n CLINICAL
REPORTS
Margaret Brady, PhD, RN, CPNP California State University, long Beach Department of Nursing
Margaret Grey, DrPH, RN University of Pennsylvania School of Nursing Philadelphia, Pennsylvania
Ambulatory Management . in Children Sue Martinez,
B
urn injuries are usually the result of an accidental event and are often traumatic for victims and their families. This article focuses on burn injuries that can be treated in an outpatient setting. Most pediatric burns involve children who are less than 5 years of age. The peak incidence occurs in the 1 to 2-year-old group. The curious and adventurous nature of toddlers, coupled with their normal lack of sophisticated motor skills, makes toddlers accident prone in general. In all studies, the incidence of burns in boys outnumbers those in girls (Uchiyama & German, 1987). Scalds from hot liquids are the major cause of burns in children. Scalds account for 56% of all pediatric burns versus approximately 20% of adult burns. Spillage of scalding liquid is the greatest hazard for toddlers. Most of these injuries occur in the kitchen. Tap water scalds are usually serious injuries that result from submersion in hot water in the bathtub or sink or from hot water being added to a bath. Burns from contact with hot objects are the next most common injury in children. Hot objects include irons, heaters, oven doors, or curling irons. In most cases, the objects cause deep burns on a small area of the body. Other causes of burn injury in children include playing with matches, house fires, and injuries from electrical cords (Jay, Bartlett, Danet, & Allyn, 1977). The incidence of clothing fires has decreased because of the USC of flame-retardant fabrics. Electrical injury to the mouth is a problem in the toddler age group exclusively and results from the child biting into an electrical cord. n
CLASSIFICATION
OF BURN WOUNDS
In the initial evaluation of a burn two factors must be considered: the intensity of the heat or causative agent and the amount of time of exposure. These two factors
Sue Martinez is currently the assistant director of Nursing Medical Center, University of California, Irvine, Calif.
32
Critical
Care at UCI
of Burns n
RN, MSN
provide information essential for the child’s management plan. Exposure to a high temperature for a brief period of time, such as a splash of hot liquid, results in a more superficial injury than does a prolonged exposure. A patient who is submerged in hot water or who is unable to escape from the source of heat experiences prolonged exposure that results in a deep injury. Traditionally, burns have been classified into first, second, and third degree injuries. Although this classification is still occasionally used, it is being abandoned for a more functional and descriptive assessment that allows a more precise evaluation of the burn wound (Bonaldi & Frank, 1987). The superficial burn wound or first-degree burn results in damage limited to the epidermal layer. The area is reddened and may be slightly edematous. Superficial burns are uncomfortable. Pain relief is usually achieved with over-the-counter medications or a cool cloth to the area. Medical treatment usually is not indicated. Partial-thickness burns or second-degree burns result in damage to the epidermal layer and to varying depths of the dermis. Characteristics of a partial-thickness burn include redness, swelling, blisters, a moist appearance, pain, and sensitivity to the air. Because the dermal layer contains many structures, healing and outcomes vary. The ability to regenerate skin cells occurs in the dermis; therefore, some partial thickness burns heal within 2 to 3 weeks. If regenerative cells from the dermis are damaged, skin grafting may be required. The amount of scar tissue formation also depends on the degree of damage to the dermal layer. Other dermal appendages, such as hair follicles and sweat glands, may or may not be damaged. Only time confirms the extent of this type of injury. Full-thickness burns or third-degree burns result in damage to the epidermis, the dermis, and all dermal appendages. Characteristics of a full-thickness burn include a white or black appearance, swelling, and a dry surface. In addition, if destruction of nerve endings has
JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Patient
n
FIGURE
occurred, these bums may be less painful than par&& thickness burns. Sometimes, initial differentiation between a deep partial-thickness and a full-thickness burn is difficult. The classification of the burn may be postponed and determined later, based on the course of healing. The Rule of Nines is used to measure the amount of
Management
Exchange
33
1
surface area involved in a burn injury. This method divides the body into sections, with each section equal to a multiple of nine. The percentage of burn injury is calculated based on the following guide: each arm is 9%; each leg is 18%; the front and back trunk are both measured at 18%; the head is 9%; and the genital area is calculated at 1%. The surface area of a small bum can
34
Patient Management
Volume 6, Number 1 January-February 1992
Exchange
4 FIGURE 2
be estimated by using the palm of the patient’s hand to represent 1% of body surface area. n
ASSESSMENT
