Conditions That Produce Fluid and Electrolyte Imbalance

Prevention: The best intervention for diarrhea is prevention. The fecal-oral route spreads most infections, and parents need information about preventive measures such as personal hygiene, protection of the water supply from contamination, and careful food preparation.

Meticulous attention to perianal hygiene, disposal of soiled diapers, proper hand washing, and isolation of infected persons also minimizes the transmission of infection. (See Infection Control, Chapter 27.)

Parents need information about preventing diarrhea while traveling. Caution them against giving their children adult medications that are used to prevent traveler’s diarrhea. Until vaccines or other prophylactic measures are safe for children, the best measure during travel to areas where water may be contaminated is to allow children to drink only bottled water and carbonated beverages (from the container through a straw supplied from home). Children should also avoid tap water, ice, unpasteurized dairy products, raw vegetables, unpeeled fruits, meats, and seafood.

Compensated Shock: When vital organ function is maintained by intrinsic mechanisms and the child’s ability to compensate is effective, cardiac output and systemic arterial BP are usually normal or increased. However, blood flow is generally uneven or maldistributed in the microcirculation. Early clinical signs are subtle and include apprehension, irritability, normal BP, narrowing pulse pressure, thirst, pallor, and diminished urinary output.

Decompensated Shock: As shock progresses, perfusion in the microcirculation becomes marginal despite compensatory adjustments, and the signs are more obvious and indicate early decompensation. These signs are tachypnea; moderate metabolic acidosis; oliguria; and cool, pale extremities with decreased skin turgor and poor capillary filling. The outcomes of circulatory failure that progress beyond the limits of compensation are tissue hypoxia, metabolic acidosis, and eventual dysfunction of all organ systems.

Irreversible Shock: Irreversible, or terminal, shock implies damage to vital organs (e.g., the heart or brain) of such magnitude that the entire system is disrupted regardless of therapeutic intervention. There is pronounced systemic vasoconstriction and hypoxia of visceral and cutaneous circulations with hypotension, acidosis, lethargy or coma, and oliguria or anuria. The child is totally obtunded. A thready and weak pulse, hypotension, periodic breathing or apnea, anuria, and stupor or coma are signs of impending cardiopulmonary arrest. Death occurs even if cardiovascular measurements return to normal levels with therapy.

Ventilatory Support: The lung is the organ most sensitive to shock. The decrease in or redistribution of blood flow to respiratory muscles plus the increased work of breathing can rapidly lead to respiratory failure. Critically ill patients are unable to maintain an adequate airway. To place the lung at rest and improve ventilation, endotracheal intubation is initiated early with positive-pressure ventilation and supplemental oxygen. Blood gases, oxygen saturation (using pulse oximetry), and pH are monitored frequently.

Increased extravascular lung water caused by edema—both hydrostatic and permeable—contributes to the development of respiratory complications. Hydrostatic edema occurs from the elevation of pulmonary microvascular pressure as a result of left ventricular dysfunction; permeable edema occurs when damage to alveolar cell and pulmonary capillary epithelium causes fluid to leak into the interstitial space, resulting in ARDS. (See Chapter 32.) Direct therapy toward maintaining normal arterial blood gas measurements, normal acid-base balance, and circulation. Make efforts to remove fluid and prevent its accumulation by increasing oncotic pressure and decreasing microvascular hydrostatic pressure. Promote elevated oncotic pressure by diuresis with furosemide or mannitol, colloid administration, or both.

Cardiac Support: In many cases rapid restoration of blood volume is the main therapy needed in the resuscitation of the child in shock. An isotonic crystalloid solution (normal saline or lactated Ringer’s solution) is usually the first choice for fluid replacement. Crystalloid is given in IV boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary. The child’s response is assessed after each bolus. An increase in BP and a decrease in heart rate indicate successful resuscitation. An increased cardiac output results in improved capillary circulation and skin color. Colloids (protein-containing fluids) are often administered to children in shock; albumin is the most common. Because albumin is a protein solution, it remains in the vascular space much longer than crystalloid fluids. A smaller volume of albumin can be given to increase intravascular volume and support cardiac output; with crystalloid fluids, a larger volume is needed to achieve the same effect. In general, because of the infectious risks, blood is administered only in situations of known blood loss, active bleeding, or markedly decreased hematocrit. Fresh-frozen plasma is used to correct coagulopathies, not as volume replacement.

For the critically ill child with shock and multisystem organ dysfunction, more aggressive monitoring is necessary. Central venous measurements of right atrial pressure or pulmonary wedge pressure help guide fluid therapy. In children with persistent shock, place a Swan-Ganz catheter for more accurate monitoring. Determination of arterial blood gases, hematocrit, serum electrolytes, glucose, and calcium concentrations provides additional information concerning composition of circulating blood. Correction of acidosis, hypoxemia, and any metabolic derangements is mandatory.

Vasopressor Support: Temporary pharmacologic support may be required to enhance myocardial contractility, reverse metabolic or respiratory acidosis, and maintain arterial pressure. The principal agents used to improve cardiac output and circulation are the exogenous catecholamines, administered by constant infusion pump. Dopamine is the preferred drug in most situations because it also improves renal perfusion. Other agents (e.g., dobutamine, isoproterenol, epinephrine) may be used to improve cardiac output, depending on the situation.

Metabolic acidosis is usually corrected with adequate tissue perfusion and improved renal function. This is accomplished with adequate ventilatory support, including oxygen, and restoration of blood volume and peripheral circulation. Sodium bicarbonate may also be administered to correct acidosis resulting from shock. It should be given in small boluses that are diluted to avoid acute changes in osmolality. The major complications of bicarbonate administration are sodium overload and hyperosmolality.

Calcium chloride may be administered to improve cardiac function and to offset the reduced ionized calcium associated with large amounts of albumin, whole blood, or fresh-frozen plasma. Diuretics, such as furosemide (Lasix), cause a reduction in ventricular filling pressures without changing cardiac output or heart rate and promote sodium and water excretion by the kidney in cases in which pulmonary congestion is a problem.

Other Therapies: Peritoneal dialysis may be necessary if hyperkalemia, acidosis, hypervolemia, or altered mental status occurs. Nutritional support is provided by both enteral and parenteral routes. Prevention of infection is a primary concern because host resistance is depressed in patients in shock. Other complicating disorders, such as disseminated intravascular coagulation and GI problems (e.g., paralytic ileus, stress ulceration), are managed appropriately. The intraaortic balloon pump may be used for a child with low cardiac output who is refractory to conventional medical management. Extracorporeal membrane oxygenation, where available, is used occasionally as a last resort.

Family Support: Throughout the intense activity, do not overlook the parents. A member of the staff, such as a nurse, social worker, or clergy, may be called to provide comfort and support. If the family is not at the hospital, someone should contact them at frequent intervals to inform them about what is being done and whether there is any improvement. Ideally, someone should remain with the parents to serve as a liaison between them and the intensive care team. However, this is not always feasible in such a critical situation. As soon as possible, the parents should be allowed to see the child.

Edema Formation: Thermal injury to the vessels in the two outer zones results in increased capillary permeability. At the same time, vasodilation causes an increase in hydrostatic pressure within the capillaries. The increased hydrostatic pressure, combined with the increased capillary permeability, causes loss of water, protein, and electrolytes from the circulating volume into the interstitial spaces.

To understand the physiologic mechanism of the formation of burn edema, an understanding of the microvascular fluid balance is necessary. Burn injury not only causes edema at the site, but extravasated and sequestered fluid and protein also enters nonburned tissue. The directly injured cells have a damaged cell membrane that leads to an increase in sodium and potassium shift, resulting in cell swelling. Intracellular water and sodium increase. This process not only occurs in injured cells, but also with those that are not directly heat injured. Edema develops when the rate of fluid being filtered from the microvessels exceeds that of the lymph flow. The amount of edema depends on the type and extent of burn injury (Kramer, Lund, and Beckman, 2007).

