Pediatrics, part 91: Integumentary Disorders - Nursing Care of Burns

Hi, I'm Cathy with Level Up RN. In this video, I'll be discussing nursing care of pediatric patients with burn injuries, focusing on the key information that you need to know in nursing school. At the end of the video, I'm going to give you guys a quiz to test your understanding of some of the key facts I'll be covering. So definitely stay tuned for that. And if you've been following along with our video playlist using your Pediatric Nursing flashcards, we are all the way at the end of this deck, so you did it. If you do have our flashcards, be sure to pull out your flashcards on burns and pay close attention to the bold red text on the back of these cards because those are the things that you are likely to get tested on in nursing school.

The first thing I want to talk about is how to evaluate the depth of a burn injury. So some sources may just include information on superficial, partial-thickness, and full-thickness burn injuries. However, many nursing textbooks go into more detail about burn depths, and they include superficial, superficial partial-thickness, deep partial-thickness, full-thickness, and deep full-thickness. So that is the level of detail that I'm going to go over now and what we've included in our flashcards.

With a superficial or first-degree burn, damage is limited to the epidermis. The skin will be intact and red or pink in color. There will not be any blisters present, and the burn will heal without scarring. An example of a superficial burn is a sunburn.

With a superficial partial-thickness burn, which is a second-degree burn, damage occurs to the upper part of the dermis. The affected area will be red in color, and blisters will be present. This type of burn usually heals with minimal scarring. With a deep partial-thickness burn, which is still considered to be a second-degree burn, there is damage to the lower part of the dermis. The affected area is often yellow or white in color, and when the wound heals, scarring typically occurs.

With a full-thickness burn, which is a third-degree burn, damage extends into the subcutaneous tissue. The affected area may be white, brown, or black in color, and it will have a dry, leathery appearance. Pain may not be present because the nerve endings, which are located in the dermis, have been destroyed. This level of burn injury requires skin grafting.

And finally, with a deep full-thickness burn or fourth-degree burn, damage extends beyond the subcutaneous tissue into the muscle, tendon, or bone. The affected area will be black in color with hard inelastic eschar. And again, pain may not be present because the nerve endings in the dermis have been destroyed. And at this level of burn injury, skin grafting will definitely be required.

Another part of your assessment involves estimating the percentage of the child's body that is affected by the burn injury. In pediatric patients, the Lund and Browder chart is more accurate than the rule of nines that is often used in adult patients. So with the Lund and Browder chart, each arm is 10%. The anterior and posterior trunk are 13% each. And then the percentage that you would assign for the head and legs will depend on the child's age. So honestly, in nursing school, I wouldn't get hung up on the details of the Lund and Browder chart. But I would know that this chart would be used for pediatric patients as opposed to the rule of nines.

Another key thing that you need to assess for when a child presents with a burn injury is whether abuse is suspected. If the child presents with symmetrical burns, burns in the shape of an object, such as a cigarette, or when the explanation of what happened is not consistent with the burn injury, then abuse would be suspected. And as the nurse, you are legally obligated to report suspicion of abuse. You do not need to prove anything, but you just need to report your assessment findings that lead you to suspect abuse.

Let's now talk about nursing care during the emergent phase of a burn injury. Of course, we want to stop the burning process. We need to maintain a patent airway, and we would provide oxygen and ventilatory support as needed. We also need to assess for signs and symptoms of smoke-inhalation injury, such as soot around the nares, sooty sputum, and singed eyebrows. Fluid resuscitation is another key thing that needs to be provided during the emergent phase of a burn injury in order to prevent hypovolemia. So you will need to secure IV access with a large-bore catheter and also insert a Foley catheter to closely monitor urine output. You'll be administering lactated ringers with a goal of maintaining urine output between 1 and 2 milliliters per kilogram per hour in children under 30 kilograms and a urine output between 0.5 and 1 milliliter per kilogram per hour in children over 30 kilograms. Other key things that you need to do as the nurse during the emergent phase of a burn injury is administer IV opioids for pain, maintain the child's body temperature, and administer a tetanus vaccination if required.

Once we move from the emergent phase to the acute phase of a burn injury, our focus will be on wound healing, infection control, nutrition, and mobility. In terms of wound healing, your patient may require debridement of the wound and the placement of a skin graft. For a patient with a skin graft, you want to elevate and immobilize the site and also monitor for signs and symptoms of infection. Topical medications that are often used with burn injuries include sulfur sulfadiazine, as well as mafenide acetate. Preventing infection is also key. You would administer antibiotics as prescribed. You would utilize aseptic technique when caring for your patient's wounds. You would restrict visitors per the facility's policy, and you would not allow any fresh plants or flowers in the patient's room. In terms of mobility, in order to prevent contractures, you want to assist the patient with passive and/or active range-of-motion exercises. And then we need to make sure our patient is getting adequate nutrition because they will require additional calories and protein to facilitate wound healing. And in many cases, the patient may require supplementation with TPN or tube feedings.

All right. It's quiz time, and I've got five questions for you.

Question number one. A burn wound that is red in color with the presence of blisters is indicative of what burn depth?

The answer is superficial partial-thickness.

Question number two. The rule of nines should be used to estimate the percentage of a child's body affected by a burn injury. True or false?

The answer is false. A tool that is more accurate for children, such as the Lund and Browder chart, should be used.

Question number three. Sooty sputum and singed eyebrows are signs of what complication of a burn?

The answer is a smoke-inhalation injury.

Question number four. How is the rate of fluid administration determined for a patient with a severe burn injury?

The answer is the rate is determined by the patient's urine output.

Question number five. What kind of analgesics are provided for a patient with a severe burn injury?

The answer is opioid analgesics.

All right. That's it for this video. I hope it was helpful. Thank you so much for watching, and good luck with studying.

[BLOOPERS]

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