Pediatric Integumentary Disorders

8/2/2019 Pediatric Integumentary Disorders

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Pediatric Integumentary DisordersBURNSMANAGEMENT OF BURNS IN CHILDRENBurns are a frequent form of childhoodinjury. They may be caused by heat,electrical energy, or chemicals. Theeffects of burns are not limited to theburn area. Very serious burns mayinclude:

Second-degree burn of 12% to15% or more of body surfacearea.

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 leadingcause of accidental deaths inchildhood, with the highestincidence of burns occurring inchildren younger than age 5.

Children at high risk are oflower socioeconomic statusand of single parents.However, any child, supervisedor unsupervised, is at risk for aburn injury.

Scalds are the leading cause ofinjury in children, followed byflame burns.

Burns from a hot liquid aremost common in childrenyounger than age 3.

o Child left unsupervisedin tub turns on hotwater tap.

o Tap water temperatureabove 120 F (48.9C) (at 130 F [54.4C] it takes only 30

seconds to produce afull-thickness injury in

adult skinless timein the very young).

o Child placed in tub ofhot water that has notbeen tested.

o Spilling of hot liquid,such as coffee or teaon child. Spillingoccurs especially whenpot handles stick out

on top of stove, whenhot liquids and foodsare removed frommicrowave oven, andwhen child grabs orpulls items fromsurfaces.

o Ingestion andaspiration of hot foodsand liquids frommicrowave oven aswell as scald burns toskin and palate from

hot formula. Burns from open flames:

o House fires.o Child climbing on

stove, resulting inignited clothing.

o Children playing withlighters, especially 3-to 10-year-olds.

o Playing or working withgasoline.

o Automobile accidentswith subsequent fire.

o Juvenile fire setters. Electrical burns are most

common in toddlers andadolescents and may becaused by:

o Child playing withelectrical outlets orappliances.

o Child playing withextension cords;children commonlybite through the cord.

o

Child playing onrailroad tracks;climbing trees and

touching high-tensionwires; lightning.

Other causes:o Caustic acid or alkali

burns of the mouthand esophagus

o Chemical burns of theskinchild playingwith gasoline thatcomes in contact withskin (usually gasolineignites)

o Burns inflicted on thechild as a result ofneglect or abuse (anestimated 30% of allchildren with burnsbrought to a hospital;immersion and contactburns most common)

o Smoke inhalation andinhalation fromproducts ofcombustion ofsynthetics, such asplastics and rayon;may yield cyanide,formaldehyde

o Radiationburnssunburn mostcommon, may besecondary to cancerradiation therapy

o Contact burns fromtouching hot surfaces,such as radiators,

wood-burning stoves,fireplaces, or openovens

o Fireworks burns,typically as a result ofmisuse and lack ofadult supervision; maybe combined withexplosive hand injuries

o Friction burns such asthose seen withexercise treadmills inthe home

NURSING ALERT

With combined injury, management oftrauma takes precedence over theburn.

Pathophysiology and EtiologySee Burns in Adults, page 1121.Clinical ManifestationsCharacteristics of Burn Wounds

See page 1126 forcharacteristics of first-,second-, and third-degreeburns.

Electrical burns:o Especially of the

mouth in child youngerthan age 2; may chewor suck on live wire.

o Are progressive andmay take up to 3weeks to fully manifestthe extent of injury

Symptoms of ShockSymptoms of shock appear soon afterthe burn.

Rapid pulse, low bloodpressure (BP)

Subnormal temperature Pallor, cyanosis, prostration Failure to recognize parents or

other familiar people Poor muscle tone; may

become flaccid

Symptoms of ToxemiaSymptoms may develop 1 to 2 daysafter burn.

Prostration, fever, rapid pulse Glucosuria, decreased urine

output Vomiting, edema These symptoms may progress

to coma or death

NURSING ALERT


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The fever of toxemia is not to beconfused with expected burnfever, which may be as high as103 F (39.4 C) because of thehypermetabolic state.Upper Respiratory Tract InjuryCauses inflammation or edema of theglottis, vocal cords, and upper tracheaand is characterized by symptoms ofupper airway obstruction.

