BYBY

DEPARTMENT OF PEDIATRIC DEPARTMENT OF PEDIATRIC

NURSINGNURSING

Venue:Venue: KKCTH, Chennai. KKCTH, Chennai. 11.11.200911.11.2009

APOLLO COLLEGE OF NURSING APOLLO COLLEGE OF NURSING CHENNAI- 95CHENNAI- 95

M.Sc Nursing., 2nd yrM.Sc Nursing., 2nd yr2008-2010 batch2008-2010 batch

CNE PROGRAMMECNE PROGRAMME

NURSING CARE OF CHILD NURSING CARE OF CHILD WITH BURNSWITH BURNS

Guide:Guide:

Dr. Latha Venkatesan, Phd (N) Dr. Latha Venkatesan, Phd (N)

Prof .Helen.Perdita, Phd (N),Prof .Helen.Perdita, Phd (N),

Ms. Kala.V, Lecturer, MSc (N),Ms. Kala.V, Lecturer, MSc (N),

Ms. Cecilia Mary, Lecturer, Msc (N)Ms. Cecilia Mary, Lecturer, Msc (N)

By: By: Ms.Ms. Bansara Cathreen,Bansara Cathreen,

Ms. Karpagam.S, Ms. Karpagam.S,

Ms. Jayaselvi.S, Ms. Jayaselvi.S,

Ms. Mani megali.G,Ms. Mani megali.G,

Ms.Viji.RMs.Viji.R

Msc Nursing Pediatrics 2Msc Nursing Pediatrics 2ndnd yrs yrs

2008 – 2010 batch2008 – 2010 batch

Definition of BurnsDefinition of Burns

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

Layers of SkinLayers of Skin

Functions of SkinFunctions of Skin

Skin is the largest body organ, protects underlying tissuesSkin is the largest body organ, protects underlying tissues

Helps to maintain temperatureHelps to maintain temperature

Helps to maintain fluid and electrolyte balance.Helps to maintain fluid and electrolyte balance.

There are two layers in skin calledThere are two layers in skin called

EpidermisEpidermis DermisDermis

Pediatric BurnsPediatric Burns

Thin skinThin skin Increased severity of burnsIncreased severity of burns

Larger body surface areaLarger body surface area Rapid fluid lossRapid fluid loss Increased heat lossIncreased heat loss HypothermiaHypothermia

Immature immunologic responseImmature immunologic response SepsisSepsis

Possibility of child abusePossibility of child abuse

Causes of Burn InjuriesCauses of Burn Injuries

ThermalThermal ScaldScald FlameFlame

RadiationRadiation ChemicalChemical ElectricalElectrical

Household Burn RisksHousehold Burn Risks

KitchenKitchen Living RoomLiving Room

BathroomBathroom OutdoorsOutdoors

Developmental TrendsDevelopmental Trends

Infants and ToddlersInfants and Toddlers AdolescentsAdolescents

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

20% are household scalds20% are household scalds

95% occur indoors95% occur indoors 60% occur outdoors60% occur outdoors

Most play is indoorsMost play is indoors Increased experimentationIncreased experimentation

Increased responsibilities for Increased responsibilities for outdoor choresoutdoor chores

Degrees of BurnsDegrees of Burns

Degrees of Burn InjuriesDegrees of Burn InjuriesBased on depth of burn injuriesBased on depth of burn injuries

First Degree BurnsFirst Degree Burns: : First degree burns produce redness, swelling, First degree burns produce redness, swelling,

and minor pain. The skin is dry and without and minor pain. The skin is dry and without blisters. blisters.

Healing time is about three to six days. The Healing time is about three to six days. The superficial skin layer could peel off as early as superficial skin layer could peel off as early as one to two daysone to two days

First degree BurnsFirst degree Burns

Second Degree BurnsSecond Degree Burns

Damage to dermis Partial thickness.Damage to dermis Partial thickness.

These burns produce blisters, severe pain, These burns produce blisters, severe pain, and redness. and redness.

