RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH BANGALORE-54

CHN ASSIGNMENT I

TOPIC: Burn in children

Submitted to, Submitted by,

Mrs VANITHA MA’AM SRUTI GHOSH
DEPT OF CHILD HEALTH NURSING 3RD YEAR BSC (N)
RINER,560054 ROLL NO. 81
Date of submission- 24.07.24 RINER,560054
 RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH BANGALORE-54
LESSON PLAN
Programme : Bsc . Nursing
Placement : III year
Course : Child Health Nursing
Topic : Burn in children
Allotted Teacher : Mrs Vanitha ma’am
Allotted Hour : 01 hour
Date & Time : 24-07-2024
Method of : Lecture cum discussion
teaching
AV. Aids : Power point, Chart
Learner’s previous knowledge: The learners will have basic knowledge about Burn in children.

CENTRAL OBJECTIVES:
 By the end of this class, students will gain in-depth knowledge about burn , classification , pathophysiology , depth of injury ,
estimation , emergency management , therapeutic management , nursing management.

SPECIFIC OBJECTIVES:
 Define Burn
 Explain the types burn
 Describe the Pathophysiology of burn
 Explain the Estimation of burn injury
 Discuss the Emergency management of burn
 Discuss the Therapeutic management of burn
 Discuss the Nursing management of burn
 SPECIFIC TIME CONTENT TEACHING AND EVALUATION
OBJECTIVES LEARNING
ACTIVITY
Introduction 3 minutes BURNS IN CHILDREN Explain regarding What do you know
to Burn in burn in children about Burn?
children Burns are common and serious childhood injury
causing prolonged effect on growing child with various
complications and fatal prognosis. Learners listen
The exact data about the incidence of burn injury is actively
not available. Children are at higher risk of burn injury than
adults. Approximately one-fourth of burns cases are below
10 years of age, and about 65% of burnt children are below
5 years of age. Over 80% of burn accidents occur in the
child's own home. Scalds from hot liquids constitute
maximum numbers and others are due to flame burns,
electrical or chemical burns.
 Definition:
Define Burn 3 minutes A burn is a type of injury to flesh or skin caused by heat, To describe the What is Burn?
electricity, chemicals, friction, or radiation. It can be caused definition of
intentionally or unintentionally. Infants and toddlers are Burn
more prone to get burn injury due to their curiosity and lack
of supervision. Burn can be a small scald injury or severe Learners listen
burn resulting severe trauma or death. actively

Explain the 10 minutes Burn can be classified in different aspects. They are – To explain the types What are the different
types of Burn ❖ According to Depth of Burn Injury. of burn. types of Burn?
❖ According to Extent of Burn injury.
Learners listen
❖ According to Severity of Burn.
attentively
❖ According to Causes.

According to Depth of Burn Injury

Superficial burns (partial thickness burns)

Superficial partial thickness burns: Burn injury involves

epidermis and superficial layers of dermis, i.e., up to papillary
dermis. The wound usually heals in less than two weeks
period of burns.
 Superficial deep dermal burns: Burn injury involves
beyond papillary dermis and takes more than two weeks time
for healing.

Full thickness burns: Burn injury involves all layer of skin

and sometimes underlying tissues are also destroyed. The
wound does not heal normally and needs skin grafting.

According to Extent of Burn Injury

First degree burns: Superficial burns manifested as pink

to red discolored area with slight edema. Pain may present
up to 48 hours and relieved by cooling. Within 5 days
epidermis peels off, pink skin may persist for a week, no scar
develops. Healing takes place spontaneously within 10 to 15
days, if not infected.

Second degree burns:

❖ Superficial second degree burns are presented as

pink or red discoloration of the area with blister
formation, weeping and edema. Superficial skin
layers are destroyed. Wound becomes moist and
painful and takes several weeks to heal. Scaring
may develop.
 ❖ Second degree deep dermal burns are manifested
as mottled white and red area become pale on
pressure. The area may or may not be sensitive to
touch but sensitive to cold air. Hair does not pull
out easily. Wound takes several weeks to heal and
scar may develop.