The American Burn Association defines burns of less than 10% of the body surface as minor injuries that can be managed appropriately with outpatient care. Seconddegree burns of up to 20% of the body surface are identified as moderate injuries that may be considered for outpatient care either initially or after a brief hospitalization for fluid resuscitation. Health professionals need to remember that burn injuries can be a manifestation of child abuse. Approximately 9% to 11% of burn injuries in children are nonaccidental. The peak incidence of nonaccidental bum injuries occurs in youngsters 13 to 24 months of age (Uchiyama & German, 1987). Multiple cigarette bums and hot iron burns are obvious forms of inflicted injury. Scald injuries, unfortunately, comprise most nonaccidental burns, and, in most instances, intentional scald burns are similar in appearance to accidental bums. Thus a thorough evaluation is required for all children with scald injuries. The pattern of a burn and/or absence of splash marks become important factors in the differentiation of an accidental injury from an intentional injury, The pediatric history and physical examination are the most valuable tools in detecting nonaccidental injuries. In many instances, children who in previous years
would have been admitted to a hospital because of their burns can now be managed as outpatients. After fluid resuscitation, resolution of edema, and family assessment, children are often sent home and treated as outpatients. Frequently parents have concerns about keeping their child at home. Thorough teaching about burn care and support for parents are of utmost importance. Reinforcement of the need to comply with the burn treatment plan must continue throughout the entire course of ambulatory care. n
WOUND
MANAGEMENT
Treatment of the burn wound is best done in an aggressive and meticulous manner. Children should be treated daily during the first few days to monitor their progress and wound healing. The most effective method of burn care is cleaning the wound either by soaking or spraying it to remove the residue from previous dressings and any devitalized tissues or proteinaceous material that has collected and coagulated on the wound. Washing can be done with cotton or gauze pads. Laparotomy pads like those used in the operating room work well. They are soft, lint free, and most effective in cleaning the wound. If whirlpool agitation is available, it is helpful. However, soaking the burn or spraying its surface with water softens the eschar and loosens the debris so that maximum cleansing occurs, with minimal contact of the wound.
journal of Pediatric Health
Patient
Care
n
Management
Exchange
35
FIGURE 3
After the wound is cleansed, the burns are dressed. Silver Sulfadiazene (SSD) is the topical agent most commonly used. SSD can be spread on fine mesh gauze and applied to the burn wound. The gauze should not be wrapped around the wound but rather cut in strips and placed on the burn in a series of successive strips (Figure 1, A and B). This method of wrapping eliminates the potential for circulatory impairment associated with edema in fresh burns. Additional SSD is applied over the gauze after it is placed on the wound. A tubular net bandage is then applied to help hold the gauze in place. Tubular net comes in a variety of sizes to fit all body parts from fingers to trunk. Bulky bandages can be used instead of tubular net, but bulky dressings limit mobility and independence. In younger children, this restriction may be a desirable effect. In some casesbulky dressings, especially on hands may prevent the child from removing the dressings during rest or play (Figure 2). This type of dressing can be c:hanged daily in the ambulatory setting. As healing progresses and the family becomes more comfortable with the process, they can be taught to clean and redress the wound at home, thereby, decreasing the frequency of clinic visits. Other dressing techniques include those of the barrier type such as Biobrane (Winthrop Pharmaceuticals, New York, N.Y.) or Hydron (National Patent Medical, Dayville, Ct.). These are clear barriers that promote drainage of excess fluid and exudate while prohibiting bacterial growth. These two dressings are best used on
fresh, clean wounds because they do not contain topical antibiotics such as SSD. These barrier dressings can remain in place for 5 to 7 days. A clear advantage of these products is that the number of return visits that are needed is minimized. However, the application of a barrier dressing is more precise than applying gauze and cream and can be difficult to do on a moving child. Culturing of burn wounds is done on a weekly basis or more frequently if infection is suspected (Figure 3). Systemic antibiotics are used only for documented infections. With aggressive wound care, prophylactic antibiotics are unnecessary in minor burn injuries. OTHER CONSIDERATIONS Pain Management
n
A vital part of successful ambulatory burn care is adequate pain control. The pain medication most frequently used in children is acetaminophen with codeine elixir. It commonly is used before wound care and during the day as needed. Most children quickly advance to over-the-counter acetaminophen as healing occurs. In cases of severe pain, an injection may be ordered before wound care. Nutrition The importance of nutrition in wound healing is well known. The challenge of assuring adequate intake in a child who may be in pain and who is normally a “picky” eater can be a difficult one. Being at home with
36
Patient
Management
