BURNS

• Burns are injuries to body tissue caused by excessive heat

(greater than 104°F [40°C]).
• Burns are the second most common unintentional injury
seen in children 1 to 4 years of age and the third most
common cause of injury in children 5 to 14 years of age.
• Younger children are most at risk for scald burns that are
caused by hot liquids or steam.
• Older children are more likely to be burned from flames
after they move too close to a campfire, heater, or
fireplace; touch a hot curling iron; or play with matches or
lighted candles (CDC, 2021b).
Assessment
• To assist with burn classification, determine “Where
is the burn?” and “What are its extent and depth?”
(Mitchell et al., 2020).
• Along with the size and depth, be certain to assess
and document the location of the burn. Face and
throat burns, for example, are particularly hazardous
because there may be accompanying but unseen
burns in the respiratory tract that could lead to
respiratory tract obstruction.
Assessment
• Hand burns are hazardous because if the fingers
and thumb are not positioned properly during
healing, adhesions will inhibit full range of motion
in the future.
• Burns of the feet carry a high risk of secondary
infection. Genital burns are also hazardous
because edema of the urinary meatus may
prevent a child from voiding.
• With adults, the “rule of nines” is a quick method of
estimating the extent of a burn.

• For example, each upper extremity represents 9% of the

total body surface; each lower extremity represents two
9s, or 18%, and the head and neck represent 9%.
Because the body proportions of children are different
from those of adults, this rule does not always apply
and is misleading in the very young child.
• Data for determining the extent of burns in children are
shown in Figure 52.7. Computer analysis is now
available to rapidly assess the extent of burns.
Rule Of Nines For Burns In Babies And
Young Children
• The size of a burn for a baby or young child can be quickly estimated by
using the "rule of nines." This method divides a baby's body surface
area into percentages.

• The front and back of the head and neck are 21% of the body's surface
area.
• The front and back of each arm and hand are 10% of the body's surface
area.
• The chest and stomach are 13% of the body's surface area.
• The back is 13% of the body's surface area.
• The buttocks and genital area are 6% of the body's surface area.
• The front and back of each leg and foot are 13.5% of the body's surface
area.
Figure 52.7 Determination of extent of burns in children.
Depth of Burn
When estimating the depth of a burn, use the appearance of the burn and the sensitivity of the
area to pain as criteria. Descriptions of tissue at various burn depths are shown in Table 52.2 and
illustrated in Figures 52.8, 52.9, 52.10, and 52.11.

Figure 52.8 Depths of burns.

Figure 52.9 Partial-thickness burns. A. An infant with a first-degree burn on the arm and chest caused by scalding
with hot water. B. A toddler with a second-degree burn caused by scalding. The area appears severely reddened and
moist with some blistering. (A: © Dr. P. Marazzi/SPL/Science Source/Photo Researchers. B: © NMSB/Custom
Medical Stock Photograph.)
Figure 52.10 Full-thickness (third-degree) burn of the foot. Both layers of skin are involved
with this type of burn. (©
Dr. Michael English/Custom Medical Stock Photograph.)

Figure 52.11 A. An adolescent’s hand scarred from third-degree burns. Note

the proper extension and alignment of the hand and fingers, which were
maintained by the use of splints during healing (B). (© Dr. P.
Marazzi/SPL/Science Source/Photo Researchers.)
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• Many burns are compound, involving first-, second-, and third-
degree burns, or there may be a central white area insensitive
to pain (third degree), surrounded by an area of erythematous
blisters (second degree), and surrounded by another area that
is erythematous only (first degree).

• Be certain to undress children with burns completely in order

to inspect the entire body. Because a first-degree burn is
painful and a third-degree burn is not, a child may be crying
from a superficial burn that is obvious on the arm, although the
condition needing the immediate attention is a third-degree
burn on the chest covered by a jacket.
• Be certain to ask what caused the burn because different
materials cause different degrees of burn. Hot water, for
example, causes scalding, a generally lesser degree of
burn than one caused by flaming clothing.
• Lastly, determine whether other family members
sustained burns. Parents, for example, may have burned
hands from putting out the fire on the child’s clothes.
Assure that other family members, including children, are
safe if there was damage to the home.
• In obtaining a health history, ask about other health
problems and medication allergies in the child.
Emergency Management for Minor Burns
• Immediately apply cool water to decrease the skin temperature and
prevent further burning.
• Application of an analgesic–antibiotic ointment and a gauze bandage
to prevent infection is usually the only additional treatment required.
• Be certain that parents have a follow-up appointment in about 2 days
to have the dressing changed and the area inspected for a secondary
infection.
• Advise parents/caregivers to keep the dressing dry (no swimming or
getting the area wet while bathing) until the burn is healed—about 1
week.
Emergency Management for
Moderate Burns
• Moderate or second-degree burns typically are
blistered. It is not necessary to drain the blisters
initially, as this is a source of infection. The burn
should be covered with a topical antibiotic such as https://mimsshst.blob.core.windows.net/drug-
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silver sulfadiazine and burn dressing gauze (does not PG