Third degree burns: It includes destruction of epithelial

cells even fat, muscles and bone. Reddened areas do not
blanch with pressure. It is not painful, inelastic and
discoloration may vary from waxy white to brown. Eschar
develops as leathery devitalized tissue, which must be
removed. Granulation tissue develops and grafting is required
if the burnt area is larger than 3 to 5 cm. Grafting is done after
wound debridement.

First degree and second degree burns are included

in partial thickness burns. The third degree burns is
considered as full thickness burns.

Fourth degree burns:

• Complete destruction of the epidermis,
dermis, and subcutaneous tissue.

• Extends into underlying fat, muscle and bone.

• Wound becomes black, dry and eschar forms,

no capillary refill, no sensation.
 • Requires surgical excision.

Children's skin is much thinner and therefore more

susceptible to deep burns.

According to Severity of Burn Injury

Severity of burn injury depends upon total area injured,
depth of injury, location of injury, age, general health of the
child presence of additional injury or chronic diseases and
level of consciousness.
Minor burns: 10% of total body surface area (TBSA) burnt
with first and second degree burns.

Moderate burns:10 to 20% TBSA burnt and second

degree burns.
2 to 5% TBSA burnt and third degree burn, but not
involving eyes, ears, face, genitals, hands, feet or
circumferential burns (over chest or abdomen).

Major burns:20% or more TBSA burnt and second degree

burns.
All third degree burns greater than 10% TBSA burnt.

All burns involving face, eyes, ears, feet, hands and/ or

genitals.
 Complicated burns with trauma, fracture, head injury,
cancer, diabetes mellitus, pulmonary diseases and all at-risk
patients.

According to causes:
Thermal Injury:
Scalds: This can occur commonly at home from
spilling of hot liquids in kitchen or bathroom. The severity of
the burn is closely related to temperature of the liquid. Liquid
at 60°C will burn children in less than 5 sec, compared with 10
min if the liquid is at 49°C. About 70% burns in children are
caused by scalds.

Flame: This is very common type of burn injury,

which may occur by cooking ovens, playing with match sticks,
unextinguished cigarettes, or fireworks. They may be
associated with inhalational injury. This injury may be deep
dermal or full thickness burn.

Chemical Injury: Ingested cleansing agents are the

common causes of chemical burns to children. This requires
emergency treatment.

Electrical Injury: This can be caused by heavy electrical

contacts while putting objects into plug points, chewing cords,
or handling loose electrical points. Electrical burn can cause
deep injury involving the underlying muscles.
 Radiation Injury: It occurs from over exposure to
ultraviolet rays from the sun.

Describe the 5 minutes Pathophysiology of burn can be defined in two ways – To describe the What are the zones
Pathophysio- • Local Skin response pathophysiology of of tissue injury?
Logy of burn • Systemic response burn

Local skin response: Local response depends on the zone Learners listen
of tissue injury. Skin becomes white or gray with- out actively and
blanching in case of zone of coagulation injury. attentively.
This is the area of greatest destruction, tissue
necrosis, and irreversible cell damage.
When the
zone of stasis is
affected, skin
becomes red due to
vasoconstriction
leading to sludging of
blood cells and
tissue edema but the
damage is
salvageable. Zone of hyperaemia is least affected and
redness of skin with blanching occurs.
 Systemic response: If total body surface area burnt is
more than 30%, release of cytokine and inflammatory
agents may cause various systemic effects –

❖ Cardiovascular changes:
• Increased capillary permeability.
• Loss of intravascular protein and
fluids into interstitial compartment.
• Decreased myocardial contractility
due to release of tumor necrosis
factor alfa.
• Peripheral and splanchnic
vasoconstriction.
❖ Respiratory changes:
• Bronchoconstriction
• ARDS in severe burns
❖ Metabolic changes:
• 3 fold increase in basal metabolic
rate
• Increased basal body temperature
• Splanchnic hypoperfusion
• Hypoglycemia
❖ Immunological changes:
• Decreased humeral and cell
mediated immunity
• Cellular changes
• Phagocytosis of bacteria on burn
wound
 • Decreased platelets and fibrinogen
level leading to brief episodes of DIC

❖ Renal changes:
• Release of aldosterone leading to
increased water retention and
reabsorption of sodium
• Acute tubular necrosis
❖ GI changes:
• Acute gastric dilatation leading to
abdominal distension and
regurgitation
• Malabsorption
• Ulceration of gastroduodenal
mucosa
• Hyperacidity of gastric secretion
increasing susceptibility to curling
ulcer.

