NURSING CARE

BURN INJURY IN BURNS UNIT .

CASE STUDY

Group:
MARTIN MWANGI MUITA
BETTY MUTEMBEI KINANU
EMMA BWARI

Gertrude’s school of nursing in partial fulfillment requirement in diploma in

Critical care nursing

Objectives

After accomplished this case, the student will be

- Select the appropriate nursing theory and apply its principles in rendering nursing care to
a patient with suffering second degree burn wound prior.
- Discuss the anatomy and physiology of the integumentary system that are directly
affected in a second degree burn and relate the concept to the actual situation to the
patient
- Explain the pathophysiology of a burn wound infection
- Determine the nursing priorities and nursing management requisite and executable in a
second degree burn case, and incorporate these data with nursing care plan.
- Distinguish the different pharmacologic actions of the drugs involved in treatment of a
second degree.
- Formulate relevant health teachings and outpatient care for a patient with a second degree
after being discharge
INTRODUCTION
A case study of a one and half years old boy admitted in hospital after sustaining
29%burns,according to Lund and Browder the child had 2 nd and 3rd degree burns of the face,
circumferential burn of left upper arm, anterior and posterior of the trunk
A burn is an injury to the skin following exposure to heat source, chemicals, electricity and
radiation. Burns causes severe skin damage in which many of the affected cells die. It represents
one of the most traumas a body can sustain.
Worldwide fire related burns are the most common type of burns with over 90% occurring at
home.84% burns in paediatric occurs at home, particularly in the kitchen,80% are
unsupervised[ CITATION Sto17 \l 2057 ].

Most burns occur in children under 5 years. Scald burn being the most frequent at 79%, mostly
on infants and toddlers when crawling or walking, followed by flame burns and least are
electricity burns. Limbs being the common site of burns at 69%, because most children use
hands to explore (McBride et al, 2020).

DEMOGRAPHICS
Name : Baby B
Age : 1.5years
Sex : male
Activity/ Behaviour : Irritable and consolable
Religion : Christian:
Birth weight : 3100 Grams
Present Weight : 12kg
Diagnosis : 29% burns
Admission Date : 8/1/2020
Discharge Date
Diagnosis : 29% Burns
Physician : Doctor Wambire
PATIENT HISTORY
PRESENTING HISTORY
Child was well till the 8/1/2021, 8.30 p.m. when he accidently hit boiling tea on a stove after
falling from a bed. Sustained burns on face, left arm, anterior and posterior trunk.
The mother reported to a have left for the shop, the immediate neighbour who heard a distress
cry came for the rescue of the child, was taken to the nearby private nursing home was given
analgesia, cleaned the wound, dressed it, then referred to a level 6 hospital for further
management. On arrival the child was reviewed by the doctor, intubated, a nasal gastric tube put
in place and treatment sheet written. Blood sample was collected for total blood count as well for
white blood cells count. Resuscitation fluid of ringers lactate 450ml first 8hours and the next
450mls for the next 16hours and syrup morphine 2mg given.
Vital signs where;
Temperature: 37.8
Pulse : 110 b/m
Respirations: 30 b/m
Spo2 reading: 97%
Later the child transferred to the burns unit for the rest of management
PAST MEDICAL HISTORY
The child has never been admitted before, born to a 23year old mother of Gravid2+0. A highly
exposed infant (HEI), on Niverapine 5ml per oral once daily and Septrin 5mls per orally once
daily.
Delivery was a spontaneous at 38/40 weeks of delivery, no birth trauma, APGAH score of
9/1,10/5,10/10 had weight of 3200gram.
IMMUNIZATION HISORY
He has received all immunization as per Kenya Expanded Program of immunizations (KEPI) as
follows: at birth: Oral polio vaccine birth to prevent polio disease and BCG (a scar visible) to
prevent tuberculosis, 6weeks he received polio vaccine, Pentavalent to prevent him against
diphtheria, pertussis, tetanus, hemophilia influenza type B and hepatitis B, Pneumococcal
vaccine to prevent pneumonia and Rota vaccine to prevent diarrhea diseases, received the same
at week 10. But at week 14 only Rota vaccine was dropped
6months received Measles for prevention of measles and Vitamin A for boosting immunity
1 year Albendazole200mg and Vitamin all well recorded on child welfare booklet

DIETRY HISTORY
The child was exclusively breast fed up to 6 months of age and weaning was introduced,
beginning from semi-solid to solid food. The child mostly likes proteins example; beans ,
potatoes, meat and eggs. Looks generally nourished. Stopped being breastfed at 1 year

FAMILY SOCIAL HISTORY

He is the third born in a family of three. Mother works as casual laborer reason to why she is always away
to vend for the family, a known H.I.V positive client on HAARTs, as well separated with the father when
2months old. Lives in a 1 single Mabati rental house in Bangladesh Ongata Rongai

They don’t have electricity in there house, reason for likelihood of more incidences of accidents in the
house.

SYSTEMIC ASSESSMENT
BEHAVIOUR

FACIAL FEATURES
Mouth

The lips appear pink in color, no fissures present. Buccal mucosa appears pink and moist,
tongues is pink with normal ligament.
Developed milk teeth 8 in number and well arraigned, 4 lower jaw and 4 on upper jaw. Gums not
bleeding and kept clean.
Soft and hard palate are complete and intact
Neck
On palpation the trachea is slightly deviated to the left. Thyroids not enlarged no mass present,
no whiplash, and no nuchal rigidity.
Nose
Sustained a burn of the tip of the nose. The nasal septum was medially placed, separating the
right from the left nostril. Mucosa layer appears pink and moist no discharge.
EARS
NECK
DEVELOPMENTAL MILESTONES

The baby was born at term 38/40 weeks gestation, had a good sucking reflex. Was able to hold
the head, make sounds and had a coordination movement of hands at three months. Weaning
started at 6 months on semi solid food example mashed potatoes. At 11months he would walk
holding on furniture, stand erect with minimal support. At thirteen a Months he would try to utter
some words, at fifteen months he would walk and express himself verbally, in childhood stage.
RESPIRATORY
The child was orally intubated, with an ETT tube size 4.5cm, length of 15cm. On inspection the
chest looked normal of symmetry, no any deformity, no swelling and no tenderness. On
auscultation, there was bilateral entry of air into the lungs. The respiratory rate was 28b/min

GASTROINTESTINAL
The abdomen is normal round shaped. Umbilicus stamp present, no herniation, no scar. On
percussion there was no gas or fluid heard, on palpation no tenderness, the abdomen was soft the
bladder was not palpable nor was it distended.