one’s own family is more conducive to eating than being hospitalized. Parents may need special instruction in ways to maximize the nutritional value of foods that their child eats. Fluids are important especially early in the course of treatment when fluid loss is a concern. High-caloric fluids such asjuices, carbonated beverages, or milk can be used. Peanut butter may be a palatable source of protein. Although any caloric intake is welcome, “empty” calories should be avoided. Food preferences must be considered to provide proper nutrition and ensure adequate caloric intake. In some cases, nutritional supplements may be required. If nutrition is a problem or weight loss occurs, referral to a dietitian may be necessary. n
HOME SAFETY
The importance of evaluating the circumstances of the burn injury to screen for problems of maltreatment is mandatory. However, most burns in children occur as a result of a limited knowledge of home safety. Family teaching in this area is a major component of ambulatory care. Burn prevention is extremely important, and teaching should address hazardous situations in relation to every room in the child’s home. Many children sustain accidental burns when they are teething, have a cold or ear infection, or have other ailments. When children are ill, mothers generally do not sleep as well as usual, are stressed and fatigued, and are less alert to the child’s activity. Accidents tend to happen in these instances. Turning in pot handles, pulling up dangling cords, and never leaving a child unattended are basic points that must be discussed with parents. In planning care, these facts cannot be ignored. A home health care visit may be required to identify safety concerns, provide safety instruction, assist with burn care in the home, or help parents as they cope with what has happened to their child. LONG-TERM Scar Control
n
Volume 6, Number 1 January-February 1992
Exchange
FOLLOW-UP
Scar management may be the most challenging aspect of treating a burn patient. Most children with scald injuries from hot liquid spills heal quickly and develop little or no scarring. However, even the most experienced practitioners of burn care cannot predict if or how much scarring will occur. Many factors contribute to the severity of scarring: (1) depth of burn, (2) length of time for healing to occur, (3) grafting, (4) age, and (5) skin character. Scars remain immature for 12 to 18 months after the burn. As scars mature, many color and texture changes occur (Schneider & Simonton-Thorne, 1987). Patients should be referred to a bum or plastic
surgeon familiar with burn scars who can best follow the progression of the scarring and treat it accordingly. Most definitive surgical treatment is delayed until the scars are matured. The months spent in waiting may be the most difficult period of coping and adjustment for the child and especially the family. School Reentry Returning to school can be a very traumatic part of the bum recovery process. Most burn centers have a school reentry program. These programs provide services that include formal educational instruction for the child, as well as programs that involve question-and-answer sessions for teachers and classmates to prepare them for the child’s return to the classroom. Children who are treated at facilities without school reentry programs can be accepted into a school reentry program at any burn center with such a program. Reconstructive
Surgery
Small burns that involve the hands or other functional areas of the body often require reconstructive surgery after scars are mature or when growth spurts occur. In these situations, families should be referred to a burn center or plastic surgeon with experience in reconstructive surgery for long-term follow-up. Teaching Needs Teaching family members and/or the child about burn care involves many areas and is an ongoing process. Nurses need to be involved in teaching families how to change dressings so that family members or older children with burns can become adept at this task. Once the basic techniques of dressing change are mastered, the number of required visits for dressing changes at the outpatient clinic declines in favor of more frequent home care. Instruction about the importance of nutrition to wound healing is also needed. Pain management strategies should be discussed. These strategies include methods to maximize pain medication or the use of alternative, noninvasive pain relief measures that can involve distraction with music or cutaneous stimulation such as rubbing a nonburned part of the body (McCaffery, 1979). After healing has occurred, parents and children should be assured that itching is a normal phenomenon. In small children, mittens may be needed to prevent the child from scratching the newly healed skin. Benadryl, sold over the counter, is an effective antipruritic agent; however, the side effect of drowsiness must be discussed. Newly healed burns should be protected from the sun for as long as 1 year after the burn. Healed
lournaloi Pediatric
Health
Patient
Care
The techniques discussed in this article have been developed over time in a burn center. Health providers in ambulatory care settings may want to adapt these techniques of wound management to their practice sites. It should be emphasized that any delay in healing or deterioration of the wound requires a change in therapy (such as a nutritional assessment, wound culture, or change in dressing modality). In most instances, burn centers will accept all burn patients, even those with minor injuries. However, this may not be convenient if the nearest center is far from the child’s home. In any case, burn center staff will always answer questions from practitioners in need of advice or assistance. Do not hesitate to use this resource.