adhere to the burn) to prevent damage to the burned

site and promote healing.
• The child usually returns in 24 hours to assess their
pain and observe site for signs of infection. Blisters
may be debrided (cut away) to remove possible
necrotic tissue as the burn heals.
C. The nurse would recommend applying cool water to reduce the water temperature and
stop the burning as well as reduce the pain.
Emergency Management for Severe Burns
• The child with a third- or fourth-degree burn is critically
injured and requires immediate care.
• Care includes fluid therapy, systemic antibiotic therapy, pain
management, and physical therapy.
• The goal is to prevent disability caused by scarring, infection,
or contracture.
Emergency Management for Electrical Burns
of the Mouth

• The immediate treatment for electrical burns of the mouth is to unplug

the electric cord and control bleeding if present. This can be done by
pressing a towel against the burn site.
• In the emergency room, pain management and wound care are essential.
Clean the wound with an antiseptic solution.
• Most children with electric burns are admitted to an observation unit for
at least 24 hours because edema in the mouth could lead to airway
obstruction.
Emergency Management for
Electrical Burns of the Mouth

• Soft foods and fluids may be easiest to swallow.

• Electrical burns of the mouth turn black as local
tissue necrosis begins. They heal with white, fibrous
scar tissue, possibly leaving a malformation of the lips https://image.slidesharecdn.com/oralbur

or cheeks and difficulty speaking clearly afterward. n-160525065549/75/oral-burn-30-

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This can be minimized by using a mouth appliance,

which helps maintain lip contour. Many children
need follow-up care by a plastic surgeon to restore
the lip contour.
In children, the formula is
edited to 3 ml x % TBSA x
weight (kg). Often lactated
ringers (i.e., a solution
containing sodium chloride,
sodium lactate, potassium
chloride, and calcium chloride)
are used. Subsequently,
maintenance fluids composed
of normal saline with 5%
dextrose may also be
administered to children to
prevent hypoglycemia and
electrolyte abnormalities.
• This formula is used for burns that encompass more than 20% of
the total body surface area or 10% of the body surface in children
or the elderly, that are either deep partial thickness (i.e., second-
degree burns) or full thickness (i.e., third-degree burns).

• The Parkland formula is not used for first-degree burns as these

burns do not typically cause significant hemodynamic shifts.
Burn prevention information for parents/caregivers
includes:
1. Install smoke alarms in the home, on every floor, and near all
rooms in which family members sleep.
2. Monitor smoke alarms by testing them monthly to make sure they
are working properly. Use long-life batteries.
3. Create a family fire escape plan, involve the children in the
planning, and practice frequently.
4. Never leave food unattended on the stove and always supervise or
restrict the use of stoves, ovens, and microwaves with children.
5. Check the water heater temperature and make sure that the
thermostat is set to 120°F or lower. Always test the water before
children enter the bathtub or shower (CDC, 2021b).
Nursing Diagnoses and Related Interventions
Because pain and anxiety often accompany burn care, relieving them is
always an important concern.
Nursing Diagnosis: Pain and anxiety related to thermal damage to body
cells
Outcome Evaluation: Child states (age dependent) that pain and
anxiety are at a tolerable level; rates pain at 2 or below on a pain rating
scale.
• Morphine sulfate IV or via epidural injection is commonly the agent of
choice for pain relief. Performing burn care such as debridement (the
removal of necrotic tissue from a burned area) may be done with the
use of patient-controlled analgesia or conscious sedation.
• In addition to having pain from a burn, children may be required to
remain in awkward positions to keep joints overextended, so the
skin over them does not heal with a contracture.
• If the anterior throat is burned, for example, the child’s head
needs to be hyperextended to keep the scar tissue that forms
on the anterior neck from pulling the chin down against the
chest in a permanent position.
• If children have burns over extremity joints, they may have splints
applied over their burn dressings to maintain the joints in
extension. This will help decrease contractures from developing.
Be certain that parents/caregivers understand the importance of
keeping the splint in place at all times.
• Encourage children to talk about their injury and how it occurred
(a form of debriefing) so that they can integrate this unexpected
event into their life.
• Although most children are awake and very aware of the pain and
treatments involved, children who experience smoke inhalation
from the fire that caused their injury may become unconscious
from brain anoxia.
Nursing Diagnosis: Fluid volume deficiency related to fluid shifts from
severe burn
Outcome Evaluation: Skin turgor remains good; hourly urine output is
greater than 1 mL/kg, with specific gravity between 1.003 and 1.030; vital
signs are within acceptable parameters for child’s age.
• In addition to hypovolemia, because so much of the child’s skin surface
may be exposed for examination, a child is prone to hypothermia (keep
body parts not burned well covered).
• Children may also develop a severe anemia following a burn because of
injury to red blood cells caused by the heat and loss of blood at the
wound site. The large amount of sodium lost from the bloodstream into
the edematous burn fluid and the release of potassium from damaged
cells can lead to both immediate hyponatremia and hyperkalemia (Table
52.3).
• To detect whether extreme hypovolemia is occurring, monitor vital
signs closely even with relatively minor burns; lactated Ringer’s
solution is the commercially available solution most compatible with
extracellular fluid, so that solution or normal saline will be
administered for fluid replacement.