The blisters can break open. Heals in ~ 1-3 The blisters can break open. Heals in ~ 1-3 weeks with no graftingweeks with no grafting

Second Degree BurnsSecond Degree Burns

Third Degree Burns Third Degree Burns : :

Damage to multiple layers including Damage to multiple layers including subcutaneous tissuesubcutaneous tissue

Full thicknessFull thickness

Heals in ~3-5 weeks; requires graftingHeals in ~3-5 weeks; requires grafting

Third Degree BurnsThird Degree Burns

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

multiples of 9.multiples of 9.

This division, called the This division, called the rule of ninesrule of nines, is , is useful in estimating the percentage of body useful in estimating the percentage of body

surface damage an individual has sustained in surface damage an individual has sustained in burns.burns.

Emergent (resuscitative)Emergent (resuscitative)

AcuteAcute

RehabilitativeRehabilitative

Remove from area! Stop the burn!Remove from area! Stop the burn! If thermal burn is large--FOCUS on the If thermal burn is large--FOCUS on the

ABC’sABC’s A=airway-check for patency, soot around nares, or A=airway-check for patency, soot around nares, or

signed nasal hairsigned nasal hair B=breathing- check for adequacy of ventilationB=breathing- check for adequacy of ventilation C=circulation-check for presence and regularity of C=circulation-check for presence and regularity of

pulsespulses

Airway/breathing Airway/breathing 

IntubationIntubation: Consider for >20% to 25% BSA : Consider for >20% to 25% BSA burned, or any respiratory distress.burned, or any respiratory distress.

Inhalation injuryInhalation injury: Assume carbon monoxide : Assume carbon monoxide poisoning with severe and/or closed-space burns. poisoning with severe and/or closed-space burns.

Administer humidified 100% O2 until Administer humidified 100% O2 until carboxyhemoglobin level 10%(consider hyperbaric carboxyhemoglobin level 10%(consider hyperbaric O2 if pH < 7.4 and COHb elevated). O2 if pH < 7.4 and COHb elevated). 

EMERGENCY MANAGEMENTEMERGENCY MANAGEMENT

  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.

AnalgesiaAnalgesia IV narcotic therapy often necessary for pain IV narcotic therapy often necessary for pain control.  control.  

GIGIPlace nasogastric tube for decompression; begin Place nasogastric tube for decompression; begin prophylaxis for Curling's stress ulcers with prophylaxis for Curling's stress ulcers with histamine-2 receptor blockers and/or antacids.  histamine-2 receptor blockers and/or antacids.  

GUGUUse Foley catheter to monitor urine output, Use Foley catheter to monitor urine output, decompress bladder, and prevent possible decompress bladder, and prevent possible soiling of wounds.soiling of wounds.

EyeEye

Ophthalmologic evaluation as necessary. Ophthalmologic evaluation as necessary. Use topical ophthalmic antibiotics if Use topical ophthalmic antibiotics if abrasions are present.abrasions are present.

Special considerationsSpecial considerations

      Tetanus immunoprophylaxis  Tetanus immunoprophylaxis  

    Temperature managementTemperature management

Cooling decreases the severity of the burn Cooling decreases the severity of the burn if administered within 30 min of injury; it if administered within 30 min of injury; it also helps to relieve pain. also helps to relieve pain.

FLUID RESUSCITATIONFLUID RESUSCITATION. .

Parkland formula (4 mL Ringer lactate/kg/% SA burned). Parkland formula (4 mL Ringer lactate/kg/% SA burned). Half of the fluid is given over the 1st 8 hr, calculated from 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 the time of onset of injury. 1st day's fluid requirement is infused as Ringer lactate solution. The remaining ½ is given infused as Ringer lactate solution. The remaining ½ is given at an even rate over the next 16 hr. at an even rate over the next 16 hr.

The rate of infusion is adjusted according to the patient's The rate of infusion is adjusted according to the patient's response to therapy. Pulse and blood pressure should return response to therapy. Pulse and blood pressure should return to normal.to normal.

An adequate urine output (>1 mL/kg/hr in children; 0.5–10 An adequate urine output (>1 mL/kg/hr in children; 0.5–10 mL/kg/hr in adolescents) should be accomplished by mL/kg/hr in adolescents) should be accomplished by varying the intravenous infusion rate. varying the intravenous infusion rate.

