Chapter 27: Care of children and young people with thermal injury

ANSWERS TO ACTIVITY 27.2: CRITICAL THINKING

The tools illustrated to measure the size of a burn were devised by clinical staff based on the size of patients at the time and all show validation limitations. List what you think the implications are if the burn size is either over- or under-estimated?

Answer: Below are the key considerations if the burn size is inaccurately assessed. These are not exhaustive lists so you may have highlighted more.

If over-estimated:

  • Too much fluid is then given. The patient becomes overloaded. Many complications can occur with fluid overload such as respiratory difficulties and compartment syndrome.
  • Additional fluid is given when not required. Patient could perhaps have been managed with oral fluids only.
  • Patient is given intravenous lines, catheter/NG tubes when they are not required.
  • Patient is transferred out of locality to a higher level of care unnecessarily.
  • Unnecessary psychological trauma for the child/family.

If under-estimated:

  • Too little fluid is given, patient becomes dehydrated.
  • Many complications can occur with being dehydrated such as organ failure, e.g. kidney failure.
  • The microcirculation to the skin is compromised so the burn injury deepens and widens. The burn injury (amount of skin loss) gets worse.

The patient could go into circulatory shock. There is a high chance of mortality with this.

ANSWERS TO ACTIVITY 27.3: REFLECTIVE PRACTICE

Use the 12 activities of daily living (ADL) to highlight the potential problems for a child aged 18 months, 5 years and 12 years for the following burn injuries:

  • Burns to the face, including eyes, ears, nose and mouth
  • Burns to the hands and feet
  • Burns to the neck, axilla, elbows, knees and ankles
  • Burns to the perineum
  • Smoke inhalational injuries

Answer: The following table is indicative of the specific considerations that may be required for injuries affecting certain parts of the body. You may have come up with more!

 

Facial burns

Hands/feet burns

Burns across joints

Perineum burns

Airway burns

Maintaining a safe environment

Close supervision may be required for all age groups.

May be more unsteady/less able to maintain own safety.

May be splinted so again may require more supervision.

May be more dependent.

 

Fully dependent.

 

Communication

Potentially unable to see, hear, talk.

Potentially unable to use hands to self-express. May need assistance to communicate.

Age dependent on whether needs can be communicated.

Potentially fully dependent.

Breathing

May be compromised.

Should not be compromised.

May require splinting or positioning to aid better ventilation.

Should not be compromised.

May require long term sedation/ventilation. May require a tracheostomy.

Eating and drinking

Will need to be fed/supplementary fed.

Should not be an issue for the older child.

Will need enteral feeds.

Elimination

Dependent as per age and not location of injury.

Will need more assistance regardless of age.

May need more assistance.

Will need frequent pad/ dressing changes to remove contaminants. May require a catheter or bowel management system.

Fully dependent if ventilated.

Washing and dressing

Fully dependent all ages. Wound care can be incorporated as part of a regular washing routine.

Likely to be more dependent. All ages.

Fully dependent.

Controlling temperature

Observe temp as per standard burn care irrespective of where the burn is.

Mobilisation

If able, more supervision needed.

Assistance required. May be less mobile. A rehabilitation plan is needed including both passive and active exercises.

May be more dependent.

Fully dependent.

Working and playing

Will need assistance/supervision for all ages.

May require more assistance.

Will need sensory stimulation, e.g. TV, music.

Expressing sexuality

 

An individualised approach to this should be taken depending on the age and stage of development of the child. Perineal/genitalia burns may cause a sense of anxiety at any stage after injury.

Sleeping

The location of the burn or age of the child may not be the sole cause of problems in this area. An individualised approach should be taken for all patients.

Death and dying

As above. Recognition and acknowledgement of the child and family’s fears/anxieties will help with this.

List how you would care for the child and family in light of the above, considering both the physical and psychological needs of both the child and the parents

Answer:

  • Provide information e.g., leaflets, on burn care treatments
  • Allow opportunities to ask questions and clarify the treatment plan
  • Allow the child to have some control in making treatment decisions
  • Listen to their fears and anxieties
  • Allow the child to express his fears/anxieties in his own way
  • Plan procedures/treatments with enough preparation time
  • Give positive reinforcement and encouragement after procedures or physiotherapy sessions
  • Instigate a daily timetable so that the patient knows what is being done and when
  • Regular ‘check-ins’ with the child/family so that understand why treatments are necessary
  • Signpost the child/family to appropriate support groups

Additional scenario

Ruby is 18 months old. She pulled a hot cup of tea over herself. She has 9 per cent TBSA partial thickness scalds to her chin, neck, anterior torso, left shoulder and left arm. 

  • Consider what her problems/ needs by using the 12 activities of daily living.
  • Consider the potential longer-term problems if healing is delayed.

The following table outlines which ADLs will be potentially affected with this size of burn injury over and above a child of this age:

ADL

NEEDS

Eating and drinking

Additional fluids should not be required for this size of burn. However a diet chart should be maintained as a record of oral intake and output.

If calorie/ fluid intake is below what the child normally has within 24 hours, then advice from a dietitian should be obtained.

Healing will be compromised if dietary intake is poor. 

Washing and dressing

The burn wound is likely to be covered with dressings. Initially, it may be too painful to carry out dressing changes without a general anaesthetic.

Washing and dressing should still be encouraged/promoted even though there are dressings in situ. This can help the patient/family psychologically too as it promotes normality.  

Controlling temperature

Regular monitoring of temperature alongside other observations will indicate whether or not an inflammatory response occurs as a result of this injury or from an infection. An infection can occur at any time after injury and until the wound is fully healed.

Mobilisation

Normal mobilisation should be encouraged.

Working and playing

Normal play should be encouraged. The dressings should not be too restrictive. Utilise the skills of the play therapist.

Sleeping

A problem with sleep can occur if the child is in pain, too hot, or suffering from post burns itching.

A lack of sleep is not good for the child’s recovery or the parent/carer’s wellbeing.

If healing is delayed, then the potential problems include the following:

  • A need for surgery (skin grafting) to heal the wounds.
  • Further pain, distress/anxiety from multiple painful dressing changes.
  • Scarring and its long-term effects such as itch, sensitivity to touch, skin tightness and contracture formation which will restrict movement and function.