Fluid Loss: Fluid transport across the microcirculatory wall in normal and pathologic states is quantitatively described by the Landis-Starling equation. This equation describes the physical forces and physiologic mechanisms that govern fluid transfer between vascular and extravascular compartments. Normal capillary barriers that separate the intravascular and interstitial compartments are disrupted, which results in severe depletion of plasma volume and an increase in extracellular fluid. Clinically this is manifested as hypovolemia (Warden, 2007).

Circulatory Status: Significant circulatory alterations take place in the zone of stasis located around the dead coagulated tissue. Heated red blood cells become spherical. These heat-damaged cells, together with hemoconcentration from fluid shifts, depressed cardiac output, and tissue edema, reduce the blood flow in the burned area, resulting in capillary stasis. Thrombi develop, which further impedes circulation and produces tissue ischemia and necrosis. Hyperviscosity and impaired blood flow are attributed to the release of substances such as thromboplastin and clot-activating factors from damaged cells. These substances cause the production of microemboli, platelet adhesion and aggregation, and increased pain and edema. Circulation in the area around partial-thickness wounds ceases immediately after injury but is usually restored within 24 to 48 hours. In full-thickness burns, however, the vascular supply is completely occluded, and no appreciable circulation is reestablished until granulation takes place at the interface between burned and unburned skin.

Tissue Repair: With reasonable care, superficial partial-thickness injuries heal spontaneously and uneventfully through the generative capacity of the stratum germinativum and epithelial cells of the lining of skin appendages. The wound should heal in approximately 14 days with minimum scarring.

Deep partial-thickness burns heal more slowly by regeneration from the epithelial lining of skin appendages, sweat glands, and hair follicles. A thin epithelial covering develops in 25 to 35 days, but this type of burn may require several months to heal. Scarring is common. Infection, trauma, or severe hypothermia easily converts a partial-thickness wound to a full-thickness injury, especially in the normally thinner skin of young children. Fluid loss and metabolic consequences may be considerable.

Cell destruction by coagulation necrosis occurs in full-thickness burns. Dead tissue and exudate convert to a thick, leathery eschar in 48 to 72 hours; the eschar liquefies and begins to separate in 12 to 21 days if not surgically excised. This process is a result of autolysis, leukocyte digestion, and disintegration of collagen fibers. The dead avascular tissue provides an ideal environment for bacterial growth. If tissue is not grafted, new granulation tissue forms on the wound bed. The wound heals slowly by proliferation from the edges, with a high risk of infection and severe scarring. Full-thickness burns result in severe edema with fluid and electrolyte shifts and extensive metabolic changes.

Cardiovascular System: Animation—Capillary Leak

The immediate postburn period is marked by dramatic alterations in circulation, known as burn shock. A precipitous drop in cardiac output precedes any change in circulating blood or plasma volumes. This initial decrease in cardiac output (approximately 50% of normal resting values) is attributed to a circulating myocardial depressant factor that is associated with severe burn injury and directly affects the contractility of the heart muscle. As a result of fluid losses through denuded skin, increased capillary permeability, and vasodilation, the circulating volume decreases rapidly; cardiac output is reduced even further, usually leveling off at approximately 20% of normal resting values. After adequate fluid resuscitation, cardiac output spontaneously returns to normal in 24 to 36 hours. If fluid is not replaced, cardiac output continues to decrease, resulting in inadequate perfusion, organ dysfunction, and ultimately death.

Capillary permeability with leakage of fluid takes place both in uninjured areas and in the burn wound. Together with the shrinkage of drying eschar, severe edema caused by the rapid fluid shift to the interstitial spaces may produce a tourniquet effect, resulting in compartment syndrome. Compartments are composed of groups of muscles in the extremities and are surrounded by fibrous tissue. The inability of the fascia to expand in the presence of massive edema increases the pressure in the compartment, compromising circulation and entrapping nerves. Treatment is required during the acute phase and consists of surgical incision of the burned tissue (escharotomy) to restore distal circulation. If the escharotomy is not sufficient, an incision of the muscle sheath (fasciotomy) is performed (Fig. 29-6).

Edema fluid accumulates rapidly in the first 18 hours after injury and reaches a maximum in approximately 48 hours. Capillary permeability returns to normal, and fluid is reabsorbed, chiefly by way of the lymphatics. Reabsorption usually proceeds at the rate of fluid accumulation, although it may persist longer. Redistribution of fluid is often complex and unpredictable and is marked by diuresis.

In most children the cardiovascular system is able to withstand the demands placed on it, although shock is a prominent feature of large thermal injuries. Some children are prone to congestive heart failure and pulmonary edema. In addition, peripheral circulation in infants is less efficient and more labile, which complicates the burn response and therapy in this age-group.

Renal System: Children younger than 2 years of age lack the ability to concentrate urine because of the immaturity of their renal system and are therefore at an increased risk for dehydration. In addition, the child has a relatively larger TBSA in relation to weight than an adult. These issues, combined with limited physiologic reserves, increase the fluid requirements for children during burn shock resuscitation and in compensating for evaporative water losses (Warden, 1992). Loss of fluid from the intravascular compartment causes renal vasoconstriction that in turn leads to reduced renal plasma flow and depressed glomerular filtration. When adequate fluids are provided, the glomerular filtration rate returns to normal, and by the third or fourth postburn day, urinary output increases as edema fluid is mobilized and eliminated. In the first few days oliguria is more commonly the result of inadequate fluid replacement than of acute renal failure. If the child does not respond to treatment or if there is inadequate fluid resuscitation, acute renal failure may develop, with significant kidney damage.

BUN and creatinine levels are elevated as a result of tissue breakdown, decreased circulating volume, and oliguria. Hematuria may also be evident from the hemolysis of red blood cells, and oliguria may develop as a consequence of the increased pigment load. Myoglobinuria is especially common after extensive electrical injury. Cell destruction releases large amounts of myoglobin, which occludes the kidney tubules and places the victim of electrical trauma at high risk for renal failure.

Gastrointestinal System: The GI system has been recognized as a target of systemic shock. After a burn injury, blood flow decreases to the GI system by one third even though cardiac output is maintained by resuscitation fluids. Ischemia results and can produce ulcer formation, enterocolitis (severe enough to cause full-thickness necrosis), and even intestinal perforation. Poor perfusion to the kidney and the liver can ensue, resulting in organ dysfunction. The GI tract functions as a barrier to contain GI bacteria within it. Disruption of the GI mucosal integrity is possibly a focus for sepsis in the burn patient. The exact mechanism by which bacteria and their products pass through the GI barrier is not clear. Both intracellular and transcellular processes may be involved. These consequences can be profound, and translocating whole bacteria can be a direct source of sepsis (Sheridan and Tompkins, 2007b).

With the placement of a nasogastric tube, gastric decompression empties the stomach to control aspiration of gastric contents until motility is reestablished. Take care to observe for signs of aspiration of gastric contents into the lung as a result of incompetence of the gastroesophageal junction. With GI function intact, enteral feedings with a nasogastric tube are begun immediately after acute resuscitation (Andrews, 1994).

Metabolism: The greatly accelerated metabolic rate in burn patients is supported by protein and lipid catabolism. The child has limited glycogen stores to provide energy, which therefore accelerates the protein and lipid breakdown. No other disease state produces as great a hypermetabolism as the burn injury. Therefore the child is vulnerable to prolonged starvation (Lee and Herndon, 2007). When the burn injury is extensive (>50% of TBSA), energy needs may approach twice the predicted basal requirements.