• A child may also need plasma replacement and a source of glucose

such as 5% dextrose in water. Do not administer a potassium
additive immediately after a burn until kidney function is evaluated
to be certain that extra potassium can be eliminated.
• The amount of fluid necessary is calculated carefully based
on predicted insensible fluid loss and loss that can be
predicted because of the burn (2,000 mL/m of body
2

surface per 24 hours plus 5,000 mL/m of body surface

2

burned over 24 hours). Fluid is administered rapidly for the

first 8 hours (half of the 24-hour load) and then more
slowly for the next 16 hours (the second half)
• A central venous pressure or pulmonary artery catheter
may be inserted to determine hemodynamic and fluid
volume status and evaluate that the child is receiving
adequate fluid.
• If many red blood cells were destroyed at the burn site, the
child may need packed red blood cells to maintain an
adequate hemoglobin level.
Nursing Diagnosis: Altered tissue perfusion risk related to
cardiovascular adjustments after burn injury
Outcome Evaluation: Child’s vital signs remain within normal limits for
age; hourly urine output remains greater than 1 mL/kg of body weight
per hour.

• A complete blood cell count, blood typing and cross-matching,

electrolyte and BUN determinations, and blood gas studies to
ascertain blood levels of oxygen and carbon dioxide are obtained to
monitor the shifts in fluid and electrolytes that may occur.
• Measure height, weight, and obtain vital signs on admission of a child
with a burn and continue to take vital signs every 15 minutes until
they are stable.
• Once these are stabilized, record pulse, blood pressure, and central
venous pressure closely until the child passes the immediate danger
of shock (at least 24 hours).
Nursing Diagnosis: Ineffective breathing pattern risk related to respiratory
edema from burn injury
Outcome Evaluation: Child’s respiratory rate remains within normal range
for age; lung auscultation remains clear bilaterally without adventitious
sounds.