Dyspnea, tachypnea,hoarseness

Stridor, substernal andintercostal retractions, nasalflaring

Restlessness, drooling, cough,increasing hoarseness

NURSING ALERTIncreasing hoarseness, drooling,and stridor are leading indicators

for immediate intubation.Smoke InhalationSmoke inhalation may cause no initialsymptoms other than mild bronchialobstruction during the initial phaseafter the burn. Within 6 to 48 hours,the child may develop sudden onset ofthe following conditions:

Bronchiolitis. Pulmonary edema (acute

respiratory distresssyndrome)of noncardiacorigin.

Severe airway obstruction. Delayed damage: up to 7 days

after the burn injury.

Diagnostic EvaluationCalculation of the Burn Area

Rule of Nines (used inassessment of extent of burnsin adults) has not proved to beexact when applied to youngchildren; it may be acceptableto use in child older than age

10. It is not recommended forhospital use; the Lund andBrowder chart isrecommended. Total bodysurface area (TBSA) is basedon age, thus compensating forchanges in percentagesresulting from growth (seeFigure 55-1).

o During infancy and

early childhood, therelative surface area ofdifferent parts of thebody varies with age.

o The younger the child,the greater theproportion of thesurface area isconstituted by thehead and the lesserthe proportion of thesurface area isconstituted by the

legs. A rough estimate can be

obtained by using the child'shand (palm, with fingersextended), which is equal to1%.

Categorization of Severity of Burn

Total area injured, depth ofinjury, location of injury

Age of child

Condition of patient (ie, levelof consciousness). Confusion isthe hallmark of an anoxicbrain.

Medical history (ie, chronicdisease)

Additional injuries

Schematic Classification of BurnSeverity

Minor burn10% TBSA; first-

and second-degree burn Moderate burn:

o 10% to 20% TBSA;second-degree burn

o 2% to 5% TBSA; third-degree burn notinvolving eyes, ears,face, genitals, hands,or feet orcircumferential burns

Major burn:o 20% TBSA; second-

degree burno All third-degree burns

greater than 10%;depending on age ofchild, 5% is sometimesused

o All burns involvinghands, face, eyes,ears, feet, and/orgenitals

o All electrical burnso Complicated burn

injuries involvingfracture or other majortrauma

o All poor-risk patients(ie, head injury,cancer, lung disease,diabetes)

ManagementFluid Resuscitation: I.V. FluidReplacementNote: Controversy exists regardingfluid resuscitation solution and

amount.

Fluid loss from transcapillaryleakage is greatest during thefirst 12 hours after injury anddiminishes to almost zero 12 to24 hours after injury. Fluid lossafter 48 hours is due tovaporization of water from thewound.

Replacement usually consistsof lactated Ringer's solution,an isotonic electrolyte solution.

The Parkland formula iscommonly used to determine

the fluid needed forresuscitation for burns greaterthan 15% TBSA (see page1126). In children, it isrecommended thatmaintenance fluidrequirements also be givenwith the Parkland formula. It isadministered in the samemanner.

o One half of therequirements are givenduring the first 8hours.

o The remainder is givenover the next 24 hours.

o Lactated Ringer'ssolution may be used.

o In children, the secondday's crystalloidconsists of themaintenancerequirements, and 5%

D/0.45 or 0.25 saline isused instead ofdextrose 5% in water.Colloid is per Parklandformula.

Burn Treatment

Burns may be treated by theopen or closed method or by acombination technique.

Children appear to be moremobile when a burn injury iscovered, because theyexperience less pain.

Hydrotherapy is the treatmentof choice for cleaning wounds.Isotonic saline rather thanwater may be needed for largewounds and small children.

The use of a shower tofacilitate the loosening andremoval of sloughing tissue,eschar, exudate, and topicalmedications is gainingpopularity. The


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showerwater about 90 F(32.2 C)flows over thechild; debridement is thenperformed.

