Burns

78 Burns




Overview/pathophysiology


Burn injuries represent one of the most painful and devastating traumas a person can experience. Fire and burn-related injuries are a leading cause of death from injury in children ages 1-14. Most burns in children are relatively minor and do not require hospitalization, but each year an estimated 113,600 children 14 yr and younger are treated for fire/burn-related injuries, and 518 children die from unintentional fire/burn injuries (SAFE KIDS, Feb. 2009). Thermal burns (hair curlers/curling irons, radiators, kerosene heaters, wood burning stoves, ovens and ranges, irons, gasoline, and fireworks) are the leading cause of fire/burn injuries in children 14 yr and younger.


The causative agent for burns varies depending on the child’s developmental age. For instance, in children 4 yr and younger hospitalized with burn-related injuries, most are treated for scald burns caused by hot liquids, steam, or hot foods (e.g., coffee or soup), with the highest incidence in children younger than 2 yr. Ninety-five percent of these scald burns occur in residences and often relate to everyday activities such as bathing, cooking, and eating. Every day, 300 young children are taken to emergency departments as a result of scalds (Shriners, Scalds, Jan. 2010). Chemical burns, another commonly seen burn in children, occur from touching or ingesting a caustic agent such as a cleaning solution and are also seen more often in younger children. The most common type of burn-related injury in older children is flame burn. Each year in the United States approximately 2800 children 14 yr or younger are injured and 850 are killed in residential fires (USFA Kids, Jan. 2010). Children 10-14 yr of age are about four times more likely to get in trouble with gasoline, while children 13 yr and older are in the highest at-risk group for gasoline and other flammable substance burns. In 2007, about 2600 children 14 yr and younger were treated in emergency departments for injuries involving fireworks during firework season, mid June until mid July (SAFE KIDS, Fireworks, Jan. 2010). The least common type of burn injury is electrical, usually occurring in children 12 yr and younger and often associated with household electrical or extension cords.


Another source of burn injury is child abuse. About 10% of all burns in children are caused by child abuse. In the presence of unusual burns such as immersion (glove and stocking) burns, burns that spare flexor surfaces, contact burns from cigarettes or irons, and zebra burn lines from contact with a hot grate, child abuse should be suspected (London, 2007). The majority of child abuse burn victims are younger than 2 yr and are almost always younger than 10 yr.




Factors affecting severity of the burn and seriousness of the injury:



1. Percentage of total body surface area (TBSA) burned: Use modified rule of nine for children (i.e., percentage of TBSA of head varies with age of child; at 1 yr old, it is 19%; at 5-9 yr old, it is 13%).

2. Burn depth:


a. Superficial (first-degree) burn involves epidermis and heals within 5-7 days without scarring.

b. Partial-thickness (second-degree) injury involves epidermis and varying degrees of the dermis. It may be superficial (usually healing within 14 days with variable scarring) or deep dermal (usually heals within 30 days if no infection occurs and with extensive scarring).

c. Full-thickness (third-degree) burn involves the epidermis and dermis and extends into the subcutaneous tissue. Nerve endings, sweat glands, and hair follicles are destroyed. It cannot reepithelialize and requires surgical excision and wound grafting.

d. Fourth-degree is a full-thickness burn that involves underlying structures—muscles, fascia, and bones.

3. Wound location: Certain body areas carry a higher risk of complications and require specialized care (e.g., burns of the hand and feet and across joints can interfere with growth and development because of scar formation).

4. Age of the child: For example, the very thin skin of a premature infant would take longer to heal and be damaged more easily than that of a healthy 3 yr old.

5. Causative agent.

6. Presence of respiratory involvement.

7. General health of the child.

8. Presence of concomitant injuries.


Children most at risk:



• Children 4 yr and younger because of their natural curiosity and lack of awareness of danger are especially at risk for scald and contact burns and for sparkler injury.

• Children with disabilities related to developmental level or physical inability to get out of harm’s way are especially at risk for scald and contact burns.

• Boys are at greater risk than girls.

• Children in homes without smoke detectors are at greatest risk for fires and fire-related death and injury.

• Children 5-14 yr old are at highest risk for fireworks-related injuries.


Differences in effects of burn injury in children:



• There is a higher mortality rate in very young children who have been severely burned compared to older children and adults with comparable burns.

• Lower temperatures and shorter exposure time can cause more severe burns in children than in adults because of the child’s thinner skin.

• Larger body surface area as compared with adults puts severely burned children at increased risk for fluid and heat loss.