ANNUAL NAPNAP CONFERENCE San Antonio, Texas March 1 l-l 4, 1992
VOLUNTEERS Volunteers
are
needed
37
Bona& L. A., & Frank, D. H. (1987). Pathophysiology of the burn wound. In B. M. Achauer (Ed.), Marsqment ofthe burnedpatient (pp. 22-45). Norwalk, Conn.: Appleton and Lange. Jay, K. M., Bartlett, R. J., Danet, R., & AIIyn, P. A. (1977). Bum epidemiology: A basis for burn prevention. Journal of Trauma. 17, 946947. McCaffery, M. (1979). Nursing management ofthe patient with pain. Philadelphia: J. B. Lippincott. Schneider, R. M., & Simonton-Thorne, S. (1987). Treatment of joints and scars. In B. M. Achauer (Ed.),Managrrnent ofthe burned patient (pp. 223-241). Norwalk, Conn.: Appleton and Lange. Uchiyama, N., & German, J. (1987). Pediatric considerations. In B. M. Achauer (Ed.), Management of the burned patient (pp. 223241). Norwalk, Conn.: Appleton and Lange. Warden, G. D., Kravitz, M., & Schnebly, A. (1981). The outpatient management of moderate and major burn injuries. Journal ofBum Care and Rehabilitation, 2, 159- 161.
CONCLUSION
13th
Exchange
REFERENCES
burns are sensitive to sun and sunburn more severely than normal skin. Sunburns result in exaggerated hypertrophic scar formation. n
Management
to serve
NEEDED as monitors
or mod-
erators for the educational sessions at the 13th Annual NAPNAP Conference to be held in San Antonio, Texas, March 1 l-14, 1992. The theme will be “NAPNAP: Advocates for Healthy Children.” The Texas Chapter of NAPNAP is serving both as the host chapter, providing information about attractions and services in the area, and as volunteer coordinator. If you are interested in serving as either a monitor or moderator or if you have questions about these jobs, please contact Becky Morrison, 2515 Norsworthy Dr., Dallas, TX 75228, (214) 879-6102 (w), (214) 328-2339 (h).
REPORTS
Margaret Brady, PhD, RN, CPNP California State University, long Beach Department of Nursing
Margaret Grey, DrPH, RN University of Pennsylvania School of Nursing Philadelphia, Pennsylvania
Ambulatory Management . in Children Sue Martinez,
B
urn injuries are usually the result of an accidental event and are often traumatic for victims and their families. This article focuses on burn injuries that can be treated in an outpatient setting. Most pediatric burns involve children who are less than 5 years of age. The peak incidence occurs in the 1 to 2-year-old group. The curious and adventurous nature of toddlers, coupled with their normal lack of sophisticated motor skills, makes toddlers accident prone in general. In all studies, the incidence of burns in boys outnumbers those in girls (Uchiyama & German, 1987). Scalds from hot liquids are the major cause of burns in children. Scalds account for 56% of all pediatric burns versus approximately 20% of adult burns. Spillage of scalding liquid is the greatest hazard for toddlers. Most of these injuries occur in the kitchen. Tap water scalds are usually serious injuries that result from submersion in hot water in the bathtub or sink or from hot water being added to a bath. Burns from contact with hot objects are the next most common injury in children. Hot objects include irons, heaters, oven doors, or curling irons. In most cases, the objects cause deep burns on a small area of the body. Other causes of burn injury in children include playing with matches, house fires, and injuries from electrical cords (Jay, Bartlett, Danet, & Allyn, 1977). The incidence of clothing fires has decreased because of the USC of flame-retardant fabrics. Electrical injury to the mouth is a problem in the toddler age group exclusively and results from the child biting into an electrical cord. n
CLASSIFICATION
OF BURN WOUNDS
In the initial evaluation of a burn two factors must be considered: the intensity of the heat or causative agent and the amount of time of exposure. These two factors
Sue Martinez is currently the assistant director of Nursing Medical Center, University of California, Irvine, Calif.
