BURNS

BEATRICE NKOROI
 INCIDENCE AND ETIOLOGY

• Children are at high risk for burns.

• Fire-related burns are the 11th leading cause of
death for children aged 1 to 9 years; infants have
the highest global death rate from this cause of
any age group.
• Electrical and chemical burns are relatively rare
in children.
• Contact burns and scalds contribute significantly
to fire-related disabilities in children.
• Leading causes of scald injuries in children are
hot tap water and hot soup.
 Incidence and etiology
• Some consequences of burns are long lasting and
include hypertrophic scarring, contractures, keloid
formation, and the need to amputate a limb.
• Physical disfiguration that results from burn
injuries challenges the self-esteem of the involved
children.
• When children suffer a significant burn, they and
their parents can experience post-traumatic stress
disorder
Types of burns
• Four major types of burns: Thermal (Most Common In
Children), Electrical, Chemical, and Radiation.
• Thermal burns occur from flames, flash, inhalation, scalds,
or contact with hot objects.
• Household or residential fires are responsible for most
flame burns.
• Flash injuries are caused by explosions, especially of
combustible fuels such as gasoline, kerosene, and charcoal
lighter.
• Inhalation burns occur when children breathe superheated
gases, steam, or hot liquids which burn their airways and
lungs.
• Smoke inhalation, often from house fires, is a major
determinant of mortality associated with burns.
• Scald burns occur when hot liquids spill on a child or from hot
tap water.
• Contact burns result from touching a hot object such as an
oven, hot irons, and radiators.
• As children become more mobile and curious, they are
exposed to additional household burn hazards, such as
electricity.
• Inserting objects into electric sockets or chewing on electrical
wires can cause electrical burns.
• These burns are often not highly visible, but internal damage
may be extensive.
• Chemical burns occur when children ingest or are exposed to
caustic agents such as household cleaning products.
• Radiation burns commonly result from overexposure to the
ultraviolet rays of the sun
 PATHOPHYSIOLOGY
• Burns are caused by a transfer of energy from a heat
source to the body.
• Heat may be transferred through conduction or
electro- magnetic radiation.
• Burns are categorized as thermal (which includes
electrical burns), radiation, or chemical.
• Tissue destruction results from coagulation, protein
denaturation, or ionization of cellular contents.
• The skin and the mucosa of the upper airways are the
sites of tissue destruction.
• Deep tissues, including the viscera, can be damaged by
electrical burns or through prolonged contact with a
heat source.
 PATHOPHYSIOLOGY

• Disruption of the skin can lead to increased fluid loss,

infection, hypothermia, scarring, compromised
immunity, and changes in function, appearance, and
body image.
• The impact of a burn can range from a minor local
injury to multisystem involvement when a major burn
is sustained.
• When a burn covers more than 15 to 20% of a child’s
body surface area, the inflammatory response extends
beyond the injury site, and multiple organs and body
systems are affected.
• If fluids are not administered quickly enough, the
child’s blood pressure can plunge to a critically low
level, and the child can go into shock and die.
• Even if resuscitation fluids are quickly and
appropriately administered and the child survives
the first 48 hours, the risk of death remains high
because the skin barrier has been compromised,
making the child susceptible to infection.

• The release of cytokines and other inflammatory

mediators at the site of injury has a systemic
effect once the burn reaches 30% of total body
surface area.
 Cardiovascular changes
Capillary permeability is increased, leading to loss
of intravascular proteins and fluids into the
interstitial compartment.
Peripheral and splanchnic vasoconstriction occurs.
Myocardial contractility is decreased but the rate
increases.
24 hours after burn injuries, cardiac output returns
to normal if adequate fluid resuscitation has
been given.
• This together with fluid loss from the burn
wound, result in systemic hypotension,
hyperviscosity and end organ hypoperfusion.
 Respiratory changes
• Inflammatory mediators cause
bronchoconstriction, and in severe burns
respiratory distress syndrome can occur.
• Airway obstruction caused by gross oedema of
the throat.
• May have an increased respiratory rate as a
result of pulmonary oedema (secondary to
smoke inhalation) or as an attempt to
compensate the increased metabolic rate.
 Metabolic changes
• The basal metabolic rate increases up to three
times its original rate.
• This, coupled with splanchnic hypoperfusion,
necessitates early and aggressive enteral
feeding to decrease catabolism and maintain
gut integrity.
• Muscle mass may also decrease due to
catabolism.
 Digestive system
• Decreased blood supply
• Risk of curling’s ulcer (duodenal ulcer that
develops 8-14 days after burns. (first sign is
vomiting of bright blood).
 Nervous system
• Pain depending on the degree of burns
 Endocrine System

• Increased secretions of adrenaline and nor-

adrenaline in response to the injury may lead
to increased body temperature and increased
cell metabolism
 Lymphatic System

• Inflammation increases as a result of damaged

tissue, which results in greater strain on the
lymphatic system and pitting oedema.
 Urinary