• If a child inhaled smoke from a fire, the injury from the smoke inhalation
can be more serious than the skin surface burns received because smoke
coming from a fire is at the temperature of the fire or is the same as
exposing the upper respiratory tract to open flame. In addition, toxic
substances released by the fire may cause local irritation to the respiratory
tract.
• If carbon monoxide is inhaled with the smoke, it enters red blood cells in
place of oxygen, limiting the oxygen supply to body cells. If this is extensive,
it can lead to loss of consciousness because of cerebral anoxia.
• To help rule out smoke inhalation, obtain a history to assess whether
the fire occurred in a closed space, such as a garage. Assess for burns
of the face, neck, or chest, which would indicate that the fire was
near the nose and respiratory tract. Assess the quality of the child’s
voice (it will be hoarse if the throat is irritated from smoke).
• Carefully monitor the respiratory rate of all burned children because
respiratory rate increases with respiratory obstruction. A child also
may become restless because of lack of oxygen. Measurement of
oxygen saturation will indicate the degree of hypoxia present from
carbon monoxide intoxication.
• The best therapy for displacing carbon monoxide and providing
adequate oxygenation to body cells is the administration of 100%
oxygen.
• The child may need endotracheal intubation or a tracheostomy with
assisted ventilation to ensure adequate oxygen is reaching the lungs.
• Bronchodilators and antibiotics may be prescribed as a prophylactic
measure because symptoms of smoke inhalation may develop 8 to 24
hours after the burn when the child’s temperature increases or a
chest X-ray reveals collecting edematous fluid and decreased
aeration. High-frequency ventilation may be helpful to keep alveoli
functioning.
• Some children need ECMO support because smoke inhalation has
compromised their lung function.
Nursing Diagnosis: Impaired urinary elimination risk related to burn
injury
Outcome Evaluation: Child’s urine output is greater than 1 mL/kg of
body weight per hour.
• Because the child’s blood volume can decrease immediately after a
burn, renal function can be altered when adequate function is
needed to excrete the breakdown products from burned cells.
Monitor blood volume to detect whether hypovolemia is occurring
and maintain IV fluid administration to maintain urinary output at
about 1 mL/kg of body weight per hour.
• Monitor the specific gravity of urine to determine if the kidneys have
the ability to concentrate urine to conserve body fluid (failing kidneys
lose this ability rapidly). Monitoring urinary output is crucial to
determine kidney function.
• An indwelling urinary (Foley) catheter should be inserted in the
emergency department for a child with extensive burns to obtain a
baseline urine for analysis and provide access for specimens to be
obtained.
• If hemoglobin in tubules develops, a diuretic may be administered to
maintain kidney function. The urine will return to a normal color if the
diuretic is effective.
Nursing Diagnosis: Malnutrition risk related to burn injury
Outcome Evaluation: Child’s weight remains within one standard
deviation from prior age-appropriate growth percentiles;skin turgor
remains good; urine specific gravity remains between 1.003 and 1.030.
• After burns, the metabolic rate increases in children as the body
begins to pool its resources to adjust to the insult. If children do not
receive enough calories in IV fluid to accommodate this increased
metabolic need, their body will begin to break down protein for use, a
particularly dangerous problem because the child needs protein to be
available for burn healing.
• Additionally, if the breakdown of protein is extreme, it can lead to
severe acidosis.
• After a severe burn, some children feel nauseated because
bowel peristalsis halts (paralytic ileus) from the systemic
shock.
• Symptoms of intestinal obstruction, such as vomiting,
abdominal distention, and colicky pain, follow within hours
of the burn.
• To prevent aspiration of vomitus, an NG tube will be inserted
and attached to low, intermittent suction. It then remains in
place until bowel sounds are detected to make certain that
the GI tract is again functioning. This can be as long as 24 to
72 hours in severely burned children.
• If a bleeding ulcer does occur, gastric lavage with iced saline may be
necessary. Blood for transfusion should be readily available because
the blood loss from a GI ulcer can be rapid and severe.
• Because of these potential GI concerns, children with severe burns
usually are placed on nothing by mouth (NPO) for 24 hours. After
this time, most children are able to eat, and oral feedings are
resumed. To supply adequate calories for increased metabolic needs
and spare protein for repair of cells, the diet is high in calories and
protein (Orsborn & Braund, 2020–2021).
• Children may also need supplemental vitamins (particularly B and C),
iron supplements, and high-protein drinks between meals to ensure
an adequate protein intake (Orsborn & Braund, 2020–2021).
Nursing Diagnosis: Injury risk related to effects of burn, denuded skin
surfaces, and lowered resistance to infection with burn injury
Outcome Evaluation: Child’s temperature remains at 98.6°F (37°C); skin
areas surrounding burned areas show no signs of infection such as erythema
or warmth.
• There appears to be some defect in the ability of neutrophils to
phagocytize bacteria after a burn injury, in addition to the failure of the
formation of immunoglobulin G antibodies. For these reasons, a child has
reduced protection against infection for some time after a severe burn.
Staphylococcus aureus and group A β-hemolytic streptococci are the Gram-
positive organisms and Pseudomonas aeruginosa is the Gram-negative
organism most likely to invade burn tissue.
• In addition to bacteria, fungi such Candida also may invade burns (Orsborn
& Braund, 2020–2021). Children are usually prescribed an antibiotic to
prevent these infections and tetanus toxoid vaccine to prevent tetanus.
• Bacteria and fungi can penetrate the burn eschar readily, so
this tissue offers little protection from infection, necessitating
nose, throat, and wound cultures to be obtained immediately
