PEDIATRIC NURSING BURNS

1. Burns
• An injury occuring from destruction of the skin
by thermal forces.

2. Incidence and Etiology:
• depends on cause:
• Thermal – most common in children; mostly
from flames, explosions/flash, scalds, contact
with hot objects
• Electrical
• Chemical
• Radiation – over-exposition to UV rays

3. Classification
• Burns are classified by depth, type and extent
of injury
• Every aspect of burn treatment depends on
assessment of the depth and extent

4. Classification by depth
• Categories of burns based on depth of tissue
destruction:
• Superficial (1st Degree): Epidermis, painful
(very)/ red, heals easily in 5-10 days, no
systemic effects and no scarring.
• Partial thickness (2nd Degree): upper layer of
dermis, bright red, moist, Painful (extremely),
sensitive to cold air, blistered, heals in 14-21
days with some scarring if deep dermal layer
involved.

5. • Full thickness (3rd and 4th Degree): Epidermis
and dermis and subcutaneous tissue, form
eschar (thick leather-like dead skin), whitish
, leathery.dry appearance, less painful,
scarring, and contractures may form.
• 4th degree – tendons, bones and muscles
involved. Usually electrical burns. Requires
skin grafting, skin flaps, possible amputation
to full heal.

6. Burn extent
• Burn extent is calculated only on individuals
with second and third degree burns
• Palmar method: the child’s palm is used to
estimate the burnt area which represents
approximately 1% of the total body surface
area.
• body surface area chart below according to
age

7. LUND AND BROWDER METHOD
• Front and back of the head about 20%
• Front and back of the head 2%
• Upper limbs 10% each
• Trunk 15% anterior 15% posterior
• Buttocks 3% each
• Lower limbs 15% each

8. Rule of nine in children
• HEAD =18%
• ANTERIOR TRUNK-18%
• POSTERIOR TRUNK-18%
• UPPER LIMB-9%+9%=18%
• LOWER LIMB-14%+14%=28%
• PERINEUM-1%

9. Imaging studies
• CXR
• Plain Films / CT scan: Dependent upon
history and physical findings

10. Treatment
• Admit all children with burns covering > 10% of
their body surface; those involving the face,
hands, feet, perineum and joints; those that are
circumferential(surrounding the thorax or an
extremity) and those that cannot be managed in
an outpatient ward.
• Initially, burns are sterile. Focus treatment on
speedy healing and prevention of infection.

11. Cont’
• Consider whether the child has a respiratory
injury due to smoke inhalation.
– If there is evidence of respiratory distress, provide
supplementary oxygen, and ensure the airway
are safe and remain safe by regular observation.
Inform the anaesthetist if there is potential
airway obstruction
– Severe facial burns and inhalation injuries may
require early intubation or tracheostomy to
prevent or treat airway obstruction

12. • Fluid resuscitation is required for burns covering >
10% total body surface.
• Use Ringer’s lactate or normal saline with 5%
glucose; for maintenance, use Ringer’s lactate with
5% glucose or half-normal saline with 5% glucose.
• The total daily fluid requirement of a child is
calculated with the following formula: 100 ml/kg for
the first 10 kg, then 50 ml/kg for the next 10 kg,
thereafter 25 ml/kg for each subsequent kg.
• – First 24 h: Calculate fluid requirements by adding
maintenance fluid requirements to the additional
emergency fluid requirements (volume equal to 4
ml/kg for every 1% of surface burnt).

13. • 100ml×10=1000ml
• 50ml×10=500ml
• 25ml×10=250ml
• 4ml×30×30=3600ml
Total fluids=5350mls in 24hours

14. Cont’
• Administer half of total fluid in first 8 h, and remaining
fluid in next 16 h.
• Example: 20 kg child with a 25% burn:
• Total fluid in first 24 h = (100×10+ 10*50) + 4 ml x 20 kg
x 25% burn
• = 1500 ml + 2000 ml
• = 3500 ml (1750 ml over first 8 h)
• – Second 24 h: give half to three quarters of fluid
required during the first day.