See page 1127 for woundcleaning and debridement,hydrotherapy, topicalantimicrobials, surgicalmanagement, and burn woundgrafting. It is important to use

bacitracin ophthalmic ointmenton a child's face because achild may touch or rub his faceand get the ointment into hiseyes. Topical bacitracin willcause conjunctivitis if it getsinto the eyes.

ComplicationsVary according to severity of burninjury; commonly occur, especiallywith severe burn injuryAcute

Infection; burn wound sepsis,pneumonia, urinary tractinfection (UTI), phlebitis, toxicshock syndrome

Curling's (stress) ulcer, GIhemorrhage; rarely seen nowthat histamine-2 (H2) blockersare commonly usedprophylactically, especially inburns greater than 20% TBSA

Acute gastric dilation, paralytic

ileus; occurs especially in childyounger than age 2 withgreater than 20% injury anddevelops early in postburnperiod, lasting 2 to 3 days

Renal failure Respiratory failure; severe

inhalation injury is the insultmost likely to cause death

Postburn seizures Hypertension Central nervous system

dysfunction Vascular ischemia

Anemia and malnutrition; mayresolve when the burn area iscovered

Fecal impaction Depression secondary to

hospitalization and changingbody image

Long-term

Growth and developmentdelays secondary tomalnutrition

Scarring, disfigurement, andcontractures

Psychological trauma

Nursing Assessment

Initially, perform emergencyassessment of the burn patientto determine priorities of care.

o Airway, breathing, andcirculation: airway maybe compromised withinhalation injury

o Extent of burn injuryo Additional injuries

(Although establishinga patent airway alwayscomes first, traumatakes precedence overthe burn.)

Obtain a history of the injury;for example, ask if the childwas involved in an automobileaccident or dropped from awindow for rescue to helpestablish if additional injuriesmay exist.

Obtain a complete medicalhistory, including childhooddiseases, immunizations(especially tetanus status),current medications, allergies,recent infections.

Subsequently, focusassessment on fluid volumebalance, condition of the burn

wounds, and signs of infection(burn wound, pulmonary,urinary).

Assess level of comfort andemotional status; providereassurance while performingassessment and determiningpriorities.

Nursing Diagnoses

Decreased Cardiac Outputrelated to fluid loss andhypermetabolic state

Risk for Infection related toaltered skin integrity,decreased circulation, andimmobility

Impaired Gas Exchange relatedto inhalation injury, pain, andimmobility

Risk for Injury related toparalytic ileus and stress

Imbalanced Nutrition: LessThan Body Requirementsrelated to hypermetabolicstate and poor appetite

Impaired Physical Mobilityrelated to dressings, pain, andcontractures

Acute Pain related to burnwound and associatedtreatments

Disturbed Body Image related

to pain, scarring, anddisfigurement Fear and Anxiety related to

pain, treatments, procedures,and hospitalization

Impaired Parenting related tocrisis situation, prolongedhospitalization, anddisfigurement

Nursing InterventionsSupporting Cardiac Output

Be alert to the symptoms ofshock that occur shortly after a

severe burntachycardia,hypothermia, hypotension,pallor, prostration, shallowrespirations, anuria.

Monitor the administration ofI.V. fluids because major burnsare followed by a reduction inblood volume due to outflow ofplasma into the tissues.

Maintain and record intake andoutput to provide an accuratemeasure of volume.

o Record time andamount of all fluidsgiven.

o Measure urine outputevery hour and reportdiminished output asordered (0.5mL/kg/hour isconsidered minimallyacceptable urineoutput; however, 1mL/kg/hour ispreferable).

o Check urine specificgravity to determineconcentration ordilution.

With severe burn injuries,insert an indwelling catheter.

Weigh the patient daily to helpevaluate fluid balance.

Monitor sensorium, pulse,pulse pressure, capillary refill,

and blood gas values. Provide a rich oxygen

environment to combathypoxia as necessary.

Monitor electrolyte andhematocrit results as a guideto fluid replacement.

Maintain a warm, humidifiedambient environment(especially with burns of 20%TBSA) to maintain bodytemperature and decreasefluid needs.