CARDIOVASCULAR

On inspection, child has normal chest symmetry, no pallor, no deformity. On auscultation the
heart sound S1 and S2 where clearly heard. No murmurs heard. Skin pinch went back
immediately, had capillary refill of less than 2 seconds. The heart rate was- 115b/min and the
blood pressure of-105/62mmHg
NEUROLOGOCAL
Both eyes reacted to light. Had strong muscle tone for both upper and lower limbs.
Total GCS of 15/15 and was well oriented on the environment.
RENAL
On inspection, the palm had no pallor. No sign of peritoneal dialysis scar. The abdomen was not
distended.
On palpation there was no sacral oedema, abdominally the bladder was not palpable, the liver
was not enlarged. The sodium level136mmol/L,potassiumlevels4.8mmol/L,UREA3.tmmol/L and
CREAT 57 mmol/L (Low)
On abdominal percussion, there was no ascites. There was no oedema of the lower limbs.

MUSCULOSKELETAL
On the back inspection there was no protrusion of the disc or a depression, no spondylolysis and
the child showed no sign of pain. The joints moved freely no swelling noted and no tenderness

SKIN
On inspection the skin integrity of the burnt area was impaired. There was burn on the left arm,
the face, the posterior trunk and the anterior trunk. The child had an oedema on the face and on
the left arm, was well hydrated and his extremities had warm temperature gradient
TRUNK
Anterior
On inspection the trunk had 8% burn, on palpation no bulging of the disc nor discontinuity of
spinal cord,
Posteriorly
On inspection it had 8% burns.

GROWTH DEVELOPMENT
Baby B is 1 and half he is under the developmental stage of early childhood. According to Erick
Erickson’s theory the child is at autonomy vs shame. He has mastered a sense of trust when his
basic need is met; the child has moved to master a sense of autonomy. He develops a sense of
shame when not given a chance to assert himself (within his limit) developing a feeling of
inadequate and self-doubt.
Psychosexual development (Freud’s theory), the child is at the anal stage where pleasure is
centred on defecation. The child underwent normal developmental milestones without stagnating
in any of the stages. He has a total of 8 deciduous teeth. He has developed his fine motor
developmental stage as he is able to scribble as reported by the mother. On gross motor
development, the mother reports that the child can run, copies the mother in tasks, on language
development he can speak 6-8 words word vocabulary.
The child’s energy level has reduced as a result of sickness compared to her peers who are
energetic. He prefers sleeping with the mother, as reported. He fears pain especially injection and
painful experiences as well fear being punished. Overview over on the intellectual development
(Piaget’s theory) of early childhood he is in sensory-motor stage of development, the body
organs and muscles have become more functional, he develops rituals and that becomes
significant.
On Moral development (Kohlberg’s theory) the child is at pre-convectional stage, which extends
up to 9 years of age, in the phase, the child see rules as fixed and absolute, he obeys rules to
avoid punishment in order to be rewarded.
NURSING MANAGEMENT

SEVEN+1 STEPS

Mother and child interaction

The primary support system of the child is the family. Mother was actively involved in the child
care especially during feeding, bathing and changing soiled clothes when child opened bowels.
She was however very anxious and concerned due to the child hospitalization and burnt area. She
was reassured and calmed down. All information regarding the child was shared to the mother bit
to bit at different management levels to avoid giving too much information at the same time.

Hydration

With burns there is fluid shift from intravascular to interstitial space, this can lead to
hypovolemia, dehydration, hypovolemic shock and worse acute kidney injury. Rehydration of
this patient was done using ringer lactate 400 mls over first 8 hours, then 400 mls for the next 16
hours and then the child was maintained at 900 mls of ringer lactate alternating with 5% dextrose
for 24 hours. Fluid was stopped the following day as child was retaining well. To avoid
insensible heat loss , patient was kept warm by use of over head heater and use of blanket with
bed cradle to lift the weight off the patient. Heat loss would have futher led to dehydration too.

Nutrition
Good nutrition is important for healing, child was seen by the nutritionist, mother advised to give
child high protein diet which aids in repair of broken tissues thus healing of wounds. Child was
fed by the mother with help of primary nurse. Nutritious fluids like milk, yoghurt was also added
in the child menu.

Pain and comfort

When the skin is burnt, nerve endings are exposed, this makes it very sensitive and painful.
Therefore, pain management is very necessary. For pain management the patient was put on per
oral paracetamol 62.5 mg 8 hourly. 1 mg of oral morphine was given every time before dressing
was done. Comfort of the child was achieved through ensuring dirty and wet linen was changed.
Presence of the mother during wound dressing helped to keep the child calm, and it was
encouraged after reassuring the mother.

Microbial load

Burn wound destroys external protective barrier of the body. This provides an entry venue for
bacteria and other disease causing micro organism, therefore to ensure child was kept free of
infection aseptic technique was used to clean and dress the wound. Application of derma zine
which has antimicrobial property was done with every dressing. There was control of traffic to
the room where only one visitor was allowed to visit the child. Infection control technique such
as hand washing was also done.

Skin integrity

After burn wound, skin is broken thus integrity broken. Due to pain, child assumes a comfortable
position and does not like turning or movements for fear of pain. Therefore, the mother was
encouraged to the child regularly at least every one hour. Turning was closely monitored. This
was done to ensure good blood circulation and prevent development of pressure sores. Flexion
and distention of joints was also done to prevent development of contractures.

Regulatory system

This involves maintaining of the body’s homeostasis. It is important in elimination of waste

products and resting as well as control of body temperature. While at home this child slept about
14 hours per day that is 11 hours at night and around 3 hours during the day. This was kept at
near normal by ensuring child sleep was not interrupted unless during medication time.
Elimination monitoring was done using diapers, and child was passing both urine and stool well.
When child developed high body temperature, antiseptic (paracetamol) was administered, over
head heater turned off and exposure was used too.

NURSING CARE PLANS

Assessment data

Child crying a lot, withdrawing from touch

Nursing diagnosis

Acute pain related to exposed nerve endings as evidenced by child crying a lot and withdrawing
from touch

Desired outcome

Child will be free from pain in 15 minutes time

Child will stop crying

Nursing intervention

Mother was allowed to hold the child to calm him down

Paracetamol 62.5 mg was administered as an analgesic

Wound dressing was done.

Evaluation

Child stopped crying and slept calmly. Thus pain was controlled.

Assessment data

Broken skin (wound)

Nursing diagnosis

Impaired skin integrity related to thermal burn as evidenced by open wound on the skin

Desired outcome

To restore normal skin integrity in about 3 weeks.

