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:
Dr. Latha Venkatesan, Phd (N)
Prof .Helen.Perdita, Phd (N),
Ms. Kala.V, Lecturer, MSc (N),
Ms. Cecilia Mary, Lecturer, Msc (N)
By: 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

 Helps to maintain temperature

 Helps to maintain fluid and electrolyte balance.

 There are two layers in skin called

 Epidermis
 Dermis
 Pediatric Burns
 Thin skin
 Increased severity of burns
 Larger body surface area
 Rapid fluid loss
 Increased heat loss

 Hypothermia

 Immature immunologic response

 Sepsis
 Possibility of child abuse
 Causes of Burn Injuries
 Thermal
 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., 20% are household scalds

bathing, spills)

95% occur indoors 60% occur outdoors

Most play is indoors Increased experimentation

Increased responsibilities for
outdoor chores
Degrees of Burns
 Degrees of Burn Injuries
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
  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.
 Emergent (resuscitative)

 Acute

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

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

 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.
 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
 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).
 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.

 Sodium supplementation may be required if 0.5%

silver nitrate solution is used as the topical
antibacterial burn dressing.
 Sodium losses with silver nitrate therapy are
regularly as high as 350 mmol sodium/m2 burn
surface area

 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.

 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.

 Open : Topical microbials agent is applied

directly to the wound surface, and the wound
is left uncovered.
   TOPICAL AGENTS USED FOR BURNS
EASE OF USE
AGENT
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 Closed bulky dressing soaked every 2 hr and changed once
solution daily
Aquacel Ag+ Applied directly to 2nd-degree burn; occlusive dressing kept
for 10 days
Accuzyme ointment Applied daily
 Modified : Antimicrobial is applied dirctly or
impregnated into thin gauze or net secures the
area.

 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
 SURVIVAL is related to prevention of wound
contamination.

 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!
 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
 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

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

 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
 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

 Respiratory

 Renal systems
 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.
 Vulnerable to 2 types of injury
 1. Upper airway burns that cause edema formation &
obstruction of the airway.

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

 Education

 Safe-proof the home

 Increase awareness