Pediatric Integumentary Disorders BURNS MANAGEMENT OF BURNS IN CHILDREN Burns are a frequent form of childhood injury.

They may be caused by heat, electrical energy, or chemicals. The effects of burns are not limited to the burn area. Very serious burns may include:

Second-degree burn of 12% to 15% or more of body surface area. Burns of face, hands, feet, perineum, or joint surfaces. Electrical burns. Burns in the presence of other injuries. Any burn that cannot be cared for adequately at home.

Epidemiology

Burns are the second leading cause of accidental deaths in childhood, with the highest incidence of burns occurring in children younger than age 5. Children at high risk are of lower socioeconomic status and of single parents. However, any child, supervised or unsupervised, is at risk for a burn injury. Scalds are the leading cause of injury in children, followed by flame burns. Burns from a hot liquid are most common in children younger than age 3. o Child left unsupervised in tub turns on hot water tap. o Tap water temperature above 120 F (48.9 C) (at 130 F [54.4 C] it takes only 30 seconds to produce a full-thickness injury in

adult skinless time in the very young). o Child placed in tub of hot water that has not been tested. o Spilling of hot liquid, such as coffee or tea on child. Spilling occurs especially when pot handles stick out on top of stove, when hot liquids and foods are removed from microwave oven, and when child grabs or pulls items from surfaces. o Ingestion and aspiration of hot foods and liquids from microwave oven as well as scald burns to skin and palate from hot formula. Burns from open flames: o House fires. o Child climbing on stove, resulting in ignited clothing. o Children playing with lighters, especially 3to 10-year-olds. o Playing or working with gasoline. o Automobile accidents with subsequent fire. o Juvenile fire setters. Electrical burns are most common in toddlers and adolescents and may be caused by: o Child playing with electrical outlets or appliances. o Child playing with extension cords; children commonly bite through the cord. o Child playing on railroad tracks; climbing trees and

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touching high-tension wires; lightning. causes: Caustic acid or alkali burns of the mouth and esophagus Chemical burns of the skinchild playing with gasoline that comes in contact with skin (usually gasoline ignites) Burns inflicted on the child as a result of neglect or abuse (an estimated 30% of all children with burns brought to a hospital; immersion and contact burns most common) Smoke inhalation and inhalation from products of combustion of synthetics, such as plastics and rayon; may yield cyanide, formaldehyde Radiation burnssunburn most common, may be secondary to cancer radiation therapy Contact burns from touching hot surfaces, such as radiators, wood-burning stoves, fireplaces, or open ovens Fireworks burns, typically as a result of misuse and lack of adult supervision; may be combined with explosive hand injuries Friction burns such as those seen with exercise treadmills in the home

With combined injury, management of trauma takes precedence over the burn. Pathophysiology and Etiology See Burns in Adults, page 1121. Clinical Manifestations Characteristics of Burn Wounds

See page 1126 for characteristics of first-, second-, and third-degree burns. Electrical burns: o Especially of the mouth in child younger than age 2; may chew or suck on live wire. o Are progressive and may take up to 3 weeks to fully manifest the extent of injury

Symptoms of Shock Symptoms of shock appear soon after the burn.

Rapid pulse, low blood pressure (BP) Subnormal temperature Pallor, cyanosis, prostration Failure to recognize parents or other familiar people Poor muscle tone; may become flaccid

Symptoms of Toxemia Symptoms may develop 1 to 2 days after burn.

Prostration, fever, rapid pulse Glucosuria, decreased urine output Vomiting, edema These symptoms may progress to coma or death

NURSING ALERT

NURSING ALERT

The fever of toxemia is not to be confused with expected burn fever, which may be as high as 103 F (39.4 C) because of the hypermetabolic state. Upper Respiratory Tract Injury Causes inflammation or edema of the glottis, vocal cords, and upper trachea and is characterized by symptoms of upper airway obstruction.

Dyspnea, tachypnea, hoarseness Stridor, substernal and intercostal retractions, nasal flaring Restlessness, drooling, cough, increasing hoarseness

NURSING ALERT Increasing hoarseness, drooling, and stridor are leading indicators for immediate intubation. Smoke Inhalation Smoke inhalation may cause no initial symptoms other than mild bronchial obstruction during the initial phase after the burn. Within 6 to 48 hours, the child may develop sudden onset of the following conditions:

10. It is not recommended for hospital use; the Lund and Browder chart is recommended. Total body surface area (TBSA) is based on age, thus compensating for changes in percentages resulting from growth (see Figure 55-1). o During infancy and early childhood, the relative surface area of different parts of the body varies with age. o The younger the child, the greater the proportion of the surface area is constituted by the head and the lesser the proportion of the surface area is constituted by the legs. A rough estimate can be obtained by using the child's hand (palm, with fingers extended), which is equal to 1%.