• The greater proportion of body fluid to mass in children increases risk of dehydration and cardiovascular problems because of less effective cardiovascular response to changing intravascular volume. The younger the child, the greater the percentage of total body weight is water and the greater his or her percentage of extracellular fluid (i.e., interstitial fluid surrounds the cell; intravascular fluid is within the blood vessels or plasma; and transcellular fluid such as spinal fluid and sweat).

• Because of smaller muscle mass and less body fat than adults, children are at increased risk for protein and calorie deficiency.

• The younger the child, the less mature the immune system and the greater the risk for infection.

• Extensive burns may result in delayed growth.

• Hypertrophic scarring is increased, and scar maturation is prolonged.


Health care setting


Emergency department, with possible hospitalization for significant burns; some burns are treated in primary care and others at home



Assessment


Varies significantly depending on burn severity and seriousness of the injury.




Superficial burn (e.g., mild sunburn):


Erythema, moderate discomfort/pain, blanches with pressure, good capillary refill.



Partial-thickness burn:



• Superficial: Fluid-filled blisters, skin red to ivory with moist surfaces, considerable pain, blanches with pressure and refills.

• Deep: May or may not have fluid-filled blisters; blisters are often flat and dehydrated, making skin tissue-paper like; color is mottled, waxy white, and with dry surface. Nerve endings are intact, so pain is severe on exposure to air or water.


Full-thickness burn:


Varies in color from red to tan, waxy white, brown, or black. It does not blanch with pressure. Edema is present. It has a dry, leathery appearance and lacks sensation because of destruction of nerve endings. However, because it is usually surrounded by superficial and partial-thickness burns that have intact nerve endings, adjacent areas likely will be painful.



Respiratory compromise:


Upper airway edema related to injury starts within a few minutes, and the airway may occlude in minutes to a few hours, although it may be delayed up to 24-48 hr.



Respiratory distress:


Abdominal breathing in a child older than 7 yr (children are primarily abdominal breathers until that age), head bobbing with respiratory effort, nasal flaring, coughing, stridor, wheezing.



Burn shock:


With severe burns (greater than 15%-20% TBSA), a type of hypovolemic shock may occur with increased heart rate (HR), increased respiratory rate (RR), low blood pressure (BP), hypothermia, pallor, cyanosis, decreased level of consciousness (LOC), and poor muscle tone.



Physical assessment:


In addition to signs mentioned above, the examiner may notice singed nasal hairs and nasopharynx edema. It is also important to assess for other injuries such as fractures and internal injuries.



Complications:



• Pulmonary complications are the leading cause of death in thermal trauma: Inhalation injury, aspiration of gastric contents, bacterial pneumonia, pulmonary edema/insufficiency, and emboli.

• Wound sepsis: Disorientation is one of the first signs of overwhelming sepsis.

• Gastrointestinal complications: Impaired gastric and large bowel motility is common with burns greater than 20% TBSA.

• Encephalopathy: Hallucinations, personality changes, delirium, seizures, and coma. Encephalopathy is rarely seen under 10 yr of age; full neurologic recovery usually occurs. Post-burn seizures occur in children but not in adults (Hockenberry, 2007).


Diagnostic tests


Note: Topical anesthetics are used with blood draws, if possible, to decrease pain and anxiety and to provide atraumatic care.




Arterial blood gas level:


To determine respiratory status; variations from normal may signal respiratory compromise.



Chemistries:



• Fluid and electrolytes: Deficits of fluid and sodium occur with burn shock.

• Blood urea nitrogen and creatinine: Elevations may indicate renal failure.

• Glucose: May be elevated in young infants. Stress may cause either hypoglycemia or pseudodiabetes, resulting in elevated glucose levels.




Nursing diagnosis:


Deficient fluid volume

related to fluid shift from intravascular to interstitial compartment, increased metabolic demands, and decreased intake


Desired Outcomes: Within 4 hr following intervention/treatment, child has adequate fluid volume as evidenced by normal LOC for child, soft anterior fontanel (in child younger than 2 yr), moist oral mucous membranes, good/elastic abdominal skin turgor (on unaffected areas), and normal urine output (UO). For example, infant UO more than 2-3 mL/kg/hr, toddler and preschooler UO 2 mL/kg/hr, school-age child UO 1-2 mL/kg/hr, and adolescent UO 0.5-1 mL/kg/hr.




