32
Critical
Care at UCI
of Burns n
RN, MSN
provide information essential for the child’s management plan. Exposure to a high temperature for a brief period of time, such as a splash of hot liquid, results in a more superficial injury than does a prolonged exposure. A patient who is submerged in hot water or who is unable to escape from the source of heat experiences prolonged exposure that results in a deep injury. Traditionally, burns have been classified into first, second, and third degree injuries. Although this classification is still occasionally used, it is being abandoned for a more functional and descriptive assessment that allows a more precise evaluation of the burn wound (Bonaldi & Frank, 1987). The superficial burn wound or first-degree burn results in damage limited to the epidermal layer. The area is reddened and may be slightly edematous. Superficial burns are uncomfortable. Pain relief is usually achieved with over-the-counter medications or a cool cloth to the area. Medical treatment usually is not indicated. Partial-thickness burns or second-degree burns result in damage to the epidermal layer and to varying depths of the dermis. Characteristics of a partial-thickness burn include redness, swelling, blisters, a moist appearance, pain, and sensitivity to the air. Because the dermal layer contains many structures, healing and outcomes vary. The ability to regenerate skin cells occurs in the dermis; therefore, some partial thickness burns heal within 2 to 3 weeks. If regenerative cells from the dermis are damaged, skin grafting may be required. The amount of scar tissue formation also depends on the degree of damage to the dermal layer. Other dermal appendages, such as hair follicles and sweat glands, may or may not be damaged. Only time confirms the extent of this type of injury. Full-thickness burns or third-degree burns result in damage to the epidermis, the dermis, and all dermal appendages. Characteristics of a full-thickness burn include a white or black appearance, swelling, and a dry surface. In addition, if destruction of nerve endings has
JOURNAL
OF PEDIATRIC
HEALTH
CARE
Journal of Pediatric Health Care
Patient
n
FIGURE
occurred, these bums may be less painful than par&& thickness burns. Sometimes, initial differentiation between a deep partial-thickness and a full-thickness burn is difficult. The classification of the burn may be postponed and determined later, based on the course of healing. The Rule of Nines is used to measure the amount of
Management
Exchange
33
1
surface area involved in a burn injury. This method divides the body into sections, with each section equal to a multiple of nine. The percentage of burn injury is calculated based on the following guide: each arm is 9%; each leg is 18%; the front and back trunk are both measured at 18%; the head is 9%; and the genital area is calculated at 1%. The surface area of a small bum can
34
Patient Management
Volume 6, Number 1 January-February 1992
Exchange
4 FIGURE 2
be estimated by using the palm of the patient’s hand to represent 1% of body surface area. n
ASSESSMENT
The American Burn Association defines burns of less than 10% of the body surface as minor injuries that can be managed appropriately with outpatient care. Seconddegree burns of up to 20% of the body surface are identified as moderate injuries that may be considered for outpatient care either initially or after a brief hospitalization for fluid resuscitation. Health professionals need to remember that burn injuries can be a manifestation of child abuse. Approximately 9% to 11% of burn injuries in children are nonaccidental. The peak incidence of nonaccidental bum injuries occurs in youngsters 13 to 24 months of age (Uchiyama & German, 1987). Multiple cigarette bums and hot iron burns are obvious forms of inflicted injury. Scald injuries, unfortunately, comprise most nonaccidental burns, and, in most instances, intentional scald burns are similar in appearance to accidental bums. Thus a thorough evaluation is required for all children with scald injuries. The pattern of a burn and/or absence of splash marks become important factors in the differentiation of an accidental injury from an intentional injury, The pediatric history and physical examination are the most valuable tools in detecting nonaccidental injuries. In many instances, children who in previous years
would have been admitted to a hospital because of their burns can now be managed as outpatients. After fluid resuscitation, resolution of edema, and family assessment, children are often sent home and treated as outpatients. Frequently parents have concerns about keeping their child at home. Thorough teaching about burn care and support for parents are of utmost importance. Reinforcement of the need to comply with the burn treatment plan must continue throughout the entire course of ambulatory care. n