Preventing Infection


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Provide meticulous skin care toprevent infection and promotehealing.

Prevent the child fromscratching by administeringantipruritics and applyingprotective devices to hishands.

Obtain serial cultures as

ordered. Pan culturing (urine,wound, blood, and sputum)may be ordered.

Observe burn wounds witheach dressing change: assessdrainage for color, odor, andamount; necrosis; increase inpain; and surroundingerythema, warmth, swelling,and tenderness, which mayindicate infection.

Administer topicalantimicrobials and systemic

antibiotics as ordered. Observe for signs of toxemia,

such as fever, prostration,tachycardia, vomiting, andoliguria, and reportimmediately.

Be alert for the development ofpneumonia or UTI related toimmobility and invasiveprocedures. Encouragecoughing, turning, deepbreathing, ambulation, andearly discontinuation of

indwelling catheter tominimize complications. Administer tetanus prophylaxis

based on immunizationhistory.

o If primary seriescomplete (or at leastthree doses of tetanustoxoid obtained) andlast injection withinpast 5 years, it is notnecessary.

o If at least three doses

obtained and lastinjection more than 5

years, give tetanustoxoid.

o If two or fewer dosesobtained, give tetanusimmunoglobulin andtetanus toxoid.

Obtain urine, sputum, andblood cultures for two or moreconsecutive temperatures of103 F (39.4 C) or a single

temperature of 104 F (40C).

NURSING ALERTEven with meticulous skin care,the burn wound is fully colonized

in 3 to 5 days. A warm, moistenvironment becomes an excellentmedium for bacterial growth,especially of Pseudomonas.Optimizing Gas Exchange

Be alert for and reportsymptoms of respiratorydistressdyspnea, stridor,tachypnea, restlessness,cyanosis, coughing, increasinghoarseness, drooling.

Administer supplementalhumidified oxygen.

Monitor arterial blood gas(ABG) levels as necessary.

Evaluate thecarboxyhemoglobin on ABGresults (due to inhalation of

carbon monoxide, a product ofcombustion) and be preparedto support ventilation if signsof hypoxemia and respiratoryfailure develop.

Assist with pulmonary functionand bronchoscopy asindicated.

Have intubation suppliesreadily available. If unable tointubate the child, thentracheostomy may benecessary. If unable toextubate in 14 to 21 days,then may be converted to

tracheostomy for continuouspulmonary management. Thecurrent trend is to use theearlier time frame.

Relieving Gastric Dilation andPreventing Stress Ulcer

Be alert for the development of

gastric distention, especiallywith burns greater than 20%TBSA, associated injury, ortachypnea.

Maintain nothing-by-mouthstatus if distention ordecreased bowel soundsdevelop.

Insert nasogastric (NG) tube asindicated to prevent vomiting,aspiration, and paralytic ileus.

Monitor the return of bowelsounds after NG extubation

and before reinstituting oralfeeding.

Administer H2-blockers, suchas cimetidine (Tagamet), toprevent Curling's ulcerdevelopment.

Ensuring Adequate Nutrition forHealing and Growth Needs

Be aware that hypernutrition isimportant because of the

extreme hypermetabolismrelated to large burn injuries.o Twice the predicted

basal metabolic rate incalories, based onideal weight, may benecessary. Caloricrecommendation is1,800 kcal/m2 totalbody surface formaintenance, plus2,000 kcal/m2 ofburned surface area.

o Hypermetabolic stategenerally subsideswhen the majority of

the wounds are graftedor healed.

o High caloric intake tosupporthypermetabolic state;protein synthesis;calories should comefrom carbohydrates.

o High-protein intake toreplace protein lost by

exudation; supportsynthesis ofimmunoglobulins andstructural protein;prevent negativenitrogen balance.

o Vitamin and mineralsupplement needed,particularly vitamins Band C, iron, and zinc.

Maintain ambient temperatureat 82.4 F to 90 F (28 Cto 32 C) to minimize

metabolic expenditure bymaintaining core temperature.