Nursing intervention

Provide and feed child with high protein diet

Keep the wound clean and dry

Do change of dressing every alternate day and/ or when dressing is soiled.

Evaluation

Desired outcome was partially met.

Assessment data

Hotness of body. (Body temp of 38.9)

Nursing diagnosis

Ineffective thermoregulation related to disruption of skin integrity as evidenced by child having a

body temperature reading of 38.9 degree Celsius.

Desired outcome

Child will have normal body temp reading of 36.2-37.5 degree Celsius in 15 minutes.

Nursing intervention

Overhead heater was switched off.

Child was exposed.

Mother advised to give child milk that was available at the time. Child was given milk which he
took and retained.

Evaluation

30 minutes later the child had a temperature reading of 37.4 degree Celsius.

Assessment data

Mother asking how burn wound is treated and if it will ever get completely healed

Nursing diagnosis

Knowledge deficit related to management of burn wound and prognosis as evidenced by the
mother asking so many questions

Desired outcome

Mother will be knowledgeable and re assured.

Nursing intervention

Mother was given health education on management of burns to the mother and explained that
with proper management the prognosis is expected to be good.

Evaluation

Mother stopped asking questions, was calm and looking more assured.

Assessment data

Branular insitu

Nursing diagnosis
Risk for infections related to an invasive device present in Childs body (intravenous access
cannula)

Desired outcome

Child will not secondary infection.

Nursing intervention

Use aseptic technique when handling the cannulated site, this was religiously done.

Branular was always left cocked.

Branular was removed when infusions were stopped.

DRUG STUDY

Acetaminophen/ paracetamol

Action

Inhibits prostaglandin synthesis, thus blocking pain.

Uses

Used as analgesic and antipyretic

Dosage

Adult and children above 12 years of age 350-650 mg 6 hourly to a maximum of 4 g/24 hours

Child 1-12 years of age, 10-15 mg per Kg 6 hourly, maximum of 5 doses in 24 hours

Neonates to 1 year, 10-15mg per kilogram weight every 8 hours

Route of administration

per oral

per rectal
Intravenously

Intramuscular

Adverse effects

Nausea, vomiting, diarrhea, hepatotoxicity, drowsiness, rash and urticaria

Contra indication

Hypersensitivity

Chronic alcoholism

Liver failure

Evaluation

Decreased pain

Decreased fever

Morphine

Classification

Opioid analgesic

Mode of action

Binds with opioid receptors in the central nervous system altering perception of pain.

Dosage

Subcutaneously 0.05-0.2mg/kg, maximum of 15 mg/24 hours.

Given orally 0.2-0.5 mg/kg 4-6 hourly

Indications

Moderate to severe pain

Contraindications

Increased intracranial pressure, hemorrhage, hypersensitivity and bronchial asthma.

Adverse effects

Dizziness and confusion, Bradycardia, drowsiness, constipation, respiratory distress.

Nursing considerations

Monitor CNS changes

Monitor for pain

Monitor allergic reactions

Have naloxone which is an antidote for opioid near

Taper dose downward gradually to avoid dependence.

DISEASE PICTURE

Introduction

Master J had a total burn surface area of 25.5% involving the circumferential left arm, part of the
chest, the back, small part of right arm and face. It was a superficial burn wound.

Region and percentage

Head 5%

Neck 0%

Anterior trunk 8%

Posterior trunk 8%

Right arm 1%
Left arm 3.5%

Buttocks genitalia 0%

Left leg 0%

Right leg 0%

Total 25.5%

PART C.

ANATOMY OF INTEGUMENTARY SYSTEM

The integumentary system is an organ system consisting of the skin, hair, nails, and exocrine
glands. The skin is only a few millimeters thick yet is by far the largest organ in the body. The
average person’s skin weighs 10 pounds and has a surface area of almost 20 square feet. Skin
forms the body’s outer covering and forms a barrier to protect the body from chemicals, disease,
UV light, and physical damage. Hair and nails extend from the skin to reinforce the skin and
protect it from environmental damage. The exocrine glands of the integumentary system produce
sweat, oil, and wax to cool, protect, and moisturize the skin’s surface.

Epidermis

The epidermis is the most superficial layer of the skin that covers almost the entire
body surface. The epidermis rests upon and protects the deeper and thicker dermis layer
of the skin. Structurally, the epidermis is only about a tenth of a millimeter thick but is
made of 40 to 50 rows of stacked squamous epithelial cells. The epidermis is an avascular
region of the body, meaning that it does not contain any blood or blood vessels. The cells
of the epidermis receive all of their nutrients via diffusion of fluids from the dermis.

The epidermis is made of several specialized types of cells. Almost 90% of the
epidermis is made of cells known as keratinocytes. Keratinocytes develop from stem cells
at the base of the epidermis and begin to produce and store the protein keratin. Keratin
makes the keratinocytes very tough, scaly and water-resistant. At about 8% of epidermal
cells, melanocytes form the second most numerous cell type in the epidermis.
Melanocytes produce the pigment melanin to protect the skin from ultraviolet radiation
and sunburn. Langerhans cells are the third most common cells in the epidermis and
make up just over 1% of all epidermal cells. Langerhans cells’ role is to detect and fight
pathogens that attempt to enter the body through the skin. Finally, Merkel cells make up
less than 1% of all epidermal cells but have the important function of sensing touch.
Merkel cells form a disk along the deepest edge of the epidermis where they connect to
nerve endings in the dermis to sense light touch.

The epidermis in most of the body is arranged into 4 distinct layers. In the palmar
surface of the hands and plantar surface of the feet, the skin is thicker than in the rest of
the body and there is a fifth layer of epidermis. The deepest region of the epidermis is the
stratum basale, which contains the stem cells that reproduce to form all of the other cells
of the epidermis. The cells of the stratum basale include cuboidal keratinocytes,
melanocytes, and Merkel cells. Superficial to stratum basale is the stratum spinosum
layer where Langerhans cells are found along with many rows of spiny keratinocytes.
The spines found here are cellular projections called desmosomes that form between
keratinocytes to hold them together and resist friction. Just superficial to the stratum
spinosum is the stratum granulosum, where keratinocytes begin to produce waxy lamellar
granules to waterproof the skin. The keratinocytes in the stratum granulosum are so far
removed from the dermis that they begin to die from lack of nutrients. In the thick skin of
the hands and feet, there is a layer of skin superficial to the stratum granulosum known as
the stratum lucidum. The stratum lucidum is made of several rows of clear, dead
keratinocytes that protect the underlying layers. The outermost layer of skin is the stratum
corneum. The stratum corneum is made of many rows of flattened, dead keratinocytes
that protect the underlying layers.  Dead keratinocytes are constantly being shed from the
surface of the stratum corneum and being replaced by cells arriving from the deeper
layers.