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Major

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10% to 20% TBSA; second-degree burn 2% to 5% TBSA; thirddegree burn not involving eyes, ears, face, genitals, hands, or feet or circumferential burns burn: 20% TBSA; seconddegree burn All third-degree burns greater than 10%; depending on age of child, 5% is sometimes used All burns involving hands, face, eyes, ears, feet, and/or genitals All electrical burns Complicated burn injuries involving fracture or other major trauma All poor-risk patients (ie, head injury, cancer, lung disease, diabetes)

the fluid needed for resuscitation for burns greater than 15% TBSA (see page 1126). In children, it is recommended that maintenance fluid requirements also be given with the Parkland formula. It is administered in the same manner. o One half of the requirements are given during the first 8 hours. o The remainder is given over the next 24 hours. o Lactated Ringer's solution may be used. o In children, the second day's crystalloid consists of the maintenance requirements, and 5% D/0.45 or 0.25 saline is used instead of dextrose 5% in water. Colloid is per Parkland formula.

Categorization of Severity of Burn

Bronchiolitis. Pulmonary edema (acute respiratory distress syndrome)of noncardiac origin. Severe airway obstruction. Delayed damage: up to 7 days after the burn injury.

Diagnostic Evaluation Calculation of the Burn Area

Total area injured, depth of injury, location of injury Age of child Condition of patient (ie, level of consciousness). Confusion is the hallmark of an anoxic brain. Medical history (ie, chronic disease) Additional injuries

Management Fluid Resuscitation: I.V. Fluid Replacement Note: Controversy exists regarding fluid resuscitation solution and amount.

Burn Treatment

Rule of Nines (used in assessment of extent of burns in adults) has not proved to be exact when applied to young children; it may be acceptable to use in child older than age

Schematic Classification of Burn Severity

Minor burn10% TBSA; firstand second-degree burn Moderate burn:

Fluid loss from transcapillary leakage is greatest during the first 12 hours after injury and diminishes to almost zero 12 to 24 hours after injury. Fluid loss after 48 hours is due to vaporization of water from the wound. Replacement usually consists of lactated Ringer's solution, an isotonic electrolyte solution. The Parkland formula is commonly used to determine

Burns may be treated by the open or closed method or by a combination technique. Children appear to be more mobile when a burn injury is covered, because they experience less pain. Hydrotherapy is the treatment of choice for cleaning wounds. Isotonic saline rather than water may be needed for large wounds and small children. The use of a shower to facilitate the loosening and removal of sloughing tissue, eschar, exudate, and topical medications is gaining popularity. The

showerwater about 90 F Anemia and malnutrition; may (32.2 C)flows over the resolve when the burn area is child; debridement is then covered performed. Fecal impaction See page 1127 for wound Depression secondary to cleaning and debridement, hospitalization and changing hydrotherapy, topical body image antimicrobials, surgical management, and burn wound Long-term grafting. It is important to use bacitracin ophthalmic ointment on a child's face because a Growth and development child may touch or rub his face delays secondary to and get the ointment into his malnutrition eyes. Topical bacitracin will Scarring, disfigurement, and cause conjunctivitis if it gets contractures into the eyes. Psychological trauma Nursing Assessment

wounds, and signs of infection (burn wound, pulmonary, urinary). Assess level of comfort and emotional status; provide reassurance while performing assessment and determining priorities.

Nursing Diagnoses

Complications Vary according to severity of burn injury; commonly occur, especially with severe burn injury Acute

Infection; burn wound sepsis, pneumonia, urinary tract infection (UTI), phlebitis, toxic shock syndrome Curling's (stress) ulcer, GI hemorrhage; rarely seen now that histamine-2 (H2) blockers are commonly used prophylactically, especially in burns greater than 20% TBSA Acute gastric dilation, paralytic ileus; occurs especially in child younger than age 2 with greater than 20% injury and develops early in postburn period, lasting 2 to 3 days Renal failure Respiratory failure; severe inhalation injury is the insult most likely to cause death Postburn seizures Hypertension Central nervous system dysfunction Vascular ischemia

