Nursing Care Of Children With Burns

CNE PROGRAMME BY

DEPARTMENT OF PEDIATRIC NURSING Venue: KKCTH, Chennai. 11.11.2009 APOLLO COLLEGE OF NURSING CHENNAI- 95 M.Sc Nursing., 2nd yr 2008-2010 batch

NURSING CARE OF CHILD WITH BURNS Guide:

By:

Dr. Latha Venkatesan, Phd (N) Prof .Helen.Perdita, Phd (N), Ms. Kala.V, Lecturer, MSc (N), Ms. Cecilia Mary, Lecturer, Msc (N) Ms. Bansara Cathreen, Ms. Karpagam.S, Ms. Jayaselvi.S, Ms. Mani megali.G, Ms.Viji.R Msc Nursing Pediatrics 2nd yrs 2008 – 2010 batch

Definition of Burns 

A burn is a damage to the body's tissue caused by heat, chemicals, electricity ,sunlight or radiation

Layers of Skin

Functions of Skin 

Skin is the largest body organ, protects underlying tissues

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Helps to maintain temperature

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Helps to maintain fluid and electrolyte balance.

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There are two layers in skin called

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Epidermis Dermis

Pediatric Burns 

Thin skin 

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Increased severity of burns

Larger body surface area Rapid fluid loss  Increased heat loss  Hypothermia 

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Immature immunologic response 

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Sepsis

Possibility of child abuse

Causes of Burn Injuries 

Thermal  

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Scald Flame

Radiation Chemical Electrical

Household Burn Risks Kitchen

Living Room

Bathroom

Outdoors

Developmental Trends Infants and Toddlers

Adolescents

75-90% are scald burns (i.e., bathing, spills)

20% are household scalds

95% occur indoors

60% occur outdoors

Most play is indoors

Increased experimentation Increased responsibilities for outdoor chores

Degrees of Burns

Degrees of Burn Injuries

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Based on depth of burn injuries First Degree Burns: First degree burns produce redness, swelling, and minor pain. The skin is dry and without blisters. Healing time is about three to six days. The superficial skin layer could peel off as early as one to two days

First degree Burns

Second Degree Burns

Damage to dermis Partial thickness. These burns produce blisters, severe pain, and redness. The blisters can break open. Heals in ~ 1-3 weeks with no grafting

Second Degree Burns

Third Degree Burns : Damage to multiple layers including subcutaneous tissue Full thickness Heals in ~3-5 weeks; requires grafting

Third Degree Burns

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In the adult, most areas of the body can be divided roughly into portions of 9%, or multiples of 9.

This division, called the rule of nines, is useful in estimating the percentage of body surface damage an individual has sustained in burns. 

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Emergent (resuscitative)

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Acute

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Rehabilitative

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Remove from area! Stop the burn! If thermal burn is large--FOCUS on the ABC’s 

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A=airway-check for patency, soot around nares, or signed nasal hair B=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of pulses

EMERGENCY MANAGEMENT Airway/breathing  

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Intubation: Consider for >20% to 25% BSA burned, or any respiratory distress. Inhalation injury: Assume carbon monoxide poisoning with severe and/or closed-space burns. Administer humidified 100% O2 until carboxyhemoglobin level 10%(consider hyperbaric O2 if pH < 7.4 and COHb elevated).

Circulation:  Start IV fluid resuscitation for infants with burns >10% of BSA, children with burns >15% BSA, or children with evidence of smoke inhalation.  Consider a bolus of 20 mL/kg lactated Ringer's or normal saline solutions. Further fluid resuscitation should maintain a urine output >0.5 mL/kg/hr.

Analgesia IV narcotic therapy often necessary for pain control. GI Place nasogastric tube for decompression; begin prophylaxis for Curling's stress ulcers with histamine-2 receptor blockers and/or antacids. GU Use Foley catheter to monitor urine output, decompress bladder, and prevent possible soiling of wounds.

Eye Ophthalmologic evaluation as necessary. Use topical ophthalmic antibiotics if abrasions are present. Special considerations Tetanus immunoprophylaxis Temperature management Cooling decreases the severity of the burn if administered within 30 min of injury; it also helps to relieve pain.

FLUID RESUSCITATION. 

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Parkland formula (4 mL Ringer lactate/kg/% SA burned). Half of the fluid is given over the 1st 8 hr, calculated from the time of onset of injury. 1st day's fluid requirement is infused as Ringer lactate solution. The remaining ½ is given at an even rate over the next 16 hr. The rate of infusion is adjusted according to the patient's response to therapy. Pulse and blood pressure should return to normal. An adequate urine output (>1 mL/kg/hr in children; 0.5–10 mL/kg/hr in adolescents) should be accomplished by varying the intravenous infusion rate.

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Vital signs, acid-base balance, and mental status reflect the adequacy of resuscitation.

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Patients with burns of 30% of BSA require a large venous access (central venous line) to deliver the fluid required over the critical 1st 24 hr. Patients with burns of >60% of BSA may require a multilumen central venous catheter; these patients are best cared for in a specialized burn unit.

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During the 2nd 24 hr after the burn, patients begin to reabsorb edema fluid and to diurese. Colloid is usually instituted 8–24 hr after the burn injury. One preference is to use colloid replacement concurrently if the burn is >85% of total BSA. The adequacy of resuscitation should be constantly assessed using vital signs, urine output, blood gases, hematocrit, and protein levels

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A 5% albumin infusion may be used to maintain the serum albumin levels at a desired 2 g/dL. The following rates are effective. Burns of 30–50% of total BSA- 0.3 mL of 5% albumin/kg/% BSA burn is infused over a 24-hr period. Burns of 50–70% of total BSA- 0.4 mL/kg/% BSA burn is infused over 24 hr. Burns of 70–100% of total BSA- 0.5 mL/kg/% BSA burn is infused over 24 hr. Packed red cell infusion is recommended if the hematocrit falls to <24% (hemoglobin = 8 g/dL).