15. Cont’
• Monitor the child closely while giving
emergency fluids (pulse, respiratory rate,
blood pressure and urine output), taking care
to avoid circulatory fluid overload.
• – Blood may be given to correct anaemia or
for deep burns to replace blood loss

16. Prevent infection:
• – If skin is intact, clean with antiseptic solution, gently,
without breaking the skin.
• – If skin is not intact, carefully debride the burn. Except
for very small burns, debride all bullae, and excise
adherent necrotic (dead) tissue during the first few
days.
• – Give topical antibiotics or antiseptics (the options
depend on resources;they include: silver nitrate, silver
sulfadiazine, gentian violet, betadine and even mashed
papaya). Clean and dress the wound daily.
• – Small burns and those in areas that are difficult to
cover can be managed by leaving them open to the air
and keeping them clean and dry.

17. Cont’
• closed treatment for burns of the hand and feet
with a vaseline gauze and bandage
Treat secondary infection if present.
• – If there is evidence of local infection (pus, foul
odour or presence of cellulitis), treat with
amoxicillin (15 mg/kg orally three times a day) plus
cloxacillin (25 mg/kg orally four times a day). If
septicaemia is suspected,use gentamicin (7.5
mg/kg IM or IV once a day) plus cloxacillin (25–
50mg/kg IM or IV four times a day). If infection is
suspected beneath an eschar, remove the eschar

18. Cont’
Pain control
• Make sure that pain control is adequate, including before
procedures such as changing dressings.
• – Give paracetamol (10–15 mg/kg every 6 h) by mouth, or
give IV narcotic analgesics (IM injections are painful), such
as morphine sulfate(0.05–0.1 mg/kg IV every 4 h or prn)or
pethidine 1mg/kg prn if pain is severe.
Check tetanus vaccination status.
• In all cases, administer tetanus prophylaxis
• – If not immunized, give tetanus immune globulin.
• – If immunized, give tetanus toxoid booster, 0.5ml stat if
this is due.

19. Nutrition
• – Begin feeding as soon as practical in the first 24
h.
• – Children should receive a high-calorie diet
containing adequate protein, and vitamin and
iron supplements. (Omit the iron initially in
severe malnutrition.)
• – Children with extensive burns require about 1.5
times the normal calorie and two to three times
the normal protein requirements.

20. anaemia
• Check the hb and if less than 7g/dl transfuse
.give ferrous sulphate for less severe anemia.

21. • Burn contractures: burn scars across fl exor
surfaces contract. This happens even with the
best treatment (and nearly always happens
with poor treatment).
• – Prevent contractures by passive mobilization
of the involved areas and
• by splinting fl exor surfaces to keep them
extended. Splints can be made of plaster of
Paris. Splints should be worn only at night.

22. Physiotherapy and rehabilitation
• Should begin early and continue throughout the
course of burn care
• If the child is admitted for a prolonged period,
ensure that she or he has access to toys and is
encouraged to play.

23. Complications of burns
Hypothermia
Renal failure
Infection
Anemia
Contractures

24. NURSING DIAGNOSIS
• Impaired skin integrity related to thermal
injury
• Potential for infection related to skin and
tissue destruction
• Fluid volume deficit related to loss of body
fluid through injured skin tissue; fluid shift
from vascular compartment to burned tissue
• Ineffective airway clearance related to thermal
trauma of respiratory tract.

25. Exercise
• Master X one and a half years old and 11kgs has
been admitted in your ward with 30% burns.
– Calculate the total amount of ringers lactate you will
administer in the first 2 days (4mks)
– Other than the surface area burnt, explain two (2)
other factors of determining the Severity of burnt
wounds. (2 marks)
– State three acute complications of burns.(3mks)
– Discuss the specific nursing management of Master X.
In the first 24hrs (11mks)

26. GASTROENTERITIS :
Acute Gastroenteritis (AGE): diarrheal disease of rapid
onset, with or without accompanying symptoms,
signs, such as nausea, vomiting, fever, or abdominal
pain
Diarrhea: the frequent passage of unformed liquid
stools (3 or more loose, watery stool per day)
Dysentery: blood or mucus in stools