Initially, perform emergency assessment of the burn patient to determine priorities of care. o Airway, breathing, and circulation: airway may be compromised with inhalation injury o Extent of burn injury o Additional injuries (Although establishing a patent airway always comes first, trauma takes precedence over the burn.) Obtain a history of the injury; for example, ask if the child was involved in an automobile accident or dropped from a window for rescue to help establish if additional injuries may exist. Obtain a complete medical history, including childhood diseases, immunizations (especially tetanus status), current medications, allergies, Nursing Interventions Supporting Cardiac Output recent infections. Subsequently, focus assessment on fluid volume Be alert to the symptoms of Preventing Infection balance, condition of the burn shock that occur shortly after a

Decreased Cardiac Output related to fluid loss and hypermetabolic state Risk for Infection related to altered skin integrity, decreased circulation, and immobility Impaired Gas Exchange related to inhalation injury, pain, and immobility Risk for Injury related to paralytic ileus and stress Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic state and poor appetite Impaired Physical Mobility related to dressings, pain, and contractures Acute Pain related to burn wound and associated treatments Disturbed Body Image related to pain, scarring, and disfigurement Fear and Anxiety related to pain, treatments, procedures, and hospitalization Impaired Parenting related to crisis situation, prolonged hospitalization, and disfigurement

severe burntachycardia, hypothermia, hypotension, pallor, prostration, shallow respirations, anuria. Monitor the administration of I.V. fluids because major burns are followed by a reduction in blood volume due to outflow of plasma into the tissues. Maintain and record intake and output to provide an accurate measure of volume. o Record time and amount of all fluids given. o Measure urine output every hour and report diminished output as ordered (0.5 mL/kg/hour is considered minimally acceptable urine output; however, 1 mL/kg/hour is preferable). o Check urine specific gravity to determine concentration or dilution. With severe burn injuries, insert an indwelling catheter. Weigh the patient daily to help evaluate fluid balance. Monitor sensorium, pulse, pulse pressure, capillary refill, and blood gas values. Provide a rich oxygen environment to combat hypoxia as necessary. Monitor electrolyte and hematocrit results as a guide to fluid replacement. Maintain a warm, humidified ambient environment (especially with burns of 20% TBSA) to maintain body temperature and decrease fluid needs.

Provide meticulous skin care to prevent infection and promote healing. Prevent the child from scratching by administering antipruritics and applying protective devices to his hands. Obtain serial cultures as ordered. Pan culturing (urine, wound, blood, and sputum) may be ordered. Observe burn wounds with each dressing change: assess drainage for color, odor, and amount; necrosis; increase in pain; and surrounding erythema, warmth, swelling, and tenderness, which may indicate infection. Administer topical antimicrobials and systemic antibiotics as ordered. Observe for signs of toxemia, such as fever, prostration, tachycardia, vomiting, and oliguria, and report immediately. Be alert for the development of pneumonia or UTI related to immobility and invasive procedures. Encourage coughing, turning, deep breathing, ambulation, and early discontinuation of indwelling catheter to minimize complications. Administer tetanus prophylaxis based on immunization history. o If primary series complete (or at least three doses of tetanus toxoid obtained) and last injection within past 5 years, it is not necessary. o If at least three doses obtained and last injection more than 5

years, give tetanus toxoid. o If two or fewer doses obtained, give tetanus immunoglobulin and tetanus toxoid. Obtain urine, sputum, and blood cultures for two or more consecutive temperatures of 103 F (39.4 C) or a single temperature of 104 F (40 C).

tracheostomy for continuous pulmonary management. The current trend is to use the earlier time frame. Relieving Gastric Dilation and Preventing Stress Ulcer

NURSING ALERT Even with meticulous skin care, the burn wound is fully colonized in 3 to 5 days. A warm, moist environment becomes an excellent medium for bacterial growth, especially of Pseudomonas. Optimizing Gas Exchange

Be alert for and report symptoms of respiratory distressdyspnea, stridor, tachypnea, restlessness, cyanosis, coughing, increasing hoarseness, drooling. Administer supplemental humidified oxygen. Monitor arterial blood gas (ABG) levels as necessary. Evaluate the carboxyhemoglobin on ABG results (due to inhalation of carbon monoxide, a product of combustion) and be prepared to support ventilation if signs of hypoxemia and respiratory failure develop. Assist with pulmonary function and bronchoscopy as indicated. Have intubation supplies readily available. If unable to intubate the child, then tracheostomy may be necessary. If unable to extubate in 14 to 21 days, then may be converted to

Be alert for the development of gastric distention, especially with burns greater than 20% TBSA, associated injury, or tachypnea. Maintain nothing-by-mouth status if distention or decreased bowel sounds develop. Insert nasogastric (NG) tube as indicated to prevent vomiting, aspiration, and paralytic ileus. Monitor the return of bowel sounds after NG extubation and before reinstituting oral feeding. Administer H2-blockers, such as cimetidine (Tagamet), to prevent Curling's ulcer development.