The stress of injury places high demands on the body. Stress-invoked glycogen breakdown depletes the energy stores in 12 to 24 hours, after which the body resorts to glyconeogenesis for high-energy needs. Blood glucose levels may be elevated as a result of insulin resistance. Rapid protein breakdown and muscle wasting occur if sufficient protein replacement is not provided.

Body temperature reflects the net balance between heat production and heat loss. As a result of the accelerated metabolism, children with burn injuries typically exhibit an elevated body temperature, even in the absence of infection. The thermoregulatory response is activated and results in an elevation of core body temperature. Burn injured patients strive for a core body temperature of about 38° C (100.4° F). Low or “normal” temperature may indicate overwhelming sepsis, or a fatigued physiologic capability to maintain temperature, and should be viewed with concern. Routine methods of heat conservation after a major burn injury are inadequate because of excessive heat loss through evaporation and convection (Saffle and Graves, 2007). Heat is lost as a result of the energy-consuming process of water evaporation from the damaged skin surface. The body tries to raise the core and skin temperature to offset heat losses secondary to evaporation through the burn eschar (Norbury and Herndon, 2007). Infants and young children are especially vulnerable because of the large surface area relative to metabolically active tissue. Burning destroys a lipid layer and converts skin that is normally impermeable to water to a state that transmits water vapor at least four times as rapidly as unburned skin. In partial-thickness burns this loss is greatest on the day of injury; in full-thickness burns it rises slowly at first and rapidly increases to reach a peak approximately the fourth day after the burn. Evaporative losses continue until partial-thickness wounds are healed and full-thickness burns are grafted. Therefore body stores of energy are rapidly depleted unless sufficient replacement is provided or losses are reduced.

Medications that affect metabolic rate may be used to prevent loss of body protein stores, thus protecting immunity, wound healing, muscle integrity, and organ function. Oxandrolone is an anabolic steroid that works to maintain and restore muscle mass, increase weight gain, and promote wound healing. Supplements of essential amino acids such as glutamine and arginine provide an anticatabolic effect, support wound healing, indirectly preserve lean body mass, improve immune function, and provide an antioxidant quality (Demling, 2005).

Neuroendocrine System: As a response to stress of any origin, the hypothalamic-hypophyseal mechanism restores equilibrium by secreting trophic hormones, which stimulate various target organs of the neuroendocrine system. Adrenal activity is markedly increased. The medulla responds by secreting additional amounts of the catecholamines epinephrine and norepinephrine. Adrenocortical hormones reach a peak immediately after injury and remain elevated for some time. Aldosterone secretion and a release of antidiuretic hormone are sustained at a high level throughout hospitalization. Despite this increased adrenal activity, adrenal insufficiency is a rare complication.

Anemia and Metabolic Acidosis: The hematocrit is initially elevated because of hemoconcentration resulting from fluid shifts to the interstitial spaces and red blood cell destruction. In addition, a reduced red blood cell half-life results from increased cell fragility. A significant loss of circulating red blood cell mass is predominantly associated with major burns.

Most burn patients exhibit some degree of metabolic acidosis as a result of the disruption of the body’s buffering action because of the fluid shift to the extravascular spaces and the altered concentrations of potassium, sodium, chloride, and bicarbonate ions. Reduced blood volume and cardiac output result in diminished perfusion and tissue hypoxia, with a shift to anaerobic metabolism. The resultant formation of metabolic acids is usually sufficiently compensated by respiratory mechanisms. Renal compensatory activities are impaired by the decreased blood flow.

Growth and Development: Children may demonstrate postburn growth retardation. Regular height and extremity assessment are necessary to detect subtle deformities until development is normalized (see Research Focus box).

Pulmonary System: The impact of thermal injury on pulmonary function includes a full range of respiratory dysfunctions, including inhalation injury, aspiration of gastric contents, bacterial pneumonia, pulmonary edema and insufficiency, and emboli. In every age and burn size category, pneumonia is one of the most common infections in burn patients and is associated with high risk of mortality (Murphey, Sherwood, and Toliver-Kinsky, 2007).

Inhalation injuries result from trauma to the tracheobronchial tree after inhalation of the heated gases and toxic chemicals produced during combustion. Although direct thermal injury to the upper airway may occur, heat damage below the vocal cords is rare. Inspired heated air is cooled in the upper airway before reaching the trachea. Reflex closure of the cords and laryngeal spasm prevent full inhalation. Evidence of direct thermal injury to the upper airway includes burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestation may be delayed as long as 24 to 48 hours. Wheezing, increasing secretions, hoarseness, wet rales, and carbonaceous secretions are signs of respiratory tract involvement. Upper airway obstruction is often associated with burn shock and fluid resuscitation. In such situations endotracheal intubation may be necessary to preserve a patent airway.

Suspect inhalation of carbon monoxide when the injury has occurred in an enclosed space. (See Smoke Inhalation Injury, Chapter 32, for a discussion of carbon monoxide inhalation.) Inhalation of other products of combustion, such as smoke and toxic chemicals, can produce varying degrees of pulmonary damage. Smoke from burning wood is extremely irritating; burning plastic materials, especially polyvinyl chloride, release smoke with gases containing chlorine, sulfuric acid, and cyanide. Respiratory injury is manifested by mucosal erythema and edema followed by sloughing of the mucosa. A mucopurulent membrane replaces the mucosal lining and seriously compromises respiration and ventilation.

A common etiologic factor in respiratory failure in the pediatric population is bacterial pneumonia, which may be secondary to airway injury or contamination from intubation or may be acquired through hematogenous spread of bacteria. Early in the postburn period the largest percentage of pulmonary infections result from nosocomial exposure, immobility, and abdominal distention. The hematogenous variety occurs later and is related to the septic burn wound or other foci, such as phlebitis at the site of an invasive IV line. A less common complication is pulmonary edema resulting from fluid overload or ARDS in association with gram-negative sepsis. (See Chapter 32.) This syndrome results from pulmonary capillary damage and leakage of fluid into the interstitial spaces of the lung. A loss of compliance and interference with oxygenation are the consequences of pulmonary insufficiency in conjunction with systemic sepsis.

Deep burns, especially those circling the thorax, may cause restriction of chest excursion as a result of edema and inelastic eschar formation. Young children are particularly at risk because of the pliability of the skeletal structure. Hypoxia is relieved by an escharotomy of longitudinal incisions along the anterior axillary lines combined with a transverse incision at the costal level. This procedure allows expansion of the chest wall to facilitate ventilation.

Wound Sepsis: Sepsis is a critical problem in the treatment of burns and is an ever-present threat after the shock phase. Initially, burn wounds are relatively pathogen free unless contaminated with potentially infectious material such as dirt or polluted water. However, dead tissue and exudate provide a fertile field for bacterial growth. On approximately the third postburn day, early colonization of the wound surface by a preponderance of gram-positive organisms (primarily staphylococci) changes to predominantly gram-negative opportunistic organisms, particularly Pseudomonas aeruginosa. By the fifth postburn day, bacterial invasion is well underway beneath the surface of the burn wound.

Characteristics of the burn wound contribute to the proliferation of pathogenic organisms. Vascular supply to full-thickness burns is occluded immediately, and no appreciable blood is supplied to the area for approximately 3 weeks after the injury. In partial-thickness wounds the circulation to the injured area is suspended for 24 to 48 hours; circulation is then restored unless infection supervenes. Thrombosis from bacterial invasion will impair circulation sufficiently to convert partial-thickness wounds to full-thickness injuries. These large amounts of nonviable tissue also provide an excellent medium for the growth of microorganisms.

