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14 Module 21 Tissue Integrity
Lifespan Considerations Assessing a
Child With a Burn Injury
Interviewing a parent about a childs burn injury can be
difficult. If the injury was preventable, the parent may be
emotionally stressed by feelings of guilt. The nurse must
therefore use caution to avoid sounding accusatory when
questioning the parent about the injury.
The nurse should also be alert to signs of child abuse
when the history does not match the burn injury (e.g., glove
and stocking burns; burns that spare flexor surfaces; con-
tact burns from objects such as curling irons, cigarettes, and
irons; and zebra burn lines from contact with a hot grate;
Figure 2114 ). Photographs may be taken to document
these burn injuries. Child neglect may be a factor in the
burn of a child who was not adequately supervised.
Figure 2114 Burn injuries associated with child abuse.
Source: Medical-on-Line/Alamy.
client who has sustained life-threatening injuries, the three pri-
orities of care are ensuring proper airway management, main-
taining effective breathing, and promoting adequate
cardiovascular circulation. The plan of care changes as the cli-
ent moves from stage to stage, and it requires frequent updat-
ing in response to the clients changing condition. For the
stable client who has sustained a burn, goals of client care often
include the following:
The client will maintain a clear, unobstructed airway.
The client will maintain ABG values and pulse oximetry
readings that are within normal limits.
The client will demonstrate no cardiac dysrhythmias.
The client will receive adequate nutrition to meet body needs.
The client will maintain adequate fluid volume, as evidenced
by hourly urine output that meets minimum acceptable
guidelines.
The clients blood pressure and heart rate will range within
acceptable limits.
The client will demonstrate adequate wound healing.
The client will maintain adequate pain control, reporting
pain as a 3 or less on a scale of 010.
The client will not develop a healthcare-associated infection.
The client will maintain full ROM following recovery.
Implementation
Nursing interventions related to ensuring airway patency, effec-
tive ventilation, and adequate circulation, were described earlier
in this exemplar. Additional elements included in the care of the
client who sustains a burn injury include fluid and nutritional
considerations, pain management, wound care, and infection
prevention. Continuous assessment is necessary until well into
the healing process and should include assessment of client and
family feelings regarding the injury and its long-term effects.
Promote Fluid Volume Balance
Fluid resuscitation rates are adjusted periodically throughout
the emergent stage of care. The nurse should be particularly
aware of several situations that may warrant administration of
fluids at rates in excess of the calculations needed to maintain
adequate urine output. These situations include initial underes-
timation of burn size, sequestration of fluid into lung tissue in
an inhalation injury, electrical injury full-thickness burns, and
inordinately delayed starts of fluid resuscitation. To most effec-
tively promote fluid volume balance, the nurse should also do
the following:
Monitor intake and output hourly. Report decreased or inad-
equate urine output.
Regularly assess narrowed pulse pressure, which is an earlier
and more accurate indicator of shock than blood pressure or
heart rate.
Monitor hemodynamic status; inadequate fluid resuscitation
is manifested by a drop in central venous pressure (CVP)
and PAWP.
Follow prescribed protocols for IV fluid resuscitation. Ther-
apy for burn shock is aimed at supporting the client through
the period of hypovolemic instability.
Weigh the client daily. Body weight is used to calculate fluid
requirements.
Test all stools and emesis for the presence of blood. Occult
blood in emesis or stool indicates gastrointestinal bleeding.
Maintain a warm environment. Hypothermia leads to shiv-
ering and further loss of body fluid through increased energy
expenditure and catabolism.
Monitor for fluid volume overload. Older clients and clients
with underlying cardiac disease may demonstrate symptoms
of heart failure during the fluid resuscitation stage.
SAFETY ALERT
Major burn clients receive 10 or more liters of fluid and gain
weight due to fluid shifts. When their capillary membrane
integrity resumes, these clients have a high CVP and urine
output that necessitates monitoring of urine electrolytes.
Provide Effective Pain Management
All partial-thickness burns, along with extensive superficial
burns, can cause excruciating pain, as can wound care and
physical therapy. Increased levels of anxiety about treatments
and outcomes may increase a clients perception of pain. To help
manage this pain, the nurse should take the following actions:
Measure the clients level of pain using a consistent measure-
ment tool. The term pain tolerance refers to the duration and