Ensuring Adequate Nutrition for Healing and Growth Needs

Be aware that hypernutrition is important because of the extreme hypermetabolism related to large burn injuries. o Twice the predicted basal metabolic rate in calories, based on ideal weight, may be necessary. Caloric recommendation is 1,800 kcal/m2 total body surface for maintenance, plus 2,000 kcal/m2 of burned surface area. o Hypermetabolic state generally subsides when the majority of

the wounds are grafted or healed. o High caloric intake to support hypermetabolic state; protein synthesis; calories should come from carbohydrates. o High-protein intake to replace protein lost by exudation; support synthesis of immunoglobulins and structural protein; prevent negative nitrogen balance. o Vitamin and mineral supplement needed, particularly vitamins B and C, iron, and zinc. Maintain ambient temperature at 82.4 F to 90 F (28 C to 32 C) to minimize metabolic expenditure by maintaining core temperature. Minimize anorexia to increase caloric intake. o Offer small amounts of food, perhaps four to five feedings rather than three per day. o Give choice of foods; determine favorites. o Provide high-calorie, high-protein oral or NG supplementation as necessary. o Make meals a pleasant time, unassociated with treatments or unpleasant interruptions. Monitor dietary compliance with dietary goals and adjust as needed. Administer total parenteral nutrition if necessary. Administer serum albumin or fresh frozen plasma to combat hypoalbuminemia when burn area exceeds 20% TBSA.

Monitor nutritional status through weight gain, wound healing, serum transferrin, and serum albumin.

Preserving Mobility

Make sure that physical and occupational therapy are begun early to facilitate rehabilitation. Encourage range-of-motion exercises, ambulation, and position changes to minimize joint and skin complications. Position joint in opposite direction of expected contracture. Apply splints to aid joint positioning and decrease skin contractures and hypertrophy. Apply pressure garments to aid circulation, protect newly healed skin, and prevent and treat hypertrophic scar formation by promoting dermal collagen fiber growth in parallel direction. Encourage the use of pressure garments for as long as 12 to 18 months after injury, until the healed skin has matured. Medicate for pain before therapy or exercise to minimize discomfort. Use play opportunities to help the child accept the therapy program (eg, tricycle riding may be used as form of exercise).

Controlling Pain

Assess for signs of pain, such as irritability, crying, increased BP, tachycardia, decreased mobility, and inability to sleep. Administer analgesics or sedatives to relieve pain.

Analgesia may include, but is not limited to, acetaminophen (Tylenol), acetaminophen with codeine (Tylenol #2 or #3), meperidine (Demerol), morphine, oxycodone, fentanyl (I.V. or oral), hydromorphone (Dilaudid), hydroxyzine (Vistaril), ibuprofen (Motrin), ketamine (Ketalar), and fentanyl (Sublimaze). Do not use propofol (Diprivan) because it carries an increased risk of cardiac arrest in children. o In severe burns, analgesia should be given I.V. because of lack of absorption of I.M. injections during the emergency phase. Emphasis is on maintaining an alert, reasonably comfortable child. Use an alternating water or silicone bead bed to relieve pressure and provide comfort. Maintain warmth and prevent chilling. Provide diversional activities appropriate for age to distract from focus on pain. Teach simple relaxation techniques, such as relaxation breathing and guided imagery. Recognize that fear may exacerbate discomfort; provide reassurance and empathy.

Preventing Negative Body Image

Encourage child to talk about the way he feels and looks.