Occlusion of the local blood supply impairs the delivery of both humoral and cellular defense mechanisms to the burned area. Initially there is a decrease in inflammatory and phagocytic cells to the wound, but the number of phagocytes gradually increases until they are present in abundance by the third postburn week, when granulation tissue is forming. Granulation tissue, with its rich blood supply, affords increasing resistance to infection. Organisms are normally a part of skin flora; therefore cultures with an organism concentration of 105/g of tissue have been arbitrarily chosen as the level of burn wound invasion.

The microflora present at any institution are influenced by the treatment modalities and choice of antibiotics. During the past 30 years there has been a reduction in the percentage of specific bacteria and fungi recovered from burn wounds. This reduction reflects improvements in patient management, nutritional support, aggressive excision and grafting of wounds, and topical antimicrobial therapy. Sepsis, in burn injury, is a major complication and a significant factor in morbidity and mortality (Sherwood and Traber, 2007).

Gastrointestinal System: GI dysfunction is common after burn injury as evidenced by feeding intolerance; mucosa ulceration; and bleeding, particularly in the stomach and duodenum. Within 72 hours of a major burn injury a significant number of patients may develop mucosal changes. This may progress to ulceration with septic episodes and hypoxemia. Potential causes of stress ulcers in burn patients are (1) mucosal ischemia, (2) increased acid production, (3) increased acid back-diffusion, (4) energy depletion, (5) bile reflux, and (6) direct mucosal injury with placement of intraluminal tubes.

Enteral feeding is one of the most important means of providing nutrition and has led to a decrease in mortality. Early enteral feeding often prevents some of these potential complications. Aggressive fluid resuscitation aids in maintaining adequate mucosal blood flow. Antacid and H₂ receptor antagonist therapy can effectively prevent ulceration of the stomach and duodenum.

Ileus is also a common complication after a burn injury. Sepsis, electrolyte imbalance, narcotics, and renal failure are common causes. Patients experience abdominal distention and pain. Early enteral feeding again can assist in avoiding intestinal complications (Beierle and Chung, 2007).

Central Nervous System: Burn encephalopathy, as characterized by lethargy, withdrawal, or coma, occurs in children. Symptoms such as delirium and transient psychosis occur rarely among children under the age of 10 years. In such cases, electroencephalograms typically reveal diffuse, nonspecific, slow waves. In most cases burn encephalopathy can be attributed to hypoxemia, hyponatremia, hypovolemia, septicemia, and drug administration. Hallucinations are uncommon, but when they do occur, stress is the most likely cause, followed by pain and various medications. These symptoms, though short lived, are upsetting to the family and treatment team.

Proper treatment must first address organic causes of delirium or encephalopathy. The nurse must stabilize vital signs and normalize blood chemistries, glucose, and oxygenation. Sepsis must be ruled out and pain addressed. Then psychotropic medications may be administered (Thomas, Meyer, and Blakeney, 2007). There is usually full neurologic recovery, even with prolonged and serious manifestations.

Stop the Burning Process: The chief aim of rescue in flame burns is to smother the fire, not fan it. Children tend to panic and run, which serves only to spread the flames and make assistance more difficult. Place the injured child in a horizontal position and rolled in a blanket, rug, or similar article, taking care to not cover the head and face because of the danger of inhaling toxic fumes. If nothing is available, the victim should lie down, cover the mouth with the hands, and roll over slowly to extinguish the flames. Remaining in the vertical position may cause the hair to ignite or may lead to the inhalation of flames, heat, or smoke.

Major burns with large amounts of denuded skin should briefly be cooled with a single application of tepid water. Heat is rapidly lost from burned areas, and additional cooling leads to a drop in core body temperature and potential circulatory collapse. Continuous wet dressings or the application of ice promotes vasoconstriction because of cooling, resulting in impaired circulation to the burned area and increased tissue damage. Chemical burns present special circumstances and require flushing with copious amounts of water during transport to a medical facility. The use of neutralizing agents on the skin is contraindicated because a chemical reaction is initiated and further injury may result. If the chemical is in powder form, the addition of water may spread the caustic agent. The powder should be brushed off if possible. If the chemical burn produces a blister, it is advisable to open the blister with a sterile object to remove any chemical present.

Remove burned clothing to prevent further damage from smoldering fabric and hot beads of melted synthetic materials. Also remove jewelry to eliminate the transfer of heat from the metal and constriction from edema formation. These steps also provide better access to the wound and preclude more painful removal later on.

Assess the Victim’s Condition: As soon as the flames are extinguished, assess the victim’s condition. Airway, breathing, and circulation are the priority concerns. Cardiopulmonary and cerebral emergencies are always a consideration after trauma. Cardiopulmonary complications may result from exposure to electric current, inhalation of toxic fumes and smoke, hypovolemia, and shock. Institute emergency measures as appropriate.

Cover the Burn: Cover the burn wound with a clean dry cloth to prevent contamination and alleviate pain by eliminating air contact. Cover the child who has extensive burns to prevent hypothermia. No attempt should be made to treat the burn. The application of topical ointments, oils, or other home remedies is contraindicated.

Transport the Child to Medical Aid: Do not give the child with an extensive burn anything by mouth to avoid aspiration in the presence of paralytic ileus and upper airway edema and to prevent water intoxication. The child is transported to the nearest medical facility. If this cannot be accomplished within a relatively short time, establish IV access if possible with a large-bore catheter. Oxygen, if available, is administered at 100%. Give a report of the initial assessment and any interventions implemented to the medical facility assuming responsibility for the child’s care.

Provide Reassurance: Providing reassurance and psychologic support to both the family and the child helps immeasurably during postinjury crisis. Reducing anxiety helps conserve the energy needed to cope with the physiologic and emotional stress of a traumatic injury.

Establishment of an Adequate Airway: The first priority of care is airway maintenance. Thermal injuries to the face, nares, and upper torso; a history of injury in an enclosed space; an examination of the oral and nasal membranes that reveals edema, hyperemia, and blisters; and evidence of trauma to the upper respiratory passages all suggest inhalation of noxious agents or respiratory burns. If there is evidence of respiratory involvement, administer 100% oxygen and determine blood gas values, including carbon monoxide levels.

If the child exhibits changes in sensorium, air hunger, or other signs of respiratory distress, insert an endotracheal tube to maintain the airway. When severe edema of the face and neck is anticipated, perform intubation before swelling makes it difficult or impossible. A controlled intubation is preferred to an emergency procedure. Intubation allows for the delivery of humidified oxygen, the removal of secretions from respiratory passages, and the provision of ventilatory support.

Treatment may include bronchodilators (e.g., albuterol) to reduce bronchospasm. Bronchopulmonary hygiene to prevent atelectasis and pooling of secretions reduces the risk of pneumonia. Therapies include percussion and postural drainage, frequent position changes, and suctioning to remove secretions. Placing the child in a semi-Fowler position with high-flow oxygen and maximum humidity is often sufficient to relieve bronchospasm produced by trauma to the bronchial mucosa.

When full-thickness burns encircle the chest, constricting eschar may limit chest wall excursion. The child becomes increasingly difficult to ventilate. Escharotomy of the chest relieves this pressure and improves ventilation.

Fluid Replacement Therapy: The objectives of fluid therapy are compensation for water and sodium losses to the traumatized area and the interstitial spaces, replenishment of sodium deficits, restoration of circulating volume, provision of adequate perfusion, correction of acidosis, and improvement of renal function. Initiate treatment for burn shock in children with burns in excess of 15% to 20% of TBSA.