27. Diarrhea
Acute diarrhea:
Short in duration (less than 2 weeks).
Chronic diarrhea:
6 weeks or more

28. Etiologies:
Viral
70-85% of AGE in developed countries
• Rotavirus-50%
• Caliciviruses, astroviruses, and enteric
adenoviruses,Norwalk virus
Presentaion:
• Low-grade fever
• Vomiting followed by copious watery diarrhea (up to 10-
20 bowel movements per day)
• Symptoms persisting for 3-8 days

29. Etiologies:
Bacterial
Salmonella, Shigella, E. coli,
Campylobacter, Yersinia, Clostridium
difficile
Presentation:
High fevers
Shaking chills
Bloody bowel movements (dysentery)
Abdominal cramping & fecal leukocytes

30. Etiologies:
Parasitic
Giardia and Cryptosporidium
<10% of cases
Presentation:
• Watery stools
• Low-grade fever
• differentiated from viral gastroenteritis by a
protracted course or history of travel to
endemic areas

31. Pathophysiology
The primary mechanisms
(1) Osmotic diarrhea;Occurs when too much water is
drawn into the bowels. If a person drinks solutions
with excessive sugar or salt, these can draw water
from from the body into the bowel and cause above
eg Mg So4 and Na So4
(2) Secretory diarrhea: occurs when the small and large
intestines secrete rather than absorb electrolytes and
water ie there is reduced absorption and increased
secretion.
(3) Increased bowel motility diarrhea;due to reduced
transit time when food passes the bowel too quickly
could be due to infection.

32. Sign & Symptoms
• Nausea & Vomiting
• Diarrhea
• Loss of appetite
• Fever
• Headaches
• Abdominal pain
• Abdominal cramps
• Bloody stools
• Fainting and Weakness
• Heartburn
• Dehydration
• Lethargy

33. • Goals:
• Prevent dehydration
• Replacement of electrolytes maintaenance of
hydration
• Proper feeding
• Treat the cause if identified

34. Dehydration
• Due to the extracellular fluid loss. Large
portion of child fluid in extracellular spaces
(than adult) hence more susceptible to
dehydration. Dehydration if not corrected can
lead to hypovolemic shock and death.

35. • Types
• Hyptonic: Na+ loss is greater than H20 loss
hence serum Na+ falls below 130 MEq/L

36. • Hence:Intracellular becomes more
concentrated and body responds by moving
fluid from extracellular spaces to intracellular
spaces.Though this re-establishes osmotic
equilibrium, it increases fluid losses and can
lead to shock.
• Causes: Inappropriate IV therapy,
Gastroenteritis, Nephrosis, Adrenal
insufficiency, not replacing gastric secretions

37. • Isotonic DH20: Loss of Na+ and H20 equal,
hence serum Na+ levels remain normal.Fluid
loss both extra and intracellular. Since there is
no osmotic variation, much loss comes
through extracellular spaces.It is the most
common type of DH20 in children.Reduces
plasma volume leading to hypovolemic shock.

38. • Losses are replaced by IV fluid high in Na+ to
prevent a drop in Na+ serum level.Na+ is
maintained at 130 MEq/L .Below 130 MEq/L –
hypotonic DH20.

39. • Hypertonic DH20: Loss of H20 is greater than
the loss of Na+. May develops in infants who
are treated for diarrhoea with high
concentration fluids. Na+ goes beyond 150
MEq/L and serum osmolarity will increase.

40. • The body compensates by pulling H20 from
intracellular spaces to intravascular
compartment, hence intravascular volume is
maintained and shock is less apparent. But it
is the most dangerous type because the fluid
replacement strategy is much more difficult to
determine and manage.May result from sense
vomiting and diabetes insipidus

41. Clinical manifestation
• : Depends on degree.Generally the following
sysmptom will result: Weight loss, Rapid,
thready pulse, Blood Pressure, Peripheral
circulation, Urinary output, Specific gravity,
Skin turgor-elasticity, Dry mucous membranes,
, Sunken fontanel in infants.Clinical
dehydration depends on weight loss.Thus:

42. • Mild - < 5% weight loss
• Moderate - 5-10% weight loss
• Severe - > 10% weight loss

43. • Therapeutic management: Depends on
degree. The aim is to correct fluid/electrolyte
imbalances and treat the underlying cause eg.
gastroenteritis
• Oral rehydration therapy: For mild to
moderate DH20.Should contain:Glucose (20g),
Na+ (90 MEq/L),K+ (80 MEq/L),Bicarbonate-
Chloride (30 MEq/L).