The child may feel strangers and perceived rejection by friends. guilty and think that o Refer to a support the burn is punishment for some wrong deed. group or have a child o Small children may be who has recovered from burns visit child. fearful of the o Refer to a burn appearance of bandages, scars, or campusually this pressure garments; may be the first offer reassurance. opportunity for the o Encourage the use of child to wear a swimsuit after the play with dolls or injury. puppets, role-playing, or picture drawing to Initiate family consultation help the child express with a plastic surgeon about feelings and fears. future scar revision. Treat the child with warmth Encourage the older child to and affection and encourage experiment with clothing and parents to continually point out consult with a burn cosmetic their love even though child specialist to enhance has a bad burn. appearance and body image. Support child in viewing self in mirror when ready and Reducing Fear and Anxiety encourage the presence of family members. Explain procedures, surgeries, Encourage early contact with and treatments to the child other children. according to age and level of Suggest psychiatric understanding. consultation for: Allow the child to express fears o Refusing to eat. through puppets, dolls, water o Resisting all nursing play, clay, and drawings. procedures. Expect regression due to the o Resisting socialization. physical pain and Advise parents that separation psychological trauma the child from the hospital environment, is experiencing. caregivers, and other patients Encourage parents to stay with can produce excessive anxiety. a young child as much as Short-time home passes possible. (overnight, weekend) are Try to involve the child in helpful before final discharge. group play and unit activities. If the child is school-age, help Encourage involvement with prepare for school reentry; treatment plan and self-care contact teacher or discuss with activities. parents the need to prepare peers for what to expect. A Child Life therapist can be Promoting Effective Parenting invaluable during this time. Discuss issues of social Be alert to signs that parents reentry, such as responding to may react to the situation with questions and stares from depression or stress

syndromes, and encourage counseling for them to promote a healthier family. Encourage parents to assess the effects on siblings at home; they may have needs that are unrecognized or neglected as a result of this crisis. Attempt to have parents become actively involved in the child's care when they are ready to do so. o Advise parents that their visits and involvement can have a positive effect on the child's survival and recovery. o If the parents are unable to visit, telephone calls and family photographs are helpful. Give the parents the opportunity to discuss their feelings. o Parents frequently express guilt regarding their lack of supervision when the accident occurred. o Frequently, burn injury is associated with actual or perceived parental neglect. Remember that this type of injury is sudden and acute, placing the family in a state of crisis. Keep the parents informed of the child's progress. o Begin initial teaching at admission with supportive words and limited technical information. o Education and orientation to the facility and the burn

injury will decrease some anxiety and begin to build rapport on which future support can be based. Encourage meetings with other parents who have coped with trauma.

Community and Home Care Considerations

Make routine home visits to perform, teach, and supervise burn wound care. Inspect the wounds for signs of infection at every visit. Assess coping ability of child and family to care for child and provide psychological support and counseling referrals as needed. Make sure that parents can: o Discuss and demonstrate treatments, procedures, and dressing changes. o Obtain equipment necessary to perform treatment at home. o Understand reason for and adverse effects of medications as well as dietary requirements. o Follow up at appropriate intervals with the designated health care provider. Encourage the use of smoke alarms on every floor in the home, a fire extinguisher, and an emergency fire escape plan.

Family Education and Health Maintenance

clothing, seek medical Teach the family that special assistance). skin care is necessary after burn injury. Teach children how to stop, o Avoid exposure to drop, and roll if their clothes catch on fire and how to crawl sunlight; use to safety if a fire occurs in the sunscreen of sun house. protective factor 24 or higher and apply frequently. Evaluation: Expected Outcomes o Use pressure garments to prevent Absence of shock: stabilization hypertrophic scar of vital signs, normal serum formationworn 23 and electrolyte values of 24 hours for Absence of infection: normal effectiveness, for 1 to laboratory values, clean 1 years. wound, and normal o Use lotions and creams temperature to prevent skin from No respiratory distress: stable drying, cracking, and vital signs, respiratory status, itching; topical or oral and ABG levels antihistamines may be necessary for itching. No GI complications: normal o Burn area has bowel sounds and ability to decreased sensation to tolerate oral feeding touch, heat, and Adequate nutritional status: pressure; take weight gain and wound healing precautions to prevent Improved mobility: injury to area. involvement in play and other Advise the family that activities adjustment after burn is Minimal discomfort: stable vital usually prolonged and painful. signs, verbalization, and Encourage ongoing family and involvement in play individual psychological Positive body image: support. verbalization, socialization, Encourage continued physical and ability to look in mirror therapy to prevent and Relief of fear: able to play, minimize contractures and participates in care preserve function. Effective parenting: Initiate home health, involvement in child's care, psychology, physical and accurate discussion of child's occupational therapy, financial progress and treatment plan assistance, and other referrals as necessary. Teach parents and children the prevention of burn injury as well as other safety measures (see page 1359). Teach first-aid emergency care for burn injury (ie, cool burned area with cool water, remove