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

Patients with burns of 30% of BSA require a large Patients with burns of 30% of BSA require a large venous access (central venous line) to deliver the venous access (central venous line) to deliver the fluid required over the critical 1st 24 hr.fluid required over the critical 1st 24 hr.

Patients with burns of >60% of BSA may require a Patients with burns of >60% of BSA may require a multilumen central venous catheter; these patients multilumen central venous catheter; these patients are best cared for in a specialized burn unit. are best cared for in a specialized burn unit.

During the 2nd 24 hr after the burn, patients begin During the 2nd 24 hr after the burn, patients begin to reabsorb edema fluid and to diurese.to reabsorb edema fluid and to diurese.

Colloid is usually instituted 8–24 hr after the burn Colloid is usually instituted 8–24 hr after the burn injury. One preference is to use colloid replacement injury. One preference is to use colloid replacement concurrently if the burn is >85% of total BSA.concurrently if the burn is >85% of total BSA.

The adequacy of resuscitation should be constantly The adequacy of resuscitation should be constantly assessed using vital signs, urine output, blood gases, assessed using vital signs, urine output, blood gases, hematocrit, and protein levels hematocrit, and protein levels

A 5% albumin infusion may be used to maintain the A 5% albumin infusion may be used to maintain the serum albumin levels at a desired 2 g/dL. The serum albumin levels at a desired 2 g/dL. The following rates are effective.following rates are effective.

Burns of 30–50% of total BSA- 0.3 mL of 5% Burns of 30–50% of total BSA- 0.3 mL of 5% albumin/kg/% BSA burn is infused over a 24-hr albumin/kg/% BSA burn is infused over a 24-hr period.period.

Burns of 50–70% of total BSA- 0.4 mL/kg/% BSA Burns of 50–70% of total BSA- 0.4 mL/kg/% BSA burn is infused over 24 hr.burn is infused over 24 hr.

Burns of 70–100% of total BSA- 0.5 mL/kg/% BSA Burns of 70–100% of total BSA- 0.5 mL/kg/% BSA burn is infused over 24 hr. burn is infused over 24 hr.

Packed red cell infusion is recommended if the Packed red cell infusion is recommended if the hematocrit falls to <24% (hemoglobin = 8 g/dL). hematocrit falls to <24% (hemoglobin = 8 g/dL).

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

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

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

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

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

Methods of burn Methods of burn wound managementwound management

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

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

 TOPICAL AGENTS USED FOR BURNS

AGENT EASE OF USE

Silver sulfadiazine Closed dressings

Silvadene cream Changed twice daily

Residue must be washed off with each dressing change

Mafenide acetate 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

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

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

HydrotherapyHydrotherapy : Done in tank, : Done in tank, shower, or bed.shower, or bed.

DebridementDebridement : Done in surgery. : Done in surgery. (Loose necrotic skin is removed)(Loose necrotic skin is removed)

Bath: Bath: Given with surgical detergent, Given with surgical detergent, disinfectant, or cleansing agent to reduce disinfectant, or cleansing agent to reduce pathogenic organismspathogenic organisms

SURVIVAL SURVIVAL is related to prevention of wound is related to prevention of wound contamination.contamination.

Source of infection is child’s own flora, Source of infection is child’s own flora, predominantly from the skin, resp. tract, and GI predominantly from the skin, resp. tract, and GI tract. tract.

Prevention of cross contamination from other Prevention of cross contamination from other children is the priority for nurses!children is the priority for nurses!

Staff should wear disposable caps, gowns, Staff should wear disposable caps, gowns, gloves, masks when wounds are exposedgloves, masks when wounds are exposed

appropriate use of sterile vs. nonsterile appropriate use of sterile vs. nonsterile techniquestechniques

keep room warmkeep room warm careful handwashingcareful handwashing any bathing areas disinfected before and after any bathing areas disinfected before and after

bathingbathing

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

Allograft or homograft (same species which is usually from Allograft or homograft (same species which is usually from cadavers) is used for wound closure-- temporary--3 days to cadavers) is used for wound closure-- temporary--3 days to 2 wks2 wks

Porcine skin-heterograft or xenograft (different species)--Porcine skin-heterograft or xenograft (different species)--temporary--3 days to 2 wkstemporary--3 days to 2 wks

autograft or cultured epithelial autograft- (pt’s own skin autograft or cultured epithelial autograft- (pt’s own skin and cell culture)- permanentand cell culture)- permanent