Types of fluid and electrolyte therapy in the first 24 hours after injury remain controversial. Lactated Ringer solution appears to be the most common resuscitation fluid currently used. Proponents of crystalloids alone for resuscitation report that other solutions, specifically colloids, are no better and certainly more expensive than crystalloids for maintaining intravascular volume after burn injury. The most common reason for not using colloids is that even large proteins leak from the capillary after burn injury (Warden, 2007).

The composition of the fluid administered varies with the philosophy of the individual practitioner and may consist of an isotonic saline solution, a near-isotonic solution, or even a hypertonic saline solution. Children’s decreased tolerance to hypertonic solutions may result in hypernatremia, hyperosmolality, and intracellular dehydration. Many formulas have been proposed as guidelines for fluid administration after burn injury. Perhaps the most commonly employed regimen is the Parkland formula. It is important to remember that any formula used during resuscitation serves only as a guideline; individual adjustments must be made based on the patient’s response to therapy. Fluid replacement is maintained at a rate that provides an hourly urinary output of 30 ml in older children and 1 to 2 ml/kg in children weighing less than 30 kg (66 lb). Other parameters monitored during fluid resuscitation include vital signs, capillary refill, and sensorium.

Some common reasons for patients to require fluids well in excess of the calculated volume include underestimation of burn size (particularly in pediatric patients), pulmonary injury that sequesters resuscitation fluid in the lung, electrical injury with greater tissue destruction than is visible, and delay in the initiation of fluid resuscitation (Smith, 2000). Irreversible burn shock that persists despite aggressive fluid resuscitation remains a significant cause of death in the immediate postburn period. Exchange transfusion consisting of the replacement of circulating volume by banked whole blood provides a therapeutic modality that may benefit the patient who fails to respond to conventional resuscitation. Inflammatory response factors, thought to be important in burn shock, are removed, thus lowering the concentration present in the body, restoring capillary integrity, and substantially reducing fluid requirements.

After the initial 24 to 48 hours, the capillary seal is restored. Fluid requirements decrease to a constant that persists until wound coverage is achieved. Colloid solutions such as albumin or plasma are useful to maintain plasma volume. Fluid balance may continue to be a problem throughout the course of treatment; especially during periods of increased evaporative loss from the burn wound. Approximately 48 to 72 hours after injury, interstitial fluid returns to the vascular compartment and diuresis occurs to eliminate excess fluids. During this phase, increasing intake to match urinary output can result in circulatory overload.

Nutrition: For 2 or 3 days immediately after injury, burn patients experience a hypometabolic phase when their metabolic rate and cardiac output decrease. Following this phase patients experience a hypermetabolic phase. This hypermetabolism is characterized by a hyperdynamic circulatory response with increased body temperature, oxygen and glucose consumption, carbon dioxide production, glycogenolysis, proteolysis, and lipolysis. This response begins on the fifth postburn day and continues up to 9 months after the burn, causing erosion of lean body mass, muscle weakness, immunodepression, and poor wound healing (Norbury and Herndon, 2007). This hypermetabolism is thought to slow wound healing, prolong generalized weakness, lead to loss of lean body mass, and increase morbidity (Lee and Herndon, 2007). Nutritional support, particularly through enteral feedings, recently has become more aggressive. The continuity of these feedings is important.

Some burn patients are able to eat. Encourage a high-protein, high-calorie diet as soon as possible after resolution of paralytic ileus. However, many have poor appetites and are unable to meet energy requirements solely by oral feeding. Most children with burns in excess of 25% TBSA require supplementation with tube feeding. An absence of bowel sounds does not preclude enteral nutrition. Because the small bowel maintains motility and absorptive capabilities, the placement of a small-bore feeding tube into the duodenum allows for the safe delivery of enteral nutrition during periods of paralytic ileus associated with trauma, sepsis, and anesthesia. A nasogastric tube that decompresses the stomach protects the patient from aspiration.

Use of total parenteral nutrition (TPN) has now been essentially replaced by enteral nutrition for both theoretical and practical reasons. Enteral nutrition directly nourishes the bowel mucosa with nutrients (e.g., glutamine). Small amounts of these nutrients within the bowel lumen stimulate the function of intestinal cells and normal mucosa function. This may help preserve normal blood supply to the intestines. Maintaining intestinal integrity may reduce bacterial translocation and sepsis, as well as preserve immune function. Along with the hazards of central venous access, TPN appears to be associated with increased secretion of tumor necrosis factor and other proinflammatory mediators (Saffle and Graves, 2007).

Specific guidelines for vitamin and micronutrient supplementation for the burn patient have not been established. Limited research has been done on the homeostasis of vitamins and trace elements after burn injury (Klein, Przkora, and Herndon, 2007).

Medication: Antibiotics are usually not administered prophylactically. The administration of systemic antibiotics to control wound colonization is not indicated, since decreased circulation to the injured area prevents delivery of the medication to areas of deepest injury. Surveillance cultures and monitoring of the clinical course provide the most reliable indicators of developing infection. Appropriate antibiotics can then be instituted to treat the identified organism. Group B streptococci cultured from the throat or wounds are particularly destructive to grafted tissue. Do not overlook otitis media as a source of fever in the pediatric population.

Some form of sedation and analgesia is required in the care of burned children (Henry and Foster, 2000). During the initial resuscitation period, IV administration of narcotics, along with anxiolytics, is required for baseline and procedural pain management. Morphine, fentanyl (Sublimaze), and midazolam (Versed) are the most commonly used agents (Kahana, 2003). (See Pain Management, Chapter 7.)

Anesthetic agents such as nitrous oxide, propofol, and ketamine also are used to control procedural pain. A major drawback with nitrous oxide is that staff is exposed to the gas because it is self-administered by the patient. Propofol is a nonbarbiturate hypnotic agent without analgesic activity. It also causes depressed respiratory drive, loss of airway reflexes, and hypertension. Propofol must be given in doses large enough to cause loss of consciousness to prevent response to painful procedures. Ketamine may preserve airway reflex; however, side effects may be noted such as production of copious upper airway secretions, tachycardia, and hypertension. Ketamine can produce postadministration hallucinations, particularly in adolescent boys. Repeated use may produce tolerance, so increased doses are required over time. To avoid volatile anesthetics, a combination of midazolam and fentanyl can be given intravenously (Meyer, Patterson, Jaco, et al, 2007).

Primary Excision: In children with large, full-thickness burn wounds, excision is performed as soon as the patient is hemodynamically stable after initial resuscitation. Because the burn wound is precipitating the exaggerated physiologic response, many associated complications do not resolve until the eschar is excised and the wound is closed. One of the most effective therapies for decreasing mortality from major burn injuries is the early excision of the burn wound and its coverage by various techniques (Barrow and Herndon, 2007).

Wound Hygiene: Hydrotherapy is used to cleanse the wound and assist with separating eschar. There are variances from institution to institution on the particular method, but the common approach is to cleanse and débride once or twice a day. Hydrotherapy helps cleanse not only the wound but the entire body and also aids in maintenance of range of motion. Partial-thickness wounds require débridement of devitalized tissue to promote healing. Débridement is very painful and requires some type of analgesia before the procedure. The water acts to loosen and remove sloughing tissue, exudate, and topical medications. Mesh gauze entraps the exudative slough and is readily removed during hydrotherapy (Fig. 29-7). Any loose tissue is carefully trimmed away before the wound is redressed (Fig. 29-8).

Wound Dressings: Daily dressing changes of the burn wound are recommended to allow for inspection and cleansing of the wound. Dressing changes offer an opportunity to meticulously observe the burn for infection. The volume of draining and the physical condition of the dressing also dictate frequency of dressing change. Often wound dressings become saturated, soiled, or disheveled, indicating that additional dressing changes may be required (Hartford and Kealey, 2007).