Explain the 10 minutes Severity of burn injury is estimated on the To explain about the Name the methods
Estimation of basis of total body surface area involved, depth and site of estimation of burn used for estimation
Burn Injury injury. Total body surface area burnt is calculated by three injury. of burn injury in
methods in children: adaptation of Rule of Nine, Lund and children.
Browder chart, and hand method. Lund and Browder chart Learners listen
is more reliable than other methods. attentively
The easiest way to calculate the extent of
burns is the 'rule of hand. One hand surface
(child's own hand) with closed fingers amounts
to 1% of body surface area and this can be
used for calculation the extent of burns.
A convenient, easy and quick method of
estimation of surface area in paediatric burns
is 'Rule of Five' (Lynch and Blocker, 1963)
The most accurate estimation of extent of
burns surface area can be done by using Lund
and Browder chart, which gives the exact
percentage at different age groups in different
parts of the body.
It is time consuming and labor some to
calculate.
Discuss the 5 minutes The emergency management for Burn can be carried out To discuss about the List out the steps in
Emergency in two ways – emergency emergency
Management First Aid management of management of
• Instruct the child to stop, drop, cover face burn burn in children.
and roll if on fire.
• Remove the heat source: clothing, embers,
chemicals, etc.
• Apply tap water at room temperature onto
burned area for at least 20 min (within 3 hrs
of burn).
• Ice should never be used as it causes
vasoconstriction leading to further.
• Tissue damage and hypothermia.
• Remove anything tight: Jewellery, non-
adherent clothing etc.
• Keep rest of body warm to prevent
hypothermia
• Minor Burn- Continue cool water irrigation
for 20 min. Cover with nonadherent dressing.
Warm the patient. Seek medical advice.
• Major burn - Resuscitation and emergency
management are needed with prompt
hospitalization.

Resuscitation
• Assess for adequate airway and breathing.
• Perform cardiopulmonary resuscitation.
• Administer oxygenation.
Discuss the 10 minutes Therapeutic management can be given in various aspects- To discuss about What all therapeutic
Therapeutic Therapeutic management can be
management Fluid resuscitation: management of carried out for
The goal of fluid resuscitation is to perfuse the vital burn burn?
organs without overloading the circulatory system,
compensate water and sodium loss, correct acidosis and
improve renal function.
Fluid is administered to all patients with burns of
10% or more in children.

The Parkland formula is the initial choice of fluid regimen

with 4 mL/kg/% burn, for the first 24 hrs

Nutrition:
Nutrition support is an important component of the
overall medial management of paediatric burns patients.
Adequate nutrition is essential in children with burns to
promote optimal wound healing and recovery from burn
injury.

Burns <10% (>5% in infants)

• Infants offer breast milk or usual formula.
• Children - Offer small amounts of high
protein, high energy food and drinks at
regular intervals orally.
• Consider enteral feeding if not able to
meet requirements orally or depending on
the site of burn.
 Burns > 10% (or 5% in Infants)
• If enteral feeding is indicated it should be
commenced within the first 24-48 hrs of
burn injury to optimize nutritional
support
• Oral intake should be encouraged even
when enteral feeding is being used.
• Children should be weighed twice weekly
using the same scales and without wet
dressings wherever possible.

Medication
➢ Antibiotics, used if any clinical infection is
detected.
➢ Analgesics, used for pain management
Ex. IV Morphine
➢ Multivitamins, iron, and zinc supplements
➢ Topical administration of antimicrobial
agents, used for wound healing
➢ Tetanus prophylaxis

Wound care
➢ Meticulous wound care is essential to
prevent infection.
➢ Dressing is done with or without
debridement. It is usually done after
cleansing the wound with 0.9% NaCl.
➢ Topical antimicrobial agents are applied on
the wound.
 ➢ The wound may be left open in the air to
heal naturally.
➢ Occlusive dressing may be done with
multiple layers of bulky gauze with topical
agents and secured firmly.
➢ Topical agents commonly used are : Silver
nitrate 0.5% , silver sulfadiazine 1% ,
mafenide acetate 10% , bactriacin, etc.