Face is vascular and subject to increased Face is vascular and subject to increased edema- use open method if possible to edema- use open method if possible to decrease confusion and disorientationdecrease confusion and disorientation

eye care-use saline rinses, artificial tearseye care-use saline rinses, artificial tears hands &arms-extended and elevated on hands &arms-extended and elevated on

pillows or in slings to minimize edema, may pillows or in slings to minimize edema, may need splints to keep them in functional need splints to keep them in functional positionspositions

Ears- keep free of pressure. Ear burns-no Ears- keep free of pressure. Ear burns-no pillows! Neck burns should not use pillows in pillows! Neck burns should not use pillows in order to decrease wound contraction.order to decrease wound contraction.

Perineum-must be kept clean & dry. Perineum-must be kept clean & dry. Indwelling foley will help in this & also to Indwelling foley will help in this & also to provide hourly outputs.provide hourly outputs.

Lab tests prn to monitor electrolyte imbalance Lab tests prn to monitor electrolyte imbalance and ABGsand ABGs

Physical therapy stared immediatelyPhysical therapy stared immediately

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

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

EscharotomyEscharotomy

An escharotomy is performed by the An escharotomy is performed by the consultant as a prophylactic measure to reduce consultant as a prophylactic measure to reduce the likelihood of further damage to the tissues the likelihood of further damage to the tissues that lie distally to the circumferential eschar. that lie distally to the circumferential eschar.

The tension within the tissues is relieved by The tension within the tissues is relieved by cutting the skin with a scalpel cutting the skin with a scalpel

Limb observations are necessary, as is Limb observations are necessary, as is elevation to monitor the effectiveness of the elevation to monitor the effectiveness of the escharotomy escharotomy

ComplicationsComplications

CardiovascularCardiovascular

RespiratoryRespiratory

Renal systemsRenal systems

Arrythmias, hypovolemic shock which may lead to Arrythmias, hypovolemic shock which may lead to irreversible shockirreversible shock

circulation to limbs can be impaired by circulation to limbs can be impaired by circumferential burns and then the edema formationcircumferential burns and then the edema formation

Causes:Causes: occluded blood supply thus causing occluded blood supply thus causing ischemia, necrosis, and eventually gangrene.ischemia, necrosis, and eventually gangrene.

Escharotomies (incisions through eschar) done to Escharotomies (incisions through eschar) done to restore circulation to compromised extremities.restore circulation to compromised extremities.

Vulnerable to 2 types of injuryVulnerable to 2 types of injury 1. 1. Upper airway burnsUpper airway burns that cause edema formation & that cause edema formation &

obstruction of the airway.obstruction of the airway.

2. 2. Inhalation injuryInhalation injury can show up 24 hrs later-watch for can show up 24 hrs later-watch for resp. distress such as increased agitation or change in rate resp. distress such as increased agitation or change in rate or character of resp.or character of resp.

preexisting problem (ex. COPD) more prone to get resp. preexisting problem (ex. COPD) more prone to get resp. infectioninfection

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

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

Medical Management:Medical Management:Rehabilitation PhaseRehabilitation Phase

Surgical procedures Surgical procedures Physical therapyPhysical therapy Nutritional concernsNutritional concerns Pressure garmentsPressure garments

Pressure DressingsPressure Dressings

Extensive burns may also result in the need for Extensive burns may also result in the need for pressure garments to decrease the risk of extensive pressure garments to decrease the risk of extensive scarring . scarring .

Pressure garments are not comfortable and they must Pressure garments are not comfortable and they must be worn continuously for atleast 1 year or 2 years be worn continuously for atleast 1 year or 2 years

They are effective in reducing hypertrophic scarring They are effective in reducing hypertrophic scarring resulting from significant burn injury.resulting from significant burn injury.

Uniform pressure applied to the scar decreases the Uniform pressure applied to the scar decreases the blood supply and forces the collagen into a more blood supply and forces the collagen into a more normal alignment.normal alignment.

Prevention!Prevention!

Modify devicesModify devices

EducationEducation

Safe-proof the homeSafe-proof the home

Increase awarenessIncrease awareness