Dermis

The dermis is the deep layer of the skin found under the epidermis. The dermis is
mostly made of dense irregular connective tissue along with nervous tissue, blood, and
blood vessels. The dermis is much thicker than the epidermis and gives the skin its
strength and elasticity. Within the dermis there are two distinct regions:  the papillary
layer and the reticular layer.

The papillary layer is the superficial layer of the dermis that borders on the
epidermis. The papillary layer contains many finger-like extensions called dermal
papillae that protrude superficially towards the epidermis. The dermal papillae increase
the surface area of the dermis and contain many nerves and blood vessels that are
projected toward the surface of the skin. Blood flowing through the dermal papillae
provide nutrients and oxygen for the cells of the epidermis. The nerves of the dermal
papillae are used to feel touch, pain, and temperature through the cells of the epidermis.  

The deeper layer of the dermis, the reticular layer, is the thicker and tougher part
of the dermis. The reticular layer is made of dense irregular connective tissue that
contains many tough collagen and stretchy elastin fibers running in all directions to
provide strength and elasticity to the skin. The reticular layer also contains blood vessels
to support the skin cells and nerve tissue to sense pressure and pain in the skin.

Hypodermis

Deep to the dermis is a layer of loose connective tissues known as the hypodermis,
sub The integumentary system is an organ system consisting of the skin, hair, nails, and exocrine
glands. The skin is only a few millimeters thick yet is by far the largest organ in the body. The
average person’s skin weighs 10 pounds and has a surface area of almost 20 square feet. Skin
forms the body’s outer covering and forms a barrier to protect the body from chemicals, disease,
UV light, and physical damage. Hair and nails extend from the skin to reinforce the skin and
protect it from environmental damage. The exocrine glands of the integumentary system produce
sweat, oil, and wax to cool, protect, and moisturize the skin’s surface.

Epidermis

The epidermis is the most superficial layer of the skin that covers almost the entire
body surface. The epidermis rests upon and protects the deeper and thicker dermis layer
of the skin. Structurally, the epidermis is only about a tenth of a millimeter thick but is
made of 40 to 50 rows of stacked squamous epithelial cells. The epidermis is an avascular
region of the body, meaning that it does not contain any blood or blood vessels. The cells
of the epidermis receive all of their nutrients via diffusion of fluids from the dermis.

The epidermis is made of several specialized types of cells. Almost 90% of the
epidermis is made of cells known as keratinocytes. Keratinocytes develop from stem cells
at the base of the epidermis and begin to produce and store the protein keratin. Keratin
makes the keratinocytes very tough, scaly and water-resistant. At about 8% of epidermal
cells, melanocytes form the second most numerous cell type in the epidermis.
Melanocytes produce the pigment melanin to protect the skin from ultraviolet radiation
and sunburn. Langerhans cells are the third most common cells in the epidermis and
make up just over 1% of all epidermal cells. Langerhans cells’ role is to detect and fight
pathogens that attempt to enter the body through the skin. Finally, Merkel cells make up
less than 1% of all epidermal cells but have the important function of sensing touch.
Merkel cells form a disk along the deepest edge of the epidermis where they connect to
nerve endings in the dermis to sense light touch.

The epidermis in most of the body is arranged into 4 distinct layers. In the palmar
surface of the hands and plantar surface of the feet, the skin is thicker than in the rest of
the body and there is a fifth layer of epidermis. The deepest region of the epidermis is the
stratum basale, which contains the stem cells that reproduce to form all of the other cells
of the epidermis. The cells of the stratum basale include cuboidal keratinocytes,
melanocytes, and Merkel cells. Superficial to stratum basale is the stratum spinosum
layer where Langerhans cells are found along with many rows of spiny keratinocytes.
The spines found here are cellular projections called desmosomes that form between
keratinocytes to hold them together and resist friction. Just superficial to the stratum
spinosum is the stratum granulosum, where keratinocytes begin to produce waxy lamellar
granules to waterproof the skin. The keratinocytes in the stratum granulosum are so far
removed from the dermis that they begin to die from lack of nutrients. In the thick skin of
the hands and feet, there is a layer of skin superficial to the stratum granulosum known as
the stratum lucidum. The stratum lucidum is made of several rows of clear, dead
keratinocytes that protect the underlying layers. The outermost layer of skin is the stratum
corneum. The stratum corneum is made of many rows of flattened, dead keratinocytes
that protect the underlying layers.  Dead keratinocytes are constantly being shed from the
surface of the stratum corneum and being replaced by cells arriving from the deeper
layers.

Dermis

The dermis is the deep layer of the skin found under the epidermis. The dermis is
mostly made of dense irregular connective tissue along with nervous tissue, blood, and
blood vessels. The dermis is much thicker than the epidermis and gives the skin its
strength and elasticity. Within the dermis there are two distinct regions:  the papillary
layer and the reticular layer.

The papillary layer is the superficial layer of the dermis that borders on the
epidermis. The papillary layer contains many finger-like extensions called dermal
papillae that protrude superficially towards the epidermis. The dermal papillae increase
the surface area of the dermis and contain many nerves and blood vessels that are
projected toward the surface of the skin. Blood flowing through the dermal papillae
provide nutrients and oxygen for the cells of the epidermis. The nerves of the dermal
papillae are used to feel touch, pain, and temperature through the cells of the epidermis.  

The deeper layer of the dermis, the reticular layer, is the thicker and tougher part
of the dermis. The reticular layer is made of dense irregular connective tissue that
contains many tough collagen and stretchy elastin fibers running in all directions to
provide strength and elasticity to the skin. The reticular layer also contains blood vessels
to support the skin cells and nerve tissue to sense pressure and pain in the skin.

Hypodermis

Deep to the dermis is a layer of loose connective tissues known as the

hypodermis, subcutis, or subcutaneous tissue. The hypodermis serves as the flexible
connection between the skin and the underlying muscles and bones as well as a fat
storage area.  Areolar connective tissue in the hypodermis contains elastin and collagen
fibers loosely arranged to allow the skin to stretch and move independently of its
underlying structures. Fatty adipose tissue in the hypodermis stores energy in the form of
triglycerides. Adipose also helps to insulate the body by trapping body heat produced by
the underlying muscles.

PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM

Keratinization

Keratinization, also known as cornification, is the process of keratin accumulating

within keratinocytes. Keratinocytes begin their life as offspring of the stem cells of the
stratum basale. Young keratinocytes have a cuboidal shape and contain almost no keratin
protein at all. As the stem cells multiply, they push older keratinocytes towards the
surface of the skin and into the superficial layers of the epidermis. By the time
keratinocytes reach the stratum spinosum, they have begun to accumulate a significant
amount of keratin and have become harder, flatter, and more water resistant. As the
keratinocytes reach the stratum granulosum, they have become much flatter and are
almost completely filled with keratin. At this point the cells are so far removed from the
nutrients that diffuse from the blood vessels in the dermis that the cells go through the
process of apoptosis. Apoptosis is programmed cell death where the cell digests its own
nucleus and organelles, leaving only a tough, keratin-filled shell behind. Dead
keratinocytes moving into the stratum lucidum and stratum corneum are very flat, hard,
and tightly packed so as to form a keratin barrier to protect the underlying tissues.

Temperature Homeostasis

Being the body’s outermost organ, the skin is able to regulate the body’s
temperature by controlling how the body interacts with its environment. In the case of the
body entering a state of hyperthermia, the skin is able to reduce body temperature
through sweating and vasodilation. Sweat produced by sudoriferous glands delivers water
to the surface of the body where it begins to evaporate. The evaporation of sweat absorbs
heat and cools the body’s surface. Vasodilation is the process through which smooth
muscle lining the blood vessels in the dermis relax and allow more blood to enter the
skin. Blood transports heat through the body, pulling heat away from the body’s core and
depositing it in the skin where it can radiate out of the body and into the external
environment.

In the case of the body entering a state of hypothermia, the skin is able to raise
body temperature through the contraction of arrector pili muscles and through
vasoconstriction. The follicles of hairs have small bundles of smooth muscle attached to
their base called arrector pili muscles. The arrector pili form goose bumps by contracting
to move the hair follicle and lifting the hair shaft upright from the surface of the skin.
This movement results in more air being trapped under the hairs to insulate the surface of
the body. Vasoconstriction is the process of smooth muscles in the walls of blood vessels
in the dermis contracting to reduce the flood of blood to the skin. Vasoconstriction
permits the skin to cool while blood stays in the body’s core to maintain heat and
circulation in the vital organs.

Vitamin D Synthesis

Vitamin D, an essential vitamin necessary for the absorption of calcium from

food, is produced by ultraviolet (UV) light striking the skin. The stratum basale and
stratum spinosum layers of the epidermis contain a sterol molecule known as 7-
dehydrocholesterol. When UV light present in sunlight or tanning bed lights strikes the
skin, it penetrates through the outer layers of the epidermis and strikes some of the
molecules of 7-dehydrocholesterol, converting it into vitamin D3. Vitamin D3 is
converted in the kidneys into calcitriol, the active form of vitamin D.

Protection

The skin provides protection to its underlying tissues from pathogens, mechanical
damage, and UV light. Pathogens, such as viruses and bacteria, are unable to enter the
body through unbroken skin due to the outermost layers of epidermis containing an
unending supply of tough, dead keratinocytes. This protection explains the necessity of
cleaning and covering cuts and scrapes with bandages to prevent infection. Minor
mechanical damage from rough or sharp objects is mostly absorbed by the skin before it
can damage the underlying tissues. Epidermal cells reproduce constantly to quickly repair
any damage to the skin. Melanocytes in the epidermis produce the pigment melanin,
which absorbs UV light before it can pass through the skin. UV light can cause cells to
become cancerous if not blocked from entering the body.

Skin Color
 Human skin color is controlled by the interaction of 3 pigments: melanin,
carotene, and hemoglobin. Melanin is a brown or black pigment produced by
melanocytes to protect the skin from UV radiation. Melanin gives skin its tan or brown
coloration and provides the color of brown or black hair. Melanin production increases as
the skin is exposed to higher levels of UV light resulting in tanning of the skin. Carotene
is another pigment present in the skin that produces a yellow or orange cast to the skin
and is most noticeable in people with low levels of melanin. Hemoglobin is another
pigment most noticeable in people with little melanin. Hemoglobin is the red pigment
found in red blood cells, but can be seen through the layers of the skin as a light red or
pink color. Hemoglobin is most noticeable in skin coloration during times of vasodilation
when the capillaries of the dermis are open to carry more blood to the skin’s surface.

Cutaneous Sensation

The skin allows the body to sense its external environment by picking up signals
for touch, pressure, vibration, temperature, and pain. Merkel disks in the epidermis
connect to nerve cells in the dermis to detect shapes and textures of objects contacting the
skin. Corpuscles of touch are structures found in the dermal papillae of the dermis that
also detect touch by objects contacting the skin. Lamellar corpuscles found deep in the
dermis sense pressure and vibration of the skin. Throughout the dermis there are many
free nerve endings that are simply neurons with their dendrites spread throughout the
dermis. Free nerve endings may be sensitive to pain, warmth, or cold. The density of
these sensory receptors in the skin varies throughout the body, resulting in some regions
of the body being more sensitive to touch, temperature, or pain than other regions.

Excretion

In addition to secreting sweat to cool the body, eccrine sudoriferous glands of the
skin also excrete waste products out of the body. Sweat produced by eccrine sudoriferous
 glands normally contains mostly water with many electrolytes and a few other trace
chemicals. The most common electrolytes found in sweat are sodium and chloride, but
potassium, calcium, and magnesium ions may be excreted as well. When these
electrolytes reach high levels in the blood, their presence in sweat also increases, helping
to reduce their presence within the body. In addition to electrolytes, sweat contains and
helps to excrete small amounts of metabolic waste products such as lactic acid, urea, uric
acid, and ammonia. Finally, eccrine sudoriferous glands can help to excrete alcohol from
the body of someone who has been drinking alcoholic beverages. Alcohol causes
vasodilation in the dermis, leading to increased perspiration as more blood reaches sweat
glands. The alcohol in the blood is absorbed by the cells of the sweat glands, causing it to
be excreted along with the other components of sweat.