WOUND
MANAGEMENT
Treatment of the burn wound is best done in an aggressive and meticulous manner. Children should be treated daily during the first few days to monitor their progress and wound healing. The most effective method of burn care is cleaning the wound either by soaking or spraying it to remove the residue from previous dressings and any devitalized tissues or proteinaceous material that has collected and coagulated on the wound. Washing can be done with cotton or gauze pads. Laparotomy pads like those used in the operating room work well. They are soft, lint free, and most effective in cleaning the wound. If whirlpool agitation is available, it is helpful. However, soaking the burn or spraying its surface with water softens the eschar and loosens the debris so that maximum cleansing occurs, with minimal contact of the wound.
journal of Pediatric Health
Patient
Care
n
Management
Exchange
35
FIGURE 3
After the wound is cleansed, the burns are dressed. Silver Sulfadiazene (SSD) is the topical agent most commonly used. SSD can be spread on fine mesh gauze and applied to the burn wound. The gauze should not be wrapped around the wound but rather cut in strips and placed on the burn in a series of successive strips (Figure 1, A and B). This method of wrapping eliminates the potential for circulatory impairment associated with edema in fresh burns. Additional SSD is applied over the gauze after it is placed on the wound. A tubular net bandage is then applied to help hold the gauze in place. Tubular net comes in a variety of sizes to fit all body parts from fingers to trunk. Bulky bandages can be used instead of tubular net, but bulky dressings limit mobility and independence. In younger children, this restriction may be a desirable effect. In some casesbulky dressings, especially on hands may prevent the child from removing the dressings during rest or play (Figure 2). This type of dressing can be c:hanged daily in the ambulatory setting. As healing progresses and the family becomes more comfortable with the process, they can be taught to clean and redress the wound at home, thereby, decreasing the frequency of clinic visits. Other dressing techniques include those of the barrier type such as Biobrane (Winthrop Pharmaceuticals, New York, N.Y.) or Hydron (National Patent Medical, Dayville, Ct.). These are clear barriers that promote drainage of excess fluid and exudate while prohibiting bacterial growth. These two dressings are best used on
fresh, clean wounds because they do not contain topical antibiotics such as SSD. These barrier dressings can remain in place for 5 to 7 days. A clear advantage of these products is that the number of return visits that are needed is minimized. However, the application of a barrier dressing is more precise than applying gauze and cream and can be difficult to do on a moving child. Culturing of burn wounds is done on a weekly basis or more frequently if infection is suspected (Figure 3). Systemic antibiotics are used only for documented infections. With aggressive wound care, prophylactic antibiotics are unnecessary in minor burn injuries. OTHER CONSIDERATIONS Pain Management
n
A vital part of successful ambulatory burn care is adequate pain control. The pain medication most frequently used in children is acetaminophen with codeine elixir. It commonly is used before wound care and during the day as needed. Most children quickly advance to over-the-counter acetaminophen as healing occurs. In cases of severe pain, an injection may be ordered before wound care. Nutrition The importance of nutrition in wound healing is well known. The challenge of assuring adequate intake in a child who may be in pain and who is normally a “picky” eater can be a difficult one. Being at home with
36
Patient
Management
one’s own family is more conducive to eating than being hospitalized. Parents may need special instruction in ways to maximize the nutritional value of foods that their child eats. Fluids are important especially early in the course of treatment when fluid loss is a concern. High-caloric fluids such asjuices, carbonated beverages, or milk can be used. Peanut butter may be a palatable source of protein. Although any caloric intake is welcome, “empty” calories should be avoided. Food preferences must be considered to provide proper nutrition and ensure adequate caloric intake. In some cases, nutritional supplements may be required. If nutrition is a problem or weight loss occurs, referral to a dietitian may be necessary. n
HOME SAFETY