Topical Antimicrobial Agents: Several methods are used for covering the burn wound (Box 29-14 and Fig. 29-9). All meet the objective of preparation for permanent wound coverage, and all use some type of topical agent. Before the development of effective topical agents for reducing the incidence of invasive organisms, wound sepsis was the major cause of mortality from burn injury. The goal is to minimize wound colonization. A variety of specific agents are available, including silver sulfadiazine (Thermazene), mafenide acetate (Sulfamylon), and bacitracin. Topical agents do not eliminate organisms from the wound but can effectively inhibit bacterial growth. To be effective, a topical application must be nontoxic, capable of diffusing through eschar, harmless to viable tissue, inexpensive, and easy to apply. It should not encourage the development of resistant strains of bacteria and should produce minimum electrolyte derangement.

Some topical agents are packaged and prepared on a fine-mesh gauze, which allows ease of application (Fig. 29-10). The gauze provides necessary protection for the wound, maximizes patient comfort, increases the rate of healing, reduces the necessity for frequent dressing changes, and is cost-effective. Examples include a nanocrystalline film of pure silver (Acticoat and Silverlon) and a hydrofiber with ionic silver (Aquacel Ag). Most often these gauzes are used on superficial second-degree burns, on donor sites, and for graft care, except for Acticoat, which can also be used for full-thickness wounds (Bessey, 2007).

Temporary Skin Substitute: Permanent coverage of extensive burns is a prolonged process that requires repeated operations for débridement and grafting. Temporary skin substitutes provide transient physiologic wound closure, thereby helping control pain, absorb wound exudates, and prevent wound desiccation (Sheridan and Tompkins, 2007a). Temporary skin substitutes markedly reduce pain and facilitate movement of joints to retain range of motion.

Allograft (homograft) skin comes from human cadavers and is processed by commercial skin banks (Box 29-15). These skin banks screen donors for communicable diseases and track the skin much like blood transfusions. Allograft skin is particularly useful in the coverage of surgically excised, deep partial-thickness and full-thickness wounds in extensive burns when available donor sites are limited. Severe immunosuppression occurs in massively burned children, and the allograft becomes adherent (Fig. 29-11). The allograft can remain in place until suitable donor sites become available. Typically rejection occurs approximately 14 days after application. The use of an allograft is limited by the availability of tissue banks and the supply of suitable donors.

Although various animal skins have been used for many years to provide temporary coverage of wounds, only porcine xenograft is widely used today. Porcine xenograft does not vascularize, but it will adhere to a clean superficial burn and provide excellent pain control while the burn heals (Sheridan and Tompkins, 2007a). Pigskin dressings are replaced daily or every 2 or 3 days. They are particularly effective in children with partial-thickness scald burns of the hands and face because they allow relatively pain-free movement, which reduces contracture formation and has the added benefit of improving appetite and morale (Fig. 29-12).

When applied early to a superficial partial-thickness injury, biologic dressings appear to accelerate wound healing. They create an environment at the wound surface that is conducive to epithelial growth; this is in contrast to topical antimicrobial agents, which may slow epithelialization. Biologic dressings must be applied to clean wounds. If the dressing covers areas of heavy microbial contamination, infection occurs beneath the dressing. In the case of partial-thickness burns, such an infection may convert the wound to a full-thickness injury. It is important to observe the wound daily for any signs of an infectious process.

Synthetic Skin Coverings: A number of satisfactory skin substitutes are available for the management of partial-thickness burn wounds. Ideally, the dressing should provide many of the properties of human skin: adherence, elasticity, durability, and hemostasis. Synthetic skin substitutes are readily available, have varied shelf lives, and are relatively expensive.

Synthetic dressings are composed of a variety of materials and can be used successfully in the management of superficial partial-thickness burns and donor sites. These dressings do not contain antimicrobial properties. Examples include a pertrolatum dressing (Xeroform), synthetic silicone meshed products (Biobrane), a hydrocolloid dressing (DuoDERM), and transparent adhesive films (OpSite and Tegaderm) (Bessey, 2007). As with biologic dressings, it is important that the wound be free of debris before applying the dressing. Body temperature elevation or evidence of purulence, erythema, or cellulitis around the wound edges may indicate that the wound has become infected beneath the dressing. Prompt discontinuance of the synthetic dressing is indicated. All synthetic dressings are reputed to hasten wound healing and reduce discomfort.

Artificial Skin: Integra, a biologic two-layer product that allows the dermis to regenerate, has significantly improved burn wound healing and decreased scar formation. It is applied to partial- and full-thickness burns. The inner layer is porous woven fiber made of a pure form of collagen (a fibrous protein taken from animal tendons and cartilage) and other materials designed to induce better regeneration of the patient’s normal tissue. The outer layer is a soft silicone membrane that holds moisture for 2 to 3 weeks. The silicone layer is peeled off after the dermis is formed. The application of artificial skin does not replace the grafting procedure, but it prepares the burn wound to accept an ultrathin autograft. Advantages include faster healing of the burn wound when integrity of the dermis is restored, faster healing of donor sites with the use of ultrathin grafts, and restoration of sweat glands and hair follicles. A disadvantage is its high cost.

Permanent Skin Coverings: Permanent coverage of deep partial- and full-thickness burns is usually accomplished with a split-thickness skin graft. This graft consists of the epidermis and a portion of the dermis removed from an intact area of skin by a special instrument: the dermatome (Fig. 29-13). If all the wounds cannot be grafted at once, there are priority areas for coverage: the face, hands, joint surfaces, and neck. These preferential sites are chosen to hasten healing, establish function, and improve the patient’s sense of well-being.

With extensive burns it is often difficult to find enough viable skin to cover the wounds; therefore available donor sites are used to the best advantage by special techniques. Box 29-15 describes the various types of split-thickness skin grafts. Sheet grafts (Fig. 29-14) are used in areas where cosmetic results are most visible; mesh grafts (Fig. 29-15) result in a less desirable cosmetic and functional outcome. Requirements for the successful vascularization of any graft are listed in Box 29-16.

Until blood supply to the grafted skin is established, it is nourished by osmotic interchange with the recipient bed. Wound healing occurs as the area releases fibrin, which attaches the graft to the bed. The fibrin is infiltrated by leukocytes, fibroblasts, and the capillary buds of the granulation tissue. This process begins within hours of grafting, and vascularization is established after 3 days. Within 2 weeks the graft is attached to the recipient bed by connective tissue.

The donor site is dressed with synthetic wound coverings or fine-mesh gauze until the dressing separates at 10 to 14 days, when the wound is healed. Dressings are not changed on donor sites to avoid damage to newly healed, delicate epithelium. Healed donor sites are available for reharvesting in patients with extensive burns and limited undamaged skin (Fig. 29-16). The quality of skin from donor sites is decreased when multiple grafts are taken.

Cultured Epithelium: For more than 20 years it has been possible to culture vast numbers of epithelial cells from a small skin biopsy, and this has led to the widespread use of cultured epithelial grafts to cover burns. Colonies of epithelial cells expand into broad sheets of undifferentiated epithelial cells. The resulting sheets are attached to a petrolatum gauze carrier to ease handling. Many of the imperfections associated with epithelial cell wound closure may be attributed to the lack of dermis. Despite scattered cases, application of cultured epithelial grafts onto artificial skin has not been proven effective (Sheridan and Tompkins, 2007a). High cost is a disadvantage of using both applications.