A. PATHOPHYSIOLOGY
The pathophysiology of the burn wound is characterized by an inflammatory
reaction leading to rapid oedema formation, due to increased microvascular permeability,
vasodilation and increased extravascular osmotic activity. These reactions are due to the
direct heat effect on the microvasculature and to chemical mediators of inflammation. The
earliest stage of vasodilatation and increased venous permeability is commonly due to
histamine release. Damage to the cell membranes partly caused by oxygen-free radicals
released from polymorphonuclear leucocytes would activate the enzymes catalyzing the
hydrolysis of prostaglandin precursor (arachidonic acid) with rapid formation of
prostaglandin as the result. Prostaglandins inhibit the release of norepinephrine and may
thus be of importance in modulating the adrenergic nervous system which is activated in
response to thermal injury. The morphological interpretations of the changes in the
functional ultrastructure of the blood lymph barrier following thermal injury seem to be an
increase in the numbers of vacuoles and many open endothelial intercellular junctions.
Furthermore changes of the interstitial tissue after burn trauma are of great importance.
The continuous loss of fluid from the blood circulation within the thermally damaged
tissue causes increased haematocrit levels and a rapid fall in plasma volume, with
decreased cardiac output and hypo perfusion on the cellular level. If the fluids are not
adequately restored burn shock develops. Furthermore, the burn wound provides a vast
area of entry of surface infection with a high risk of septic shock. Four main principles are
of utmost importance in the current management of patients with severe thermal injury,
namely early wound closure, prevention of septic complications, adequate nutrition and
control of the external environment. (Ann Chir Gynaecol. 1980)

cutis, or subcutaneous tissue. The hypodermis serves as the flexible connection

between the skin and the underlying muscles and bones as well as a fat storage area.
Areolar connective tissue in the hypodermis contains elastin and collagen fibers loosely
arranged to allow the skin to stretch and move independently of its underlying structures.
Fatty adipose tissue in the hypodermis stores energy in the form of triglycerides. Adipose
also helps to insulate the body by trapping body heat produced by the underlying
muscles.

PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM

Keratinization

Keratinization, also known as cornification, is the process of keratin accumulating

within keratinocytes. Keratinocytes begin their life as offspring of the stem cells of the
stratum basale. Young keratinocytes have a cuboidal shape and contain almost no keratin
protein at all. As the stem cells multiply, they push older keratinocytes towards the
surface of the skin and into the superficial layers of the epidermis. By the time
keratinocytes reach the stratum spinosum, they have begun to accumulate a significant
amount of keratin and have become harder, flatter, and more water resistant. As the
keratinocytes reach the stratum granulosum, they have become much flatter and are
almost completely filled with keratin. At this point the cells are so far removed from the
nutrients that diffuse from the blood vessels in the dermis that the cells go through the
process of apoptosis. Apoptosis is programmed cell death where the cell digests its own
nucleus and organelles, leaving only a tough, keratin-filled shell behind. Dead
keratinocytes moving into the stratum lucidum and stratum corneum are very flat, hard,
and tightly packed so as to form a keratin barrier to protect the underlying tissues.

Temperature Homeostasis

Being the body’s outermost organ, the skin is able to regulate the body’s
temperature by controlling how the body interacts with its environment. In the case of the
body entering a state of hyperthermia, the skin is able to reduce body temperature
through sweating and vasodilation. Sweat produced by sudoriferous glands delivers water
to the surface of the body where it begins to evaporate. The evaporation of sweat absorbs
heat and cools the body’s surface. Vasodilation is the process through which smooth
muscle lining the blood vessels in the dermis relax and allow more blood to enter the
skin. Blood transports heat through the body, pulling heat away from the body’s core and
depositing it in the skin where it can radiate out of the body and into the external
environment.

In the case of the body entering a state of hypothermia, the skin is able to raise
body temperature through the contraction of arrector pili muscles and through
vasoconstriction. The follicles of hairs have small bundles of smooth muscle attached to
their base called arrector pili muscles. The arrector pili form goose bumps by contracting
to move the hair follicle and lifting the hair shaft upright from the surface of the skin.
This movement results in more air being trapped under the hairs to insulate the surface of
the body. Vasoconstriction is the process of smooth muscles in the walls of blood vessels
in the dermis contracting to reduce the flood of blood to the skin. Vasoconstriction
permits the skin to cool while blood stays in the body’s core to maintain heat and
circulation in the vital organs.

Vitamin D Synthesis

Vitamin D, an essential vitamin necessary for the absorption of calcium from

food, is produced by ultraviolet (UV) light striking the skin. The stratum basale and
stratum spinosum layers of the epidermis contain a sterol molecule known as 7-
dehydrocholesterol. When UV light present in sunlight or tanning bed lights strikes the
skin, it penetrates through the outer layers of the epidermis and strikes some of the
molecules of 7-dehydrocholesterol, converting it into vitamin D3. Vitamin D3 is
converted in the kidneys into calcitriol, the active form of vitamin D.

Protection

The skin provides protection to its underlying tissues from pathogens, mechanical
damage, and UV light. Pathogens, such as viruses and bacteria, are unable to enter the
body through unbroken skin due to the outermost layers of epidermis containing an
unending supply of tough, dead keratinocytes. This protection explains the necessity of
cleaning and covering cuts and scrapes with bandages to prevent infection. Minor
mechanical damage from rough or sharp objects is mostly absorbed by the skin before it
can damage the underlying tissues. Epidermal cells reproduce constantly to quickly repair
any damage to the skin. Melanocytes in the epidermis produce the pigment melanin,
which absorbs UV light before it can pass through the skin. UV light can cause cells to
become cancerous if not blocked from entering the body.

Skin Color

Human skin color is controlled by the interaction of 3 pigments: melanin,

carotene, and hemoglobin. Melanin is a brown or black pigment produced by
melanocytes to protect the skin from UV radiation. Melanin gives skin its tan or brown
coloration and provides the color of brown or black hair. Melanin production increases as
the skin is exposed to higher levels of UV light resulting in tanning of the skin. Carotene
is another pigment present in the skin that produces a yellow or orange cast to the skin
and is most noticeable in people with low levels of melanin. Hemoglobin is another
pigment most noticeable in people with little melanin. Hemoglobin is the red pigment
found in red blood cells, but can be seen through the layers of the skin as a light red or
pink color. Hemoglobin is most noticeable in skin coloration during times of vasodilation
when the capillaries of the dermis are open to carry more blood to the skin’s surface.

Cutaneous Sensation

The skin allows the body to sense its external environment by picking up signals
for touch, pressure, vibration, temperature, and pain. Merkel disks in the epidermis
connect to nerve cells in the dermis to detect shapes and textures of objects contacting the
skin. Corpuscles of touch are structures found in the dermal papillae of the dermis that
also detect touch by objects contacting the skin. Lamellar corpuscles found deep in the
dermis sense pressure and vibration of the skin. Throughout the dermis there are many
free nerve endings that are simply neurons with their dendrites spread throughout the
dermis. Free nerve endings may be sensitive to pain, warmth, or cold. The density of
these sensory receptors in the skin varies throughout the body, resulting in some regions
of the body being more sensitive to touch, temperature, or pain than other regions.