• The kidneys compensate for the increased

fluid loss as a result of the burn area by
decreasing urine output.
• There is potential for kidney damage as a
result of poor perfusion
 Immunological changes
• Non-specific down regulation of the immune
response occurs.
• burns area removes the first line of infection
defense.
• 1st 48hrs: Hypovolemia
• 48-72 hrs: Circulatory overload
• After 72 hrs: would healing
 CLINICAL MANIFESTATIONS
• The severity of the burn is determined by how
deeply the damage extends into the tissue and
the total body surface area involved.
• Burns are categorized according to the depth of
tissue destruction into the following categories:
Superficial Partial thickness
Deep partial thickness
Full thickness .
 Classification of burns
Superficial Partial-Thickness (Similar to First
Degree)
• Sunburn
• Low-intensity flash
Skin involvement
• Epidermis; possibly a portion of dermis
Symptoms
• Tingling
• Hyperesthesia (supersensitivity)
• Pain that is soothed by cooling
• Reddened; blanches with pressure; dry
• Minimal or no edema
• Possible blisters
• Complete recovery within a week; no scarring
• Peeling
 Classification
Deep Partial-Thickness (Similar to Second Degree)
• Scalds
• Flash flame
Skin involvement
• Epidermis, upper dermis, portion of deeper dermis
Signs and symptoms
• Pain Hyperesthesia Sensitive to cold air
• Blistered, mottled red base; broken epidermis; weeping
surface
• Edema
• Recovery in 2 to 4 weeks Some scarring and
depigmentation contractures
 Classification

Full-Thickness (Similar to Third Degree)

• Flame
• Prolonged exposure to hot liquids
• Electric current
• Chemical
Skin involvement
• Epidermis, entire dermis, and sometimes subcutaneous tissue; may
involve connective tissue, muscle, and bone
Signs and symptoms
• Pain free/Shock
• Hematuria (blood in the urine) and possibly hemolysis
• Possible entrance and exit wounds (electrical burn)
• Dry; pale white, leathery, or charred Broken skin with fat exposed, Edema
• Eschar sloughs Grafting necessary
• Scarring and loss of contour and function
• Contractures, Loss of digits or extremity possible
 1: Superficial-Thickness
Burn (First degree)
1 2 2: Partial-Thickness
3 Burn (Second degree)
3: Full-Thickness Burn
4
(Third degree)
4: Full-Thickness Burn
(Fourth degree
Rule of "nines" and Lund-Browder estimation of extent of burns
 DIAGNOSIS
• A diagnosis of burns is determined from the
clinical manifestations identified during the
history and physical examination.
 Nursing Diagnosis
1. Impaired gas exchange related to carbon monoxide
poisoning, smoke inhalation, and upper airway
obstruction
2. Ineffective airway clearance related to edema and effects
of smoke inhalation
3. Fluid volume deficit related to increased capillary
permeability and evaporative losses from the burn wound,
4. Hypothermia related to loss of skin microcirculation and
open wounds
5. Chronic pain related to tissue and nerve injury and
emotional impact of injury
6. Anxiety related to fear and the emotional impact of burn
injury
CARING FOR CHILDREN WITH MAJOR BURNS
Caring for children with major burns, emphasis is
on;
Respiratory management,
Fluid resuscitation,
Pain management,
Wound care,
Prevention of impaired mobility,
Nutritional support, and
 Psychological support.
The major initial focus is on airway, breathing,
circulation, and pain management
 RESPIRATORY MANAGEMENT

• Initial treatment consists of assessing for airway patency,

establishing it, if needed, and maintaining it.
• Pulmonary complications are a leading cause of death in
thermal burns.
• Anticipate respiratory involvement if the burn occurred
in an enclosed space or the child was found unconscious.
• Any child with a significant burn should receive
supplemental oxygen titrated to keep oxygen saturation
above 90%.
• ABGs provide evidence of smoke inhalation and the
adequacy of gas exchange.
• Most children with extensive burns require prompt
intubation and ventilation.
 Respiratory management

• Children who experience less extensive burns may

initially have a patent airway but develop stridor from
edema that occurs within a few hours of the injury.
• They may need intubation and ventilation at that
time.
• Narcotics given to control pain will depress the
respiratory drive, further compromising the
respiratory system
• Placing a nasogastric tube to empty stomach
contents and decompress it will reduce the likelihood
of vomiting and aspiration, which would create
further respiratory problems
 FLUID RESUSCITATION
• In the early stages following a major burn injury,
promptly establishing adequate IV/IO access and
beginning fluid resuscitation are essential to the
child’s survival.
• Whenever possible, the IV should be placed
away from the burn.
• All burn injuries alter capillary permeability and,
if severe enough, require fluid replacement.
• Fluid resuscitation is a major focus of seriously
burned children during the initial treatment
period in order to prevent hypovolemic shock.
• The goal is to infuse intravenous fluids (usually
Lactated Ringer’s solution) at a sufficient rate
and volume to compensate for increased
capillary permeability and the loss of
intravascular fluids.
• A large-bore central venous catheter is used in
order to administer massive fluid loads.
• Adequacy of the resuscitation is reflected in:
urine output of 1 mL/kg/hr for a child who
weighs more than 30 kg or 1-1.5 mL/kg/hr for a
child who weighs less than 30kg; stable vital
signs; and an alert and oriented mental status.
• A Foley catheter is inserted to facilitate urine output
measurement.
• Child not receiving adequate fluids may develop renal
tubular obstruction if not corrected quickly.
• After initial fluid resuscitation, capillary permeability is
regained.
• At this time, the child’s urine output will increase
dramatically because interstitial fluids are pulled back
into the bloodstream.
• Intravenous fluids should be decreased to
maintenance levels to prevent fluid overload and
pulmonary edema.
• The type and amount of fluid used will be based on
the results of blood electrolyte tests
 PAIN MANAGEMENT