Comfort Management: The severe pain of the wound and resultant therapies, the anxiety generated by these experiences, sleep deprivation, itching related to wound healing, and the conscious and unconscious interpretations of traumatic events contribute to the psychologic reactions and behaviors commonly observed in children with burns. It is important to assess the individual experiences and needs of the burn-injured child. A common myth in pediatrics is that children do not feel pain as intensely as adults do. What may be more accurate is that children do not always express their pain in the same way as adults. Children may display pain through behaviors of fear, anxiety, agitation, anger, aggression, tantrums, depression, withdrawal, and regression.

How the child’s experience of pain from the burn injury and anxiety from the hospitalization are managed has lasting psychologic effects. A careful nursing history that includes the child’s past experiences with pain and ways that caregivers successfully handled those events may provide clues to the control of current pain. Caregiver involvement is especially important for a child (Lee and Herndon, 2007). Interventions may include medications (including IV morphine and short-term anesthetics such as propofol or ketamine), relaxation techniques, distraction therapy, cutaneous stimulation by touching, and family participation. Nonpharmacologic therapies may be used as adjuncts in the treatment of pain. In young children, distraction and imagery work well (Kahana, 2003; Henry and Foster, 2000).

To reduce the anxiety associated with an unfamiliar environment and frightening treatments, it is important to offer thorough, age-appropriate explanations to the child before procedures. Compounding the pain is the child’s interpretation of it and of the procedure; this is closely related to the child’s developmental level. Children often feel anger, guilt, and depression; as in all illnesses, they may also exhibit regressive behavior. When children appear to accept pain with little or no response, psychologic consultation is in order.

Care of the Burn Wound: The nurse has a major responsibility for cleansing, débriding, and applying topical medications and dressings to the burn wound. Because dressing removal is a painful procedure, children should receive adequate analgesia before the scheduled dressing change. The nurse should administer medication so that the drug’s peak effect coincides with the procedure. Children who have an understanding of the procedure to be performed and some perceived control demonstrate less maladaptive behavior. Children respond well to participating in decisions and the actual procedure as their condition allows.

With some children, nonpharmacologic interventions are effective means of coping with pain. Distraction therapy, deep breathing, and relaxation techniques may facilitate the procedure. Most children also benefit from parental participation. Medical play is often effective in helping the younger child gain some mastery over the procedure. Incorporate those techniques that work best for the individual patient into the care plan and consistently implement them during the dressing change procedure.

Outer dressings are removed; any dressings that have adhered to the wound are easier to remove by applying tepid water. Loose or easily detached tissue is also débrided during the cleansing process. Encourage children to participate in dressing removal. Giving them something constructive to do helps them focus on something other than the procedure. In dressing the wound, it is important that all areas be clean, that medication be amply applied, and that no two burned surfaces touch each other (e.g., fingers or toes, or ears touching the side of the head). If touching, the burned surfaces will heal together, causing deformity or dysfunction.

Topical medications are applied directly to the wound with a clean gloved hand or impregnated into fine-mesh gauze before application. Then apply dressings to assist in exudate absorption, wound débridement, and increased patient comfort. All dressings applied circumferentially should be wrapped in a distal-to-proximal manner. Apply the dressing with sufficient tension to remain in place without impairing circulation or limiting motion. A stable dressing is especially important when the child is ambulatory.

Burns that involve the eyelids require special care to prevent corneal ulceration. No solution other than saline should come in contact with the eyes during the cleansing process. Avoid vigorous débridement in this area of thin, delicate tissue. Assess the patient throughout the healing process for the ability to close the eyes. Inability to close the eyes because of contracture formation, administration of paralytic agents, or corneal burns requires instilling ophthalmic ointment and covering the eyes with a patch to prevent further corneal damage (Achauer and Adair, 2000).

Universal Precautions, including the use of protective garb and barrier techniques, should be followed when caring for all patients with thermal injuries. Frequent hand and forearm washing is the single most important element of the infection control program. Implement strict policies for cleaning the environment and patient care equipment to minimize the risk of cross-contamination. All visitors and members of other departments should be oriented to the infection control policies, including the importance of hand and forearm washing and use of protective garb. Screen all visitors for infection and contagious diseases before patient contact.

Nutrition: Oral feedings are common unless the child is intubated or paralytic ileus persists. Because children often lack an appetite, the nursing staff must provide a great deal of encouragement, help, and patience. Consultation between the parents and dietitian helps determine food preferences. Include children who are old enough to participate in meal planning.

Nourishing snacks are provided between scheduled meals. Painful procedures should not be scheduled around meals; most children are too physically exhausted and emotionally upset to eat at this time. Many children eat better in an atmosphere more nearly like what they are accustomed to at home. When their condition allows, children enjoy sitting at a table for meals and interacting with other children.

Children who require enteral supplementation by tube feeding must be monitored on an ongoing basis for intolerance and tube malposition. The nurse should monitor and record any indications of abdominal distention, diarrhea, or electrolyte and metabolic derangement. Accurate documentation of oral, parenteral, and enteral nutritional intake is essential to evaluate the adequacy of nutritional support.

Prevention of Complications: Acute Care: The maintenance of body temperature is important to the child with burns. Reduction of heat loss is imperative to decrease energy demands and evaporative water loss. Ambient temperatures and humidity should be maintained at 28° to 33° C (82.4° to 91.4° F) and 80%, respectively, to control heat loss (Lee and Herndon, 2007). Large areas of the body should not be exposed simultaneously during dressing changes. Warmed solutions, linens, occlusive dressings, heat shields, a radiant warmer, and warming blankets assist in preventing hypothermia. The optimum environment for the child with burns can be uncomfortable for persons attending the child.

The chief danger during acute care is infection—wound infection, generalized sepsis, or bacterial pneumonia. The burn wound should be assessed for changes indicative of wound infection, which include conversion of a partial-thickness to a full-thickness burn injury, early eschar separation, subeschar hemorrhage, degeneration of granulation tissue, discoloration of unburned skin at the wound margins, or green discoloration of subcutaneous fat (indicative of Pseudomonas and other gram-negative organisms). In addition to the signs of developing wound infection, the child with systemic sepsis may have a core temperature of more than 38.5° C (101.3° F) or less than 36° C (96.8° F), tachycardia, tachypnea, and leukocytosis or leukopenia. Tachycardia and tachypnea are common presenting symptoms in many pediatric diseases. Children with septic shock often maintain a normal BP until they are severely ill. Shock may occur long before hypotension in children. It is a sign of late and decompensated shock. Meticulous assessment should include signs of decreased perfusion (including decreased peripheral pulses), altered alertness, prolonged capillary refill (2 seconds), mottled or cool extremities, or decreased urinary output (Goldstein, Giroir, and Randolph, 2005).

Children are reluctant to move when doing so causes pain, and they are likely to assume a position of comfort. Unfortunately, the most comfortable position is often one that encourages the formation of contractures and loss of function. Ongoing efforts to prevent contractures include the positioning and splinting of involved extremities in extension, active and passive physical therapy, and the encouragement of spontaneous movement when feasible. In addition to maintenance of proper body alignment, frequent position changes are important to improve bronchopulmonary hygiene and capillary perfusion to common pressure areas. Low–air loss beds are beneficial for the morbidly obese or for children with posterior grafts. Areas of particular concern for pressure area development in the pediatric population are the posterior scalp, heels, and areas exposed to mechanical irritation from splints and dressings.

Prevention of Complications: Long-Term Care: The rehabilitative phase of care begins once wound coverage has been achieved. Scar formation becomes a major problem as burn wounds heal (Fig. 29-17). The scar tissue is metabolically active and highly vascular; collagen is deposited in an undefined pattern. Contractile properties of the scar tissue can result in disabling contractures, deformity, and disfigurement. As long as the scar is raised, red, and firm, it is considered active (Fig. 29-18). Hypertrophic scarring typically reaches a peak approximately 4 to 6 months after wound healing, and most scars mature or become inactive in 1 to 2 years. The mature scar is characterized by pigmented color, flattening, and increased suppleness of the tissue (Fig. 29-19).