and then daily. Granulation tissue, which forms under the
eschar 3 to 4 weeks following the burn injury, is resistant to
microbial invasion.
• Systemic antibiotics are generally ineffective in controlling
wound infection of the burn. Capillary constriction at the site
of the burn site prevents effective distribution of the antibiotic.
Equipment in contact with the burn site must be sterile to
avoid introducing infection.
• Children are placed on a sterile sheet on the examining
table, and personnel caring for the severely burned child
should wear caps, masks, gowns, and gloves while
providing direct patient care.
• Children with burns are usually placed in private rooms to
help reduce the exposure to infection. Due to infection
control, children need interventions to maintain their self-
esteem and prevent social isolation.
D. The nurse would instruct the care team to allow the patient to speak of the incident.
Being burned is such a frightening event, children need “debriefing” afterward, so they are
assured they are now safe and healing. The other listed actions are appropriate.
Therapy for Burns
• Second- and third-degree burns may receive open treatment, leaving the
burned area exposed to the air, or closed treatment, in which the burned
area is covered with an antibacterial cream and many layers of gauze.
These two methods are compared in Table 52.4.
• As a rule, burn dressings are applied loosely for the first 24 hours to
prevent interference with circulation as edema forms. In applying dressing,
ensure that two burned body surfaces, such as the sides of fingers or the
back of the ears and the scalp, do not come in direct contact with each
other. These surfaces will heal together and webbing will occur.
• Do not use adhesive tape to anchor dressings to the skin; it is painful to
remove and can leave excoriated areas, which provide additional entry
sites for infection. Netting is useful to hold dressings in place because it
expands easily and needs no additional tape.
Topical Therapy
• Silver sulfadiazine (Silvadene) is the drug of choice for burn therapy to limit
infection at the burn site. It is applied as a paste to the burn, and the area
is then covered with a few layers of mesh gauze. Because silver sulfadiazine
has a sulfa base, it is an effective agent against both Gramnegative and
Gram-positive organisms and even against secondary infectious agents,
such as Candida. It is soothing when applied and tends to keep the burn
eschar soft, making debridement easier.
• If Pseudomonas is detected in cultures, nitrofurazone (Furacin) cream may
be applied. If a topical cream is not effective against invading organisms in
the deeper tissue under the eschar, daily injections of specific antibiotics
into the deeper layers of the burned area may be necessary.
• If a burned area, such as genitalia, cannot be easily dressed, the area can
be left exposed. The danger of this method is the potential invasion of
pathogens.
Escharotomy
• As natural protection for a burned area, a rigid scab (an eschar) forms over
moderately or severely burned areas. Fluid accumulates rapidly under an
eschar, putting pressure on underlying blood vessels and nerves.
• If an extremity or the trunk has been burned so that both anterior and
posterior surfaces have eschar formation, a tight band may form around
the extremity or trunk, cutting off circulation to distal body portions.
• If distal parts feel cool to the touch and appear pale, any tingling or
numbness is present, pulses are difficult to palpate, and capillary refill is
slow (longer than 5 seconds), an escharotomy (cut into the eschar) may be
performed (Orsborn & Braund, 2020–2021). Some bleeding will occur after
escharotomy. Packing the wound and applying pressure usually relieves
this.
Debridement
• Debridement is the removal of necrotic tissue on which
microorganisms could thrive from a burned area to reduce the
possibility of infection. This may be done using collagenase (Santyl), an
enzyme that dissolves devitalized tissue, or manually.
• For manual debridement, children may have 20 minutes of
hydrotherapy beforehand to soften and loosen eschar, which then can
be gently removed with forceps and scissors. Debridement is painful,
and some bleeding occurs with it.
• Premedicate the child with a prescribed analgesic and help the child
use a distraction technique during the procedure to reduce the level of
pain. Transcutaneous electrical nerve stimulation (TENS) therapy or
patient-controlled analgesia also can be helpful pain management
measures.
• Extensive debridement is done using conscious
sedation. Praise any degree of cooperation. Plan an
enjoyable activity afterward to aid in pain relief and
to help reestablish some sense of control over the
situation (Fig. 52.12).
• If burned areas are debrided in this manner daily,
granulation tissue forms underneath. When a full
bed of granulation tissue is present (about 2 weeks
Figure 52.12 A nurse
after the injury), the area is ready for skin grafting. provides comfort and
In some burn centers, this waiting period is avoided support to a child before
by immediate surgical excision of eschar and debridement. (© Kathy
Sloane/Science
placement of skin grafts. Source/Photo Researchers.)
Grafting
• Allografting is the placement of skin (sterilized and frozen) from
cadavers or a donor on the cleaned burn site. These grafts do not
grow but provide a temporary protective covering for the area. In
small children, xenografts, or skin from other sources, such as porcine
(pig) skin, may be used.
• Autografting is a process in which a layer of skin of both epidermis
and a part of the dermis (called a split-thickness graft) is removed
from a distal, unburned portion of the child’s body and placed over
the prepared burn site, where it will grow and replace the burned skin
(Orsborn & Braund, 2020–2021). The advantage of both types of
grafting is that they reduce fluid and electrolyte loss, pain, and the
chance of infection.
Grafting
• Skin for a split-thickness graft is
removed from the buttocks or
inner thigh under general
anesthesia. Large burn areas may
require mesh grafts (a strip of
partial-thickness skin is slit at
intervals so that it can be stretched
to cover a larger area; Fig. 52.13).