• Thermal destruction of tissue results in one of the most severe

and prolonged types of pain.
• Pain from the injury is compounded by performing procedures on
the wound, especially dressing changes.
• Other factors, such as fear and anxiety, contribute to children’s
perceptions of pain.
• Pain management is an essential element of quality care for
burned children because it promotes their comfort, eases their
breathing, and has a sedating effect.
• For children with minor burns, oral pain medications
• Children should always be assessed for pain using appropriate
assessment tools for their age, and pain medications should be
given prior to all painful procedures.
• Children also respond well to behavioral interventions, such as
imagery, relaxation therapies, and hypnosis.
 WOUND CARE

• The overall goal of burn care is to close the wound as

quickly as possible, either by allowing the wound to
heal on its own (secondary intention) or surgically
grafting the wound.
• Initial wound care is started after the child has been
stabilized.
• use aseptic techniques when cleaning the burned
areas and medicate the child prior to the procedure.
• The wounds are gently cleaned and debrided.
• Debridement is the removal of dead tissue from the
burn site and is associated with severe pain.
• This procedure is performed by soaking the wound for
about 10 minutes to soften the tissue.
• The wound is then washed from the inner to outer
edges using a firm, circular motion.
• Any loose or dead tissue is removed by gently
lifting it up with forceps and cutting it away.
• After the wound and surrounding areas are
cleaned, an antimicrobial cream, such as silver
sulfadiazine (Silvadene), is applied to minimize
bacterial proliferation and prevent infection.
• Some type of dressing is then applied.
 PREVENTION OF IMPAIRED MOBILITY

• Children are at risk for impaired mobility and the

development of contractures due to prolonged bed
rest, muscular atrophy and shortening, and stiffening
of burned tissues.
• It is essential to implement appropriate positioning
strategies to prevent deformities and an exercise
program to maintain muscle strength and joint
mobility.
• Particular attention should be paid to the hands and
neck since these are the most prone to rapid
contractures.
• Early exercise is encouraged and compliance can be
improved with judicious use of analgesics.
• Range of motion exercises are performed
actively at least three times a day.
• Active range of motion of muscles is possible in
infants and toddlers by using familiar toys;
however, most of the joints will require passive
range of motion exercises.
• Caregivers can support and encourage older
children to participate in active range of
motion.
 NUTRITIONAL SUPPORT

• The nutritional needs of burned children are vitally

important to their recovery.
• Protein catabolism after a burn can be severe, and burned
children’s basal metabolic rates (BMR) can increase to
more than twice normal.
• As a general rule, children’s caloric intake increased in
proportion to the percentage of their body that is burned.
• Children should be offered a variety of foods and be
allowed to choose meals when they feel better.
• Most children with major burns are unable to meet their
nutritional requirements orally; therefore,it is necessary
to use enteral feedings.
• Changes in stools (increased stooling, diarrhea) may
indicate that the child is not tolerating the feedings
 PSYCHOLOGICAL SUPPORT

• Anxiety for the child and caregivers can be

overwhelming.
• Play therapy is used to help the child deal with the
frustrations of burn therapy. It encourages the child to
move and actively participate in activities with other
children.
• Nurses in burn units find it essential to gain the trust of
the family and the child to create a healing environment
in the midst of such a stressful situation.
• Once a trusting relationship is established, the nurse can
then build the caregivers’ confidence in their abilities to
continue care after the child is discharged by modeling
proper care and involving them in the care of their child.
• When a child will survive a burn injury, nurses can help
the patient, caregivers, and families grieve the loss of
what the child was prior to the burn injury and learn to
love and accept the child, forever changed, that will go
home with them.
• As recovery continues, counseling with various support
services may be implemented to foster the child’s self-
esteem.
• When a child does not survive, nurses can cry with
families and provide much needed support and referrals
to support groups).
 Assignment
• Form three groups;
• Using a diagram prepare a concept map indicating
the relationship between nursing diagnosis.
• Formulate a nursing care plan for a child with 20%
burns;
• Include 4 Actual nursing diagnosis and 1 potential
nursing diagnosis.