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Fresh frozen plasma is indicated if clinical and laboratory assessment shows a deficiency of clotting factors, a prothrombin level of >1.5 times control, or a partial thromboplastin time of >1.2 times control in children who are bleeding or are scheduled for an invasive procedure or a grafting procedure that could result in an estimated blood loss of ≥½ the blood volume.

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Sodium supplementation may be required if 0.5% silver nitrate solution is used as the topical antibacterial burn dressing.

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Sodium losses with silver nitrate therapy are regularly as high as 350 mmol sodium/m2 burn surface area

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Oral sodium chloride supplement of 4 g/m2 burn area/24 hr is usually well tolerated, divided into 4–6 equal doses to avoid osmotic diarrhea. The aim is to maintain serum sodium levels of >130 mEq/L and urinary sodium concentration of >30 mEq/L.

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Intravenous potassium supplementation is supplied to maintain a serum potassium level of >3 mEq/dL.

Methods of burn wound management 

Exposure: Wounds are left open to air ,crust forms on partial thickness wounds and eschar forms on full thickness burns.

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Open : Topical microbials agent is applied directly to the wound surface, and the wound is left uncovered.

 

TOPICAL AGENTS USED FOR BURNS

AGENT

EASE OF USE

Silver sulfadiazine

Closed dressings

Silvadene cream

Changed twice daily

Mafenide acetate

Residue must be washed off with each dressing change Closed dressings Changed twice daily Residue must be washed off with each dressing changed 0.5% silver nitrate solution

Closed bulky dressing soaked every 2 hr and changed once daily

Aquacel Ag+

Applied directly to 2nd-degree burn; occlusive dressing kept for 10 days

Accuzyme ointment Applied daily

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Modified : Antimicrobial is applied dirctly or impregnated into thin gauze or net secures the area.

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Occlusive : Antimicrobial is impregnated in gauze or applied directly to the wound ,multiple layers of bulky gauze are placed over the primary layer and secured with gauze or net.

Hydrotherapy : Done in tank, shower, or bed.  Debridement : Done in surgery. (Loose necrotic skin is removed)  Bath: Given with surgical detergent, disinfectant, or cleansing agent to reduce pathogenic organisms 

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SURVIVAL is related to prevention of wound contamination. 

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Source of infection is child’s own flora, predominantly from the skin, resp. tract, and GI tract. Prevention of cross contamination from other children is the priority for nurses!

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Staff should wear disposable caps, gowns, gloves, masks when wounds are exposed appropriate use of sterile vs. nonsterile techniques keep room warm careful handwashing any bathing areas disinfected before and after bathing

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Coverage is the primary goal for burn wounds. Since usually not enough unburned skin for immediate skin grafting, other temporary wound closure methods are used 

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Allograft or homograft (same species which is usually from cadavers) is used for wound closure-- temporary--3 days to 2 wks Porcine skin-heterograft or xenograft (different species)-temporary--3 days to 2 wks autograft or cultured epithelial autograft- (pt’s own skin and cell culture)- permanent

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Face is vascular and subject to increased edema- use open method if possible to decrease confusion and disorientation eye care-use saline rinses, artificial tears hands &arms-extended and elevated on pillows or in slings to minimize edema, may need splints to keep them in functional positions

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Ears- keep free of pressure. Ear burns-no pillows! Neck burns should not use pillows in order to decrease wound contraction. Perineum-must be kept clean & dry. Indwelling foley will help in this & also to provide hourly outputs. Lab tests prn to monitor electrolyte imbalance and ABGs Physical therapy stared immediately

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NG tube is inserted and connected to low intermittent suction for decompression.

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When bowel sounds return (48-72 hrs) after injury, start with clear liquids and progress up to a diet high in proteins and calories

Escharotomy 

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An escharotomy is performed by the consultant as a prophylactic measure to reduce the likelihood of further damage to the tissues that lie distally to the circumferential eschar. The tension within the tissues is relieved by cutting the skin with a scalpel Limb observations are necessary, as is elevation to monitor the effectiveness of the escharotomy

Complications 

Cardiovascular

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Respiratory

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Renal systems

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Arrythmias, hypovolemic shock which may lead to irreversible shock circulation to limbs can be impaired by circumferential burns and then the edema formation Causes: occluded blood supply thus causing ischemia, necrosis, and eventually gangrene. Escharotomies (incisions through eschar) done to restore circulation to compromised extremities.

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Vulnerable to 2 types of injury 

1. Upper airway burns that cause edema formation & obstruction of the airway.

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2. Inhalation injury can show up 24 hrs later-watch for resp. distress such as increased agitation or change in rate or character of resp. preexisting problem (ex. COPD) more prone to get resp. infection

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Pneumonia is common complication of major burns Is possible to overload with fluids--leading to pulmonary edema

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Most common renal complication of burns in the emergent phase is acute tubular necrosis. Because of hypovolemic state, blood flow decreases, causing renal ischemia. If it continues, acute renal failure may develop.

Medical Management: Rehabilitation Phase    

Surgical procedures Physical therapy Nutritional concerns Pressure garments

Pressure Dressings 

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Extensive burns may also result in the need for pressure garments to decrease the risk of extensive scarring . Pressure garments are not comfortable and they must be worn continuously for atleast 1 year or 2 years They are effective in reducing hypertrophic scarring resulting from significant burn injury. Uniform pressure applied to the scar decreases the blood supply and forces the collagen into a more normal alignment.

Prevention! 

Modify devices

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Education 

Safe-proof the home

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Increase awareness