% or on the face, hands, feet, or genitalia or third-degree burn <10% of body surface or if smoke inhalation has occurred

Topical Therapy

Silver sulfadiazine (Silvadene) is the drug of choice for burn therapy to limit infection at the burn site for children. It is applied as a paste to the burn, and the area is then covered with a few layers of mesh gauze. Silver sulfadiazine is an effective agent against both gram-negative and gram-positive organisms and even against secondary infectious agents, such as Candida. It is soothing when applied and tends to keep the burn eschar soft, making débridement easier. It does not penetrate the eschar well, which is its one drawback. Antiseptic solutions, such as povidone-iodine (Betadine), may also be used to inhibit bacterial and fungal growth. Unfortunately, iodine stings as it is applied and stains skin and clothing brown. Dressings must be kept continually wet to keep them from clinging to and disrupting the healing tissue. If Pseudomonas is detected in cultures, nitrofurazone (Furacin) cream may be applied. If a topical cream is not effective against invading organisms in the deeper tissue under the eschar, daily injections of specific antibiotics into the deeper layers of the burned area may be necessary. If a burned area, such as the female genitalia, cannot be readily dressed, the area can be left exposed. The danger of this method is the potential invasion of pathogens.

Third Degree Burns: Full Thickness

Third-degree burn is a full-thickness burn involving both skin layers, epidermis and dermis. It may also involve adipose tissue, fascia, muscle, and bone. --The burn area appears either white or black Flames are a common cause of third-degree burns. Because the nerves, sweat glands, and hair follicles have been burned, third-degree burns are not painful. - - Such burns cannot heal by regeneration because the underlying layers of skin have been destroyed. - Skin grafting is usually necessary, and healing takes months. - Scar tissue will cover the final healed site. Many burns are compound, involving first-, second-, and third-degree burns. ----There may be a central white area that is insensitive to pain (third degree), surrounded by an area of erythematous blisters (second degree), surrounded by another area that is erythematous only (first degree).

Electrical Burns of the Mouth

Tissue area much larger than where the prongs or cord actually touched is involved, leaving an angry-looking ulcer. If blood vessels were burned, active bleeding will be present. The immediate treatment for electrical burns of the mouth is to unplug the electric cord and control bleeding. Pressure applied to the site with gauze is usually effective. Most children are admitted to a hospital for at least 24 hours in an observation unit because edema in the mouth can lead to airway obstruction. Supply adequate pain relief as long as necessary. Clean the wound about four times a day with an antiseptic solution, such as half-strength hydrogen peroxide, or as otherwise ordered to reduce the possibility of infection (a real danger in this area, because bacteria are always present in the mouth). Eating will be a problem for the child because the mouth is so sore. The child may be able to drink fluids from a cup best. Bland fluids, such as artificial fruit drinks or flat ginger ale, are best. Electrical burns of the mouth turn black as local tissue necrosis begins. They heal with white, fibrous scar tissue, possibly causing a deformity of the lip and cheeks with healing. This can be minimized by the use of a mouth appliance, which helps maintain lip contour. Some children have difficulty with speech sounds because of resulting lip scarring. They need follow-up care by a plastic surgeon to restore their lip contour

Burn Assessments

Undress children with burns completely so the entire body can be inspected. A first-degree burn is painful, whereas a third-degree burn is not. Therefore, a child may be crying from a superficial burn that is obvious on the arm, although the condition needing the most immediate attention is a third-degree burn on the chest, which is covered by a jacket. Be certain to ask what caused the burn Ask whether the child has any secondary health problem, ask about other children and where they are, who put out fire,anyone else hurt, anyone else need care?

Depth of Burn

When estimating the depth of a burn, use the appearance of the burn and the sensitivity of the area to pain as criteria.

Rules of Nines

With adults, the "rule of nines" is a quick method of estimating the extent of a burn. For example, each upper extremity represents 9% of the total body surface; each lower extremity represents two 9s, or 18%, and the head and neck represent 9%. ******Because the body proportions of children are different from those of adults, this rule does not always apply and is misleading in the very young child, see determination of burns in child chart.