ASSESSMENT/INTERVENTIONS RATIONALES
Assess hydration status q4h: LOC, anterior fontanel (in child younger than 2 yr), oral mucous membrane, abdominal skin turgor, and urine output. Note: Edema may occur around the burn or from fluid shifts. Child may be receiving maintenance fluids but still be dehydrated due to significantly increased insensible water losses, especially in a child with burns. Frequent assessment leads to early detection of problems and quicker treatment. Signs of impaired hydration include decreasing LOC, sunken fontanel, dry and sticky oral mucous membranes, tenting of abdominal skin, and decreased UO.
Assess intake and output (I&O) q2h. Weigh all diapers, 1 mL = 1 g. Ensure minimum urine output of 1 mL/kg/hr is met This assessment determines whether the child is receiving appropriate intake and has adequate output.
Assess vital signs (VS), capillary refill, and LOC q4h for changes related to hypovolemia. Hypovolemia may be present because of reduced circulating blood volume that occurs with plasma loss in burns. Tachycardia, changes in tissue perfusion (e.g., capillary refill more than 2 sec), and alteration in LOC are early signs of hypovolemic shock. BP will be normal initially because increased systemic vascular resistance helps to maintain it. However, perfusion with a normal BP may be inadequate to meet the body’s demands. Therefore, decreased BP can be a late sign of hypovolemia in children.
Assess daily weights, using same scale at same time of day and with same amount of clothing (no clothes, including diaper in infants). Short-term weight changes are the most reliable measurement of fluid loss or gain. Excessive weight gain could indicate fluid retention; weight loss could signal dehydration or excessive fluid loss. Either would interfere with wound healing. Consistency in weighing increases accuracy.
Administer intravenous (IV) fluids as prescribed. Fluid resuscitation is required in children with burns greater than 10% TBSA. Fluids help maintain general circulation to vital organs and capillary circulation to viable skin.
Once stabilized, ensure that child receives at least minimum maintenance fluids based on his or her weight. The smaller the child, the greater the percentage of body weight is water and the larger the percentage of extracellular fluid. Because of excess fluid loss from the burn injury and increased metabolic demands related to child’s age and increased catecholamine release caused by burn stress, child probably will need more than maintenance fluids. First, use this formula to determine maintenance fluids:
Up to 10 kg: 100 mL/kg/24 hr = ______________
10-20 kg: 50 mL/kg/24hr = ______________
More than 20 kg: 20 mL/kg/24hr = ____________
= maintenance fluid requirement
For example, child weighs 33 kg:

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Maintenance fluid requirement for child weighing 33 kg is 1760 mL/24 hr. Remember that child probably will need more than maintenance fluids.
Alert health care provider promptly to significant findings or changes. This helps ensure timely treatment.




Nursing diagnosis:


Acute pain

related to thermal injuries and medical-surgical interventions


Desired Outcome: Within 30 min to 1 hr after treatment/intervention, child’s pain level is decreased (2 or less on FACES 0-5 scale or 4 or less on FLACC [face, legs, activity, cry, consolability] or numeric 0-10 scale) or at a level acceptable to child.




























INTERVENTIONS RATIONALES
Assess child’s developmental level and establish appropriate pain scale (e.g., FLACC, Wong-Baker FACES, or numeric scales). A pain scale increases ability to accurately assess pain and degree of relief obtained.
Assess level of pain q2-4h, as well as before and after pain medication administration (e.g., 1 hr after by mouth [PO] medications, 10-20 min after IV medications). These assessments detect early changes in pain level and assess effectiveness of pain medications.
Provide pain medications/nonpharmacologic pain relief measures around the clock on a regular basis, not prn. Scheduled rather than prn pain relief provides better and more reliable pain control. Prolonged stimulation of pain receptors results in increased sensitivity to painful stimuli and will increase the amount of drug needed to relieve pain. Pain relief measures such as distraction; relaxation; repositioning; guided imagery; cutaneous stimulation such as massage, heat, or cold; and positive self-talk increase effectiveness of medication.
Explain how patient-controlled analgesia (PCA) works and that child cannot give self too much medication. Encourage child/parent to use PCA when needed if it is available. Most experts believe that when a child is capable of pushing the button on the pump, usually by 5-6 yr of age, he or she can self-administer pain medication. Some facilities allow PCA by proxy—the parent or nurse can administer the medication if the child is too ill or cannot understand the concept of pushing the button to relieve the pain.
Reassure parent that addiction rarely occurs when medication is used to relieve pain. Fear of addiction may decrease use of pain medication.
Premedicate child before painful procedures. Use topical anesthetic to decrease trauma of blood draws/IV insertion, if possible (atraumatic care). Pain medications given before painful procedures will help control pain. Time frame before procedure depends on route (e.g., 10-20 min IV and 1 hr PO).
Explain all procedures at developmental level appropriate for child. Anxiety increases pain; knowing what to expect may decrease anxiety.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Burns

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