Minimize anorexia to increasecaloric intake.

o Offer small amounts offood, perhaps four tofive feedings ratherthan three per day.

o Give choice of foods;determine favorites.

o Provide high-calorie,high-protein oral or NGsupplementation asnecessary.

o Make meals a pleasanttime, unassociatedwith treatments orunpleasantinterruptions.

Monitor dietary compliancewith dietary goals and adjustas needed.

Administer total parenteralnutrition if necessary.

Administer serum albumin or

fresh frozen plasma to combathypoalbuminemia when burnarea exceeds 20% TBSA.


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Monitor nutritional statusthrough weight gain, woundhealing, serum transferrin, andserum albumin.

Preserving Mobility

Make sure that physical andoccupational therapy are

begun early to facilitaterehabilitation.

Encourage range-of-motionexercises, ambulation, andposition changes to minimizejoint and skin complications.

Position joint in oppositedirection of expectedcontracture.

Apply splints to aid jointpositioning and decrease skincontractures and hypertrophy.

Apply pressure garments to aidcirculation, protect newlyhealed skin, and prevent andtreat hypertrophic scarformation by promoting dermalcollagen fiber growth inparallel direction. Encouragethe use of pressure garmentsfor as long as 12 to 18 monthsafter injury, until the healedskin has matured.

Medicate for pain beforetherapy or exercise tominimize discomfort.

Use play opportunities to helpthe child accept the therapyprogram (eg, tricycle ridingmay be used as form ofexercise).

Controlling Pain

Assess for signs of pain, suchas irritability, crying, increasedBP, tachycardia, decreasedmobility, and inability to sleep.

Administer analgesics orsedatives to relieve pain.

o Analgesia may include,but is not limited to,acetaminophen(Tylenol),acetaminophen withcodeine (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 notuse propofol (Diprivan)because it carries anincreased risk ofcardiac arrest inchildren.

o In severe burns,analgesia should be

given I.V. because oflack of absorption ofI.M. injections duringthe emergency phase.Emphasis is onmaintaining an alert,reasonablycomfortable child.

Use an alternating water orsilicone bead bed to relievepressure and provide comfort.

Maintain warmth and preventchilling.

Provide diversional activitiesappropriate for age to distractfrom focus on pain.

Teach simple relaxationtechniques, such as relaxationbreathing and guided imagery.

Recognize that fear mayexacerbate discomfort; providereassurance and empathy.

Preventing Negative Body Image

Encourage child to talk aboutthe way he feels and looks.

o The child may feelguilty and think thatthe burn is punishmentfor some wrong deed.

o Small children may befearful of theappearance ofbandages, scars, orpressure garments;offer reassurance.

o Encourage the use ofplay with dolls orpuppets, role-playing,or picture drawing tohelp the child expressfeelings and fears.

Treat the child with warmthand affection and encourageparents to continually point outtheir love even though childhas a bad burn.

Support child in viewing self inmirror when ready andencourage the presence offamily members.

Encourage early contact withother children.

Suggest psychiatricconsultation for:

o Refusing to eat.o Resisting all nursing

procedures.o Resisting socialization.

Advise parents that separationfrom the hospital environment,

caregivers, and other patientscan produce excessive anxiety.Short-time home passes(overnight, weekend) arehelpful before final discharge.

If the child is school-age, helpprepare for school reentry;contact teacher or discuss withparents the need to preparepeers for what to expect. AChild Life therapist can beinvaluable during this time.

Discuss issues of social

reentry, such as responding toquestions and stares from

strangers and perceivedrejection by friends.

o Refer to a supportgroup or have a childwho has recoveredfrom burns visit child.

o Refer to a burncampusually thismay be the firstopportunity for the

child to wear aswimsuit after theinjury.

Initiate family consultationwith a plastic surgeon aboutfuture scar revision.

Encourage the older child toexperiment with clothing andconsult with a burn cosmeticspecialist to enhanceappearance and body image.

Reducing Fear and Anxiety

Explain procedures, surgeries,and treatments to the childaccording to age and level ofunderstanding.