Figure 52.13 Mesh grafting is

necessary to cover large areas of
the body such as in this young
child with third-degree
burns. (© CC Studio/SPL/Photo
Researchers Inc.)
• After the grafting procedure, a bulky dressing covers the burned area.
A gauze dressing also covers the donor site on the child’s body. To
ensure the growth of the newly adhering cells underneath will not be
disrupted, do not remove or change the dressings.
• To detect infection at the sites, observe both the donor and graft
dressings for fluid drainage and odor, and assess for pain and body
temperature, all of which might indicate infection. Autograft sites
heal so quickly that they can be reused every 7 to 10 days, so any one
site can provide a great deal of skin for grafting.
Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Social isolation related to infection control precautions
necessary to control spread of microorganisms
Outcome Evaluation: Child states (age dependent) understanding of the
reason for infection control precautions; accepts it as a necessary part of
therapy.
• Infection control measures involved in the care of children with major
burns consist of more than just placing the child in a private room. Aseptic
technique and appropriate barriers are necessary to reduce the risk of
exposing the child to infection by the use of gowns, masks, caps, and sterile
gloves by healthcare providers, creating a situation where the child is
doubly isolated—by distance and by never being touched directly.
• Provide time for children to discuss their feelings about being in a
room by themselves. A question such as “It’s hard to understand a lot
of things about a hospital; do you understand why your bed is in this
special room?” gives children a chance to express their feelings.
• Show parents how to put on gowns, gloves, and masks if required so
they can feel comfortable participating in the child’s care.
• Children require stimulation in their restricted environment. If a Child
Life staff member is available, they can assist with providing age-
appropriate activities. Listening to music, playing quiet games,
drawing, being read to, and doing homework are activities (age
dependent) that children may enjoy.
Nursing Diagnosis: Impaired family processes related to the effects of
severe burns in a family member
Outcome Evaluation: Family members state that they are able to cope
effectively with the degree of stress to which they are subjected; family
demonstrates positive coping mechanisms.
• Children with severe burns always have a difficult hospitalization
because of the pain, restrictions, and (at some point) awareness of
the disfigurement that accompanies major burns.
Nursing Diagnosis: Altered body image perception related to
changes in physical appearance with burn injury
Outcome Evaluation: Child expresses fears about physical
appearance; demonstrates desire to resume age-appropriate
activities.

• Children with burns are often forced to become extremely

dependent on the nursing staff because of the position in
which they must lie and because the bulky dressings that
cover their arms or hands prevent them from self-care, such
as eating independently.
• Older children may respond by open aggressiveness such as refusing to
eat or to lie in a position they prefer as an attempt to reestablish
independence and counteract their feelings of helplessness.

• Allow secondary choices instead. Children, for example, must take the
10 o’clock medicine, but they can choose the fluid they want to swallow
after it. They must be fed meals because of the bulky dressings over
their hands, but they can decide which food they will eat first. They
must have their dressings changed, but they can choose the story you
will read them afterward.
• When children begin to see others on the
hospital unit with burn scars, however, they
do begin to realize that healing may result in
permanent scarring (Fig. 52.14). Parents and
children need time to talk about their feelings
about this because they may feel a great deal
of guilt about the incident and ways they
could have prevented the burn injury Figure 52.14 Extensive scarring on the

(Hawkins et al., 2019). chest of a 9-year-old child following a

third-degree burn. (© Dr. P.
Marazzi/SPL/Science Source/Photo
Researchers.)
• All children are concerned about whether their face will be
scarred. Burns on the chest may affect development of
breast tissue.
• Children observe the nurse’s reaction to their appearance.
The appearance of scar formation can be improved by the
application of pressure dressings that the child wears 24
hours a day.
• Counseling to help with self-image and adjustment. Some
parents need formal counseling to help them accept their
child’s changed appearance and work through guilt.