Excretion

In addition to secreting sweat to cool the body, eccrine sudoriferous glands of the
skin also excrete waste products out of the body. Sweat produced by eccrine sudoriferous
glands normally contains mostly water with many electrolytes and a few other trace
chemicals. The most common electrolytes found in sweat are sodium and chloride, but
 potassium, calcium, and magnesium ions may be excreted as well. When these
electrolytes reach high levels in the blood, their presence in sweat also increases, helping
to reduce their presence within the body. In addition to electrolytes, sweat contains and
helps to excrete small amounts of metabolic waste products such as lactic acid, urea, uric
acid, and ammonia. Finally, eccrine sudoriferous glands can help to excrete alcohol from
the body of someone who has been drinking alcoholic beverages. Alcohol causes
vasodilation in the dermis, leading to increased perspiration as more blood reaches sweat
glands. The alcohol in the blood is absorbed by the cells of the sweat glands, causing it to
be excreted along with the other components of sweat.

BURNS.

Burns are tissue damage that results from heat, overexposure to the sun or other
radiation, or chemical or electrical contact. Burns can be minor medical problems or life-
threatening emergencies.

The treatment of burns depends on the location and severity of the damage. Sunburns and small
scalds can usually be treated at home. Deep or widespread burns need immediate medical
attention. Some people need treatment at specialized burn centers and months long follow-up
care.

CAUSES OF BURNS

 Fire.
 Liquid or steam.
 Hot metal, glass or other objects.
 Hot Electrical currents.
 Radiation, such as that from X-rays.
 Sunlight or other sources of ultraviolet radiation, such as a tanning bed.
 Chemicals such as strong acids, lye, paint thinner or gasoline.
 Abuse.

 RISK FACTORS FOR BURNS/SUSCEPTABILITY
Age- children are more susceptible to burn than adult especially with poor supervision from
adults

Gender- male population is at a higher risk for burn than the female gender. This is mostly due to
their nature of work and for children play

Social economic status- poor living conditions and poor housing put people at risk for thermal
injuries. Especially from electrical short circuiting, overcrowding and hot spillages.

Medical conditions such as epilepsy will put one at risk for burn from open flames and hot
liquids.

Drug use- substances such as alcohol which may cause impaired posture balance will put one at

EPIDEMIOLOGICAL DATA OF BURNS IN CHILDREN

Global data

Globally, world health organization estimate180000 deaths of children every year caused by
thermal injuries, with non fatal burns leading to morbidity. These burns mostly occur in homes
and especially in developing countries.[ CITATION Glo18 \l 1033 ]

Regional data

In Africa, children burns are common. According to a study by Peter, 2016, which was done in
16 African countries, the researcher found out that, out of 32,862 burn patients in that year 80%
were children below age of 10 years. The mortality rate was 17% with 1 in every 5 patient losing
their lives. [ CITATION Nth16 \l 1033 ]

Local data

It is estimated that 20% of all trauma patients seen at Kenyatta National hospital are as a result of
Burn which mostly occur at homes and children beings the most victims. These children sustain
hot fluid spillage or emersion burns as a result of poor housing, overcrowding and inadequate
supervision by the care givers. Slum and shack fires have been reported frequently and have
resulted in many injuries and fatalities. [ CITATION Wan19 \l 1033 ]
CLINICAL MANIFESTATION OF BURNS

First degree

Affects the outermost layer. The epidermis remains intact, also called superficial burn.

Signs and symptoms

Pain

Redness

Peeling of dead skin 2-7 days after burn

Blanching with pressure

Minor inflammation/ swelling

Healing occurs within 2-7 days without forming a scar.

Second degree burn

Involves the entire epidermis and part of the dermis layer of the skin. Fewer healthy cells remain.
Also known as partial thickness burn

Signs and symptoms

Wet shiny weeping surface

Pain

Sensitivity to heat and touch

Superficial blisters heal in less than 21 days while deep blisters require more than 21 days to
heal.

Third degree burn

In this degree, there is total destruction of the entire epidermis and dermis layers leaving no true
skin to heal on its own.

Signs and symptoms

Less or no pain at all.

Dry leathery eschar formation.

Moderate edema.

No blister formation.

Fourth degree burn

Takes weeks to months to heal as it extends beyond the skin to involve the underlying fascia,
tissues, muscles, tendons and bones.

Signs and symptoms include

Absence of sensation

Wounds need excision and grafting

Blackened and depressed wound

PATHOPHYSIOLOGY OF BURNS.
The pathophysiology of the burn wound is characterized by an inflammatory
reaction leading to rapid edema formation, due to increased micro vascular permeability,
vasodilation and increased extravascular osmotic activity. These reactions are due to the
direct heat effect on the microvasculature and to chemical mediators of inflammation. The
earliest stage of vasodilatation and increased venous permeability is commonly due to
histamine release. Damage to the cell membranes partly caused by oxygen-free radicals
released from polymorph nuclear leucocytes would activate the enzymes catalyzing the
hydrolysis of prostaglandin precursor (arachidonic acid) with rapid formation of
prostaglandin as the result. Prostaglandins inhibit the release of norepinephrine and may
thus be of importance in modulating the adrenergic nervous system which is activated in
 response to thermal injury. The morphological interpretations of the changes in the
functional ultrastructure of the blood lymph barrier following thermal injury seem to be an
increase in the numbers of vacuoles and many open endothelial intercellular junctions.
Furthermore changes of the interstitial tissue after burn trauma are of great importance.
The continuous loss of fluid from the blood circulation within the thermally damaged
tissue causes increased haematocrit levels and a rapid fall in plasma volume, with
decreased cardiac output and hypoperfusion on the cellular level. If the fluids are not
adequately restored burn shock develops. Furthermore, the burn wound provides a vast
area of entry of surface infection with a high risk of septic shock. Four main principles are
of utmost importance in the current management of patients with severe thermal injury,
namely early wound closure, prevention of septic complications, adequate nutrition and
control of the external environment. (Ann Chir Gynaecol. 1980)

DIAGNOSTIC EVALUATION

History taking is key to establish etiology of burn.

Physical examination to assess the degree and percentage of burnt surface area.

Diagnostic tests such as kidney function test (Urea Electrolyte and creatinine) to assess effect of
burn on the kidneys, full hemoglobin to assess for level of hemoglobin and if there is any
infection. Blood gas analysis to assess for respiratory acidosis or alkalosis.