Surgery
➢ Escharotomy
➢ Fasciotomy
➢ Skin Grafting

Discuss the 10 minutes Nursing management can be carried out in two parts- To discuss about the What is the nurse`s
Nursing nursing role in managing
Management Assessment management of child with burn?
History of burn injury, estimation of severity of burn
burn, degree and site of burn injury, hemodynamic status,
etc.

Interventions

Pain management
Assess level of pain and administer
analgesia as pre- scribed.
 Provide comfort measures like foot
board, bed cradle, etc.
. Use diversional therapy like music,
cartoon show, etc.
Position in extension to minimize pain
during regaining extension.
Apply touch therapy in unburned skin to
provide com- fort.
Administer sedation during procedure.

Wound Care
Use hydrotherapy to clean the wound.
Debride the wound if needed.
Apply topical antimicrobial ointment on
the wound.
Apply mittens to prevent scratching and
picking at the wound.
Perform open or closed dressing as
required.
Maintain aseptic technique and use
standard precaution.

Maintenance of tissue perfusion, fluid volume

Monitor vital signs, capillary refill, colour
of skin, etc.
Administer crystalloid solutions as per
calculated requirement.
Maintain flow rate of fluid administration
to prevent fluid overload.
Watch for formation of edema.
 Monitor daily weight to evaluate fluid
retention.
Monitor laboratory values of serum
electrolytes.
Observe for chilling or shivering to
identify heat loss.
Avoid exposure to cold during
procedures.

Nutrition
Encourage oral feeding in case of minor
burns.
Provide high calorie, high protein diet to
ensure wound healing.
Provide enteral feeding in severe burns.
Monitor for feeding intolerance and tube
malposition.
Record intake and output strictly.
Involve the child for food preferences.

Maintain physical mobility

Perform active and passive range of
motion exercises
Use comfort devices to prevent
contractures.
Apply splints to involved joints in
extension at night to minimize
contractures.
Promote self-help activities as tolerated.
 Employ physical therapy to minimize
deformity related scar formation.
Ambulate as early as possible.

Psychological support
Encourage parents to participate in child
care.
Explore feelings of child and parents
concerning physical appearance.
Reinforce positive aspects of appearance.
Provide recreational and diversional
therapies.
Inform parents about child's progress
and reassure.
Encourage peers to visit the child.
Help the child to develop independence
and increase self esteem.

2 minutes Summary Teacher summarizes

The following topics are discussed in today’s class : the topic by
➢ Definition questioning the
➢ Types students.
➢ Pathophysiology
➢ Estimation of burn injury
➢ Emergency, therapeutic and nursing
management of child with Burn
 2 minutes Conclusion Teacher concludes
Now by implementing the available and effective the topic by
interventions, children can be well treated who are explaining how
suffering from burn and proper care can be taken to nurses play an
reduce the mortality rates. important role in
reducing the
mortality rates of
children with burn

References:
I. Panchali pal. Textbook of Pediatric Nursing. 2nd Edition. New Delhi. Paras Medical Publisher: 2021. Page no. 481-486.
II. Parul Dutta. Pediatric nursing. 5th edition. Jaypee publication: 2022. Page no. 347-351.
III. Marilyn J, Wilson D, Rodgers CC. Wong’s Essentials of Paediatric Nursing. 10th Edition. Elsevier publication. Page no. 766-778.
IV. Vinod K Paul, Arvind Bagga. Ghai Essential pediatric. 8th Edition. CBS Publication & Distributers Pvt Ltd. Page no. 706-707.
V. Terri Kyle, Susan Carman. Essentials of Pediatric Nursing, 2nd Edition. Wolters Kluwer. Page no. 1123-1130.
VI. Jane Bell, Ruth Bindler, Kay Cowen, Michele Shaw. Principles of Pediatric Nursing. 7th Edition. Pearson. Page no. 925-935.