44. • Caregivers need to know that the fluid
contains the above concentrations.

45. Type of DH20 determine treatment e.g. Isotonic
dehydration five isotonic fluids e.g. normal
saline, ringer (RL) actate, Dextrose 5% in H20,
Hypertonic solution – 10% glucose in H20,
Dextrose 5% in RL Hypotonic H20. Oral route
preferred but IV used if not possible or in
severe state.Rate of fluid replacement
depends on degree of DH20

46. • . It is based on the child’s weight and clinical
manifestations.Calculating Fluid loss from
weight loss

47. • 1Kg of body weight loss = 1L of
water
• Therefore: 1Kg of weight loss = 1000mls
of fluid loss
• e.g. America Academy of Paediatrics
recommends:
• Minimal: <3% - 10ml/Kg ORS per
stool
•

48. • Mild: 5% - 50ml/Kg ORS in
4 hours after each loose movement
• Moderate: 6-9% - 100ml/Kg ORS
• Severe: >10% - a) Emergency
• b) IV, 40m/s/Kg/hr
until child improves
• Then, 50-
100ml/Kg ORS
• Reassess oftenly

49. plan A-Diarrhea with no
dehydration
• Done according to severity of dehydration
• Give extra fluid ie breastfeed more,ors and
clean water
• Children up to 2 years give 50mls-100 after
each loose stool
• >2yrs 100-200mls after each loose stool given
as small frequent sips if vomits wait for 10 min
then continue slowly.

50. Plan B-some dehydration
• Give ors 75ml/kg plus 100-200mls of clean
water during the first 4 hours then reassess
and classify for dehydration. Then treat
appropriately
• Give extra fluid
• Continue feeding
• Give ors to use at home

51. Plan c-severe dehydration
• Give iv ringers Lactate 100ml/kg if unavailable
give nomal saline if the child can drink give ors
5ml/kg/hr. reassess every 1-2hrsif hydration
status not improving give fluids more rapidly.
Reassess the child after 3 hrs and an infant
after 6 hours. Then give appropriate plan ie A B
or C
• Can use ngt if iv access not possible with ORS
120ml/kg for 6hrs reassess after 1-2 hrs if
hydration status not improving refer for iv
therapy. After 6hrs and choose appropriate

52. Dehydration with severe
malnutrition
• Use rehydration solution for
malnutrition(resomal) contain40mmol Na,
40mmol K and 3mmol/litre. Give orally or by
ngt 5ml/kg q 30 min for the first 2 hours then
5-10ml/kg for the next 10 hrs. if rehydration is
still occuring at 6 and 10 hrs give starter F- 75
instead of resomol the same volume.
• *do not use iv route except in cases of shock
don’t use ors as it has high levels of sodium and
low of K

53. management
• Give a combination of ORS and Znso4
• Vitamin A
• intravenous therapy ringers lactate if not
available use normal saline
• Dehydration with severe malnutrition use
rehydration solution for malnutrtion(resomal)

54. cont
• Breastfeeding
• Ors if not available give uji or rice
water,yoghurt
• High caloric diet eg with cereals .dairy
products and eggs, fresh fruit juices and
bananas
• Thick soup
• Avoid a lot of sugar

55. • Drugs should be given ONLY when absolutely
necessary. Do not use antidiarrheal and anti
emetic.
• Use antibiotics for proven dysentry with
ciprofloxacin and cholera cases with
erythromycin 15mg/kg orally or iv 6hrly as 1 st
line and chloramphenical 50mg/kg as 2nd line
• Antiprotozoal ie metronidazole 15-50mg/kg od
in case of amoebiasis

56. Complication
• Dehydration
Excessive loss of fluids and minerals (electrolytes)
from the body
Common in infants and young children with viral
gastroenteritis or bacterial infection
Kidney failure, eg in infection by E.coli
• Electrolyte deficiency

57. prevention
.Early and exclusive breast feeding
• Rota virus and measles vaccination
• Vit A supplimentation
• Hand washing with running soapy water(5
instances)
• Proper disposal of feaces
• Improved water supply quantity and quality