Uniform pressure applied to the scar decreases the blood supply and forces the collagen into a more normal alignment. When pressure is removed, blood supply to the scar is immediately increased; therefore periods without pressure should be brief to avoid nourishment of the hypertrophic tissue. Continuous pressure to areas of scarring can be achieved by elastic bandages or commercially available pressure garments. Because these custom-made garments are often worn for months, revision may be required as the child grows. It is much easier to prevent scarring and contracture of the wound than to resolve an existing problem. Splints and appliances may also be necessary until wound maturation occurs (Fig. 29-20). Part of outpatient and home care often includes the continuation of regular physical therapy (Fig. 29-21).

Scar tissue has certain significant properties, particularly for growing children. Intense itching occurs in healing burn wounds and scar tissue until the scar is no longer active. Itching is usually treated with hydroxyzine (Atarax) or diphenhydramine and frequent applications of a moisturizer, such as Eucerin, cocoa butter, or Nivea. Massage therapy during the application of moisturizers is also beneficial to stretch scar tissue and help prevent contracture. Scar tissue has no sweat glands, and children with extensive scarring may experience difficulty during hot weather. Alert caregivers to this possibility and make sure they are prepared to institute alternate methods of cooling when necessary.

Scar tissue does not grow and expand like normal tissue, which may create difficulties, especially in functional areas such as the hands and over joints. Additional surgery is sometimes required to allow independent functioning in daily activities, to improve cosmetic appearance, or to restore anatomic integrity. Reconstructive surgery employs various techniques, including local or distant flaps, full- or partial-thickness grafts, tissue expanders, or pedicle flaps.

The nursing activities in the rehabilitative phase of treatment focus on the child’s and family’s adaptation to the burn injury and their ability to reintegrate into the community. The multidisciplinary team approach remains the model for support of the child and family (Fig. 29-22).

The psychologic pain and impact of severe burn injury are as intense as the physical trauma. The impact of severe burns taxes the capabilities at all ages. Very young children, who suffer acutely from separation anxiety, and adolescents, who are developing an identity, are probably the most affected psychologically. Toddlers cannot understand why the parents they love and who have protected them can leave them in such a frightening and unfamiliar place. Adolescents, in the process of achieving independence from the family, find themselves in a dependent role with a damaged body. Being different from others at a time when conformity with peers is so important is difficult to accept.

Anticipation of the return to school can be overwhelming and frightening. It is essential that health care professionals recognize the importance of preparing teachers and classmates for the child’s return. Provide teachers with information to assist the child and family and to promote the child’s optimum adjustment. Hospital-sponsored school reentry programs use a variety of methods to provide education and information about the implications of the injury, the garments and appliances, and the need for support and acceptance. Telephone calls, videotapes, information packets, and visits by members of the health care team offer opportunities to help with reintegration into the school environment—a focal point of the child’s life.

Psychosocial Support of the Child: Children should begin early to do as much for themselves as possible and to be active participants in their care. Loss of control and perceived helplessness may result in acting-out behaviors. Nurses should be sensitive to these feelings and allow the child the opportunity for choices and decision making as the condition allows. At the same time, it is important to set boundaries and establish a daily schedule to provide a sense of predictability, security, and control. During illness, children regress to a previous developmental level that allows them to deal with stress. As children begin to participate in their care, they gain in confidence and self-esteem. Fears and anxieties diminish with accomplishment and self-confidence. If the child demonstrates nonadherence in the rehabilitative phase, initiate a behavior modification program to promote or reward the child’s accomplishment in care.

Select and encourage activities on the basis of each child’s developmental level and interest. Quiet activities such as reading, coloring, and games are always appropriate. Critically ill children enjoy tapes and stories, even though they may not be able to actively participate in play. Television is a satisfactory diversion but should not replace contact with others. Play that encourages the expression of anger, frustration, and guilt is especially therapeutic. Medical play is a valuable tool to teach children what to expect and their role in the treatment process. School-age children benefit by continuing study activities as they are able.

Children need to feel they look nice. The burns, dressings, and medical equipment do little to foster a positive self-image. Small things, such as careful hair combing, a bright ribbon or pajamas, a pretty blanket, or colorful stickers will help them feel better about themselves and feel worthwhile to others.

Children need to know that their injury and the treatments are not punishment for real or imagined transgressions and that the nurse understands their fear, anger, and discomfort. They also need body contact. This is often difficult to arrange for the child with massive burns; stroking areas of unburned skin is comforting. Even older children enjoy sitting on the nurse’s or parent’s lap and being cuddled and hugged. This can be a reward or a comfort in times of stress, but most of all it is a natural part of childhood.

Psychosocial Support of the Family: There is a growing recognition that trauma affects not only the victim but also those closest to the child. Severe trauma challenges the belief that the world is safe and predictable. Parents and other family members are concerned about the child’s survival, recovery, and future potential. Recognizing and respecting each family’s strengths, differences, and methods of coping allows the nurse to respond to their unique needs by implementing a family-centered approach to care. It is the family, particularly the parents, who are the most significant persons in the child’s life.

As in any emergency situation, all attention is focused on the child, and the parents feel powerless and ineffectual. Most parents feel overwhelming guilt, whether or not the guilt is justified. They feel responsible for the injury. These feelings may have a negative effect on the child’s rehabilitation. For example, parents may indulge the child and allow poor behavior that affects physical and emotional recovery.

Nurses have the opportunity to assist parents in coping with the stresses of the child’s illness and with their own feelings of guilt and helplessness. The parents need to be informed of the child’s progress and assisted in coping with their feelings while providing support to their child. The nurse can help them understand that it is not selfish to look after themselves and their own needs to better meet the needs of their child. Definitive professional help may be needed for parents whose response to the injury is severe or whose response to stress is manifested in destructive behavior.

The parents are members of the multidisciplinary team and participate in the development of the care plan. It is important to address their input to consider all aspects of the physical, emotional, social, and cultural factors affecting the child and family and to establish a realistic home therapy program. The family’s willingness to assume responsibility for care and their ability to implement the therapeutic regimen are assessed. Explore home, school, and other environmental factors with the family, as well as financial concerns and available community resources. The nurse can then develop a specific care plan, with an anticipated follow-up program.

Caring for the Caregiver: Burn care is a complex and demanding specialty. Nurses who choose this field reap many rewards and endure many stresses. Ongoing support from peers, the multidisciplinary team, and nursing management is important to assist burn nurses in caring for themselves so they can continue to render high-quality care to their patients.

1. Yes, there are sufficient data for the nurse practitioner to arrive at some conclusions.

2. a. See Table 28-3, p. 1059, Evaluating Extent of Dehydration, and note the criteria for mild dehydration.

3. At present, Mary meets all the criteria for mild dehydration. It is highly probable that she has acute infectious diarrhea because her mother noted that she has had a “cold” for several days and she is vomiting, has diarrhea, and has an elevated temperature. The priority for nursing care at this time is to provide rehydration via an oral rehydration solution (ORS). ORS is an effective, safe, and cost-effective way to treat mild dehydration. The nurse practitioner should instruct the mother to give Mary ORS at frequent intervals and in small amounts. The mother should also be instructed to continue with breast-feeding and normal feedings. Early reintroduction of normal nutrients is desirable in cases of mild dehydration; delayed introduction of food may be harmful and can prolong the illness. Mary’s mother should also be told to avoid the use of antidiarrheal medications.

4. Yes, the evidence supports this initial plan of management.