MEDICAL/ SURGICAL MANAGEMENT

Burns greater than 10% in a child or any burn in a very young person is serious. Below is a guide
on how to estimate burns in children.
It is important to estimate the depth of the burn bearing in mind that it may change in time.

Severity of burn is determined by the burnt surface area, depth of burn and other considerations.
Burns patients have the same priorities as all other trauma patients with children given priority.

Assessment

Assess airway: breathing, beware of inhalation and rapid airway compromise

Assess circulation resuscitative fluid replacement whereby patient is given isotonic or colloid
solutions as a cocktail or separately. Resuscitation fluid is amount given in the first 24 hours
from the time of injury. Half of the calculated volume is given in the first 8 hours then the
remaining half is given in the next 16 hours. Day two give three quarters of the amount given on
day one. Formulae for calculating fluids is parklands, that is

(4ml/kg*% TBSA) + Maintenance if not taking orally

Exposure that is percentage area of burn

Disability, here assess for risk for or compartment syndrome.

Monitor urine output which should be at 1ml/kg per hour.

Wound management

This is mostly done to prevent infections. Excision and wound coverage has shown to reduce
mortality, reduce pain, reduce blood loss and bacterial infestation and most importantly shorten
hospital stay. Regular cleaning is done to remove exudates; this can be done once or twice a day.
Tetanus toxoid is given to all bums above 10% except for children below 5 years of age and
those with recent immunization history.

Pain management

During burns, except in full thickness burns, nerve endings are exposed leading to increased
sensitivity and severe pain. Analgesics are provided depending on the type and magnitude of
pain experienced by the patient. In children assessment of pain is done using proper pain
assessment tool for age. Children with thermal burn require large doses than expected over a
period of time as they do not have pain tolerance.

Nutritional requirements

Burns induce hyper metabolic state in children, contributed by release of stress hormone and
increased evaporation of water. Therefore there is need to increase energy giving foods
(carbohydrates) in the child diet. Vitamins are necessary to boost immunity and proteins for
repair of damaged tissues, during thermal injury. Feeding route depends on child’s physiologic
state. Nasogastric feeding tube is recommended for those who cannot take orally and parenteral
feeding for those children who can’t retain food. Oral Feeding should be maintained or resumed
early in cases where it was stopped to maintain gut integrity, prevent paralytic illus and reduce
bacterial translocations.

Prevention of infections

Due to destruction of the body physical barrier, burn patients are susceptible to infections.
Therefore handling of the wound should be by use of aseptic technique. Routine systemic
prophylactic antibiotics are not recommended to avoid resistance unless when being used pre
operatively.

Psychosocial needs

Soonest possible the child should be incorporated to the family routine, this helps in coping. The
parents/ care givers should be involved in child management and care plans, in order to cope
with child altered appearance. It is a challenge to cope with serious burns and especially if it
covers a large surface area, therefore support groups and family is essential for psychological
support.

GENERAL NURSING MANAGEMENT

Monitor vital signs

Monitor vital signs closely paying attention to respiratory status. Evaluate apical, carotid and
femoral pulses particularly in areas of circumferential burn injury to an extremity.

Cardiac monitoring

If indicated monitor cardiac activity and especially in patients with electrical burn.

Fluid intake and output monitoring

Monitor fluid intake and output to avoid kidney injury or overhdration. Insertion of urinary
catheter will help in output monitoring.

Wound dressing

Clean and dress wound daily and with every soiled dressing to prevent infection.
Health education

Share health messages with the caregiver on nutrition, hygiene, prevention of thermal injury and
warning signs in children. Advice them to report immediately in case of any of the warning signs
such as hotness of body, difficulty in breathing, change of extremity color or reduced level of
consciousness.

PROGNOSIS

Burns involving more than 90% of body surface area are usually fatal. A superficial burn heals in
days to weeks without scaring. Deeper partial thickness burns, may be associated with scaring
and may take weeks to heal. Full thickness burns require skin grafting, they take long to heal.

COMPARISON IN MANAGEMENT BETWEEN THE BOOK AND ACTUAL

MANAGEMENT OF PATIENT

COURSE OF BOOK PICTURE ACTUAL PICTURE OF PATIENT

DISEASE
Etiology Burns in children are
commonly
Caused by: fire, hot liquids
Or steam, electric current,
Radiation, chemicals, abuse
And hot surfaces.
Incidence and Prevalence of children burns
Prevalence Is high and especially in
Sub-Sahara Africa. Globally
80000 fatalities are reported
Yearly secondary to thermal
Burns.
Signs and symptoms They vary according to
The cause and depth of
Burn. They include: pain,
Formation of blisters,
swelling, redness and signs
Master J was accidentally burnt by hot
water when he fell into a sufuria
Containing the pre boiled water.
During master J admission period
The burns unit had a total of 9
Patients, of which children
Accounted for 55.5%, and all of
Them were as a result of thermal
Burn.
Master J, had blisters. He was crying
occasionally and at times he
Was restless. Pain management was
done by use paracetamol 62.5 mg
every 8 hours, and 1mg of morphine
 of shock such as, cool clammy
skin,palour, weakness, To dressing. Pain assessment tool
reduced
level of consciousness
Medical Fluid replacement therapy is
management Calculated using 3-4 ml/kg/
%TBSA/24 hours
Pain management is a priority
In paediatric population
Silver sulfadiazine is
Antibacterial cream of choice
Prophylaxis antibiotics are
Discouraged to avoid
Resistance Nutrition
mainly high protein
diet, carbohydrates and
Vitamins.
Prognosis/outcome 90% TBSA has poor
Prognosis since it results in
Fatality. Partial thickness burn
Results in formation of eschar.
Full thickness burn usually
Requires skin grafting.
was administered 30 minutes
used
Was FLACC.
The patient was put on iv ringer
Lactate 430 ml/8 hours, then
430 mls/16 hours and maintenance
Of 900 ml/24 of ringer lactate
Alternating with 5% dextrose.
SSD was applied every day after
Wound cleaning and sterile dressing
Applied.
High protein diet that included milk
And eggs was provided daily to
The child. Fruits which are a good
Source of vitamins were
Also provided.
Patient had a TBSA of 25.5%, which
Was superficial but depth increased
With time. At some point patient was
Done escharotomy which is a
Surgical procedure used to treat full
Thickness circumferential burn.
Fatality is not expected but patient
Will heal with most areas having
Eschar and long hospital stay