Allow the child to express fearsthrough puppets, dolls, waterplay, clay, and drawings.

Expect regression due to thephysical pain andpsychological trauma the childis experiencing.

Encourage parents to stay witha young child as much aspossible.

Try to involve the child ingroup play and unit activities.

Encourage involvement withtreatment plan and self-careactivities.

Promoting Effective Parenting

Be alert to signs that parentsmay react to the situation withdepression or stress


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syndromes, and encouragecounseling for them topromote a healthier family.

Encourage parents to assessthe effects on siblings athome; they may have needsthat are unrecognized orneglected as a result of thiscrisis.

Attempt to have parentsbecome actively involved inthe child's care when they areready to do so.

o Advise parents thattheir visits andinvolvement can havea positive effect on thechild's survival andrecovery.

o If the parents areunable to visit,telephone calls andfamily photographs are

helpful. Give the parents the

opportunity to discuss theirfeelings.

o Parents frequentlyexpress guilt regardingtheir lack ofsupervision when theaccident occurred.

o Frequently, burn injuryis associated withactual or perceivedparental neglect.Remember that thistype of injury is suddenand acute, placing thefamily in a state ofcrisis.

Keep the parents informed ofthe child's progress.

o Begin initial teachingat admission withsupportive words andlimited technicalinformation.

o Education andorientation to thefacility and the burn

injury will decreasesome anxiety andbegin to build rapporton which futuresupport can be based.

o Encourage meetingswith other parents whohave coped withtrauma.

Community and Home CareConsiderations

Make routine home visits toperform, teach, and superviseburn wound care.

Inspect the wounds for signs ofinfection at every visit.

Assess coping ability of childand family to care for child andprovide psychological supportand counseling referrals as

needed. Make sure that parents can:

o Discuss anddemonstratetreatments,procedures, anddressing changes.

o Obtain equipmentnecessary to performtreatment at home.

o Understand reason forand adverse effects ofmedications as well as

dietary requirements.o Follow up at

appropriate intervalswith the designatedhealth care provider.

Encourage the use of smokealarms on every floor in thehome, a fire extinguisher, andan emergency fire escapeplan.

Family Education and Health

Maintenance

Teach the family that specialskin care is necessary afterburn injury.

o Avoid exposure tosunlight; usesunscreen of sunprotective factor 24 orhigher and applyfrequently.

o Use pressure garments

to preventhypertrophic scarformationworn 23of 24 hours foreffectiveness, for 1 to1 years.

o Use lotions and creamsto prevent skin fromdrying, cracking, anditching; topical or oralantihistamines may benecessary for itching.

o Burn area has

decreased sensation totouch, heat, andpressure; takeprecautions to preventinjury to area.

Advise the family thatadjustment after burn isusually prolonged and painful.Encourage ongoing family andindividual psychologicalsupport.

Encourage continued physicaltherapy to prevent andminimize contractures andpreserve function.

Initiate home health,psychology, physical andoccupational therapy, financialassistance, and other referralsas necessary.

Teach parents and children theprevention of burn injury aswell as other safety measures(see page 1359).

Teach first-aid emergency care

for burn injury (ie, cool burnedarea with cool water, remove

clothing, seek medicalassistance).

Teach children how to stop,drop, and roll if their clothescatch on fire and how to crawlto safety if a fire occurs in thehouse.

Evaluation: Expected Outcomes

Absence of shock: stabilizationof vital signs, normal serumand electrolyte values

Absence of infection: normallaboratory values, cleanwound, and normaltemperature

No respiratory distress: stablevital signs, respiratory status,and ABG levels

No GI complications: normalbowel sounds and ability totolerate oral feeding

Adequate nutritional status:weight gain and wound healing

Improved mobility:involvement in play and otheractivities

Minimal discomfort: stable vitalsigns, verbalization, andinvolvement in play

Positive body image:verbalization, socialization,and ability to look in mirror

Relief of fear: able to play,participates in care Effective parenting:

involvement in child's care,accurate discussion of child'sprogress and treatment plan

Pediatric Integumentary Disorders

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