The importance of evaluating the circumstances of the burn injury to screen for problems of maltreatment is mandatory. However, most burns in children occur as a result of a limited knowledge of home safety. Family teaching in this area is a major component of ambulatory care. Burn prevention is extremely important, and teaching should address hazardous situations in relation to every room in the child’s home. Many children sustain accidental burns when they are teething, have a cold or ear infection, or have other ailments. When children are ill, mothers generally do not sleep as well as usual, are stressed and fatigued, and are less alert to the child’s activity. Accidents tend to happen in these instances. Turning in pot handles, pulling up dangling cords, and never leaving a child unattended are basic points that must be discussed with parents. In planning care, these facts cannot be ignored. A home health care visit may be required to identify safety concerns, provide safety instruction, assist with burn care in the home, or help parents as they cope with what has happened to their child. LONG-TERM Scar Control
n
Volume 6, Number 1 January-February 1992
Exchange
FOLLOW-UP
Scar management may be the most challenging aspect of treating a burn patient. Most children with scald injuries from hot liquid spills heal quickly and develop little or no scarring. However, even the most experienced practitioners of burn care cannot predict if or how much scarring will occur. Many factors contribute to the severity of scarring: (1) depth of burn, (2) length of time for healing to occur, (3) grafting, (4) age, and (5) skin character. Scars remain immature for 12 to 18 months after the burn. As scars mature, many color and texture changes occur (Schneider & Simonton-Thorne, 1987). Patients should be referred to a bum or plastic
surgeon familiar with burn scars who can best follow the progression of the scarring and treat it accordingly. Most definitive surgical treatment is delayed until the scars are matured. The months spent in waiting may be the most difficult period of coping and adjustment for the child and especially the family. School Reentry Returning to school can be a very traumatic part of the bum recovery process. Most burn centers have a school reentry program. These programs provide services that include formal educational instruction for the child, as well as programs that involve question-and-answer sessions for teachers and classmates to prepare them for the child’s return to the classroom. Children who are treated at facilities without school reentry programs can be accepted into a school reentry program at any burn center with such a program. Reconstructive
Surgery
Small burns that involve the hands or other functional areas of the body often require reconstructive surgery after scars are mature or when growth spurts occur. In these situations, families should be referred to a burn center or plastic surgeon with experience in reconstructive surgery for long-term follow-up. Teaching Needs Teaching family members and/or the child about burn care involves many areas and is an ongoing process. Nurses need to be involved in teaching families how to change dressings so that family members or older children with burns can become adept at this task. Once the basic techniques of dressing change are mastered, the number of required visits for dressing changes at the outpatient clinic declines in favor of more frequent home care. Instruction about the importance of nutrition to wound healing is also needed. Pain management strategies should be discussed. These strategies include methods to maximize pain medication or the use of alternative, noninvasive pain relief measures that can involve distraction with music or cutaneous stimulation such as rubbing a nonburned part of the body (McCaffery, 1979). After healing has occurred, parents and children should be assured that itching is a normal phenomenon. In small children, mittens may be needed to prevent the child from scratching the newly healed skin. Benadryl, sold over the counter, is an effective antipruritic agent; however, the side effect of drowsiness must be discussed. Newly healed burns should be protected from the sun for as long as 1 year after the burn. Healed
lournaloi Pediatric
Health
Patient
Care
The techniques discussed in this article have been developed over time in a burn center. Health providers in ambulatory care settings may want to adapt these techniques of wound management to their practice sites. It should be emphasized that any delay in healing or deterioration of the wound requires a change in therapy (such as a nutritional assessment, wound culture, or change in dressing modality). In most instances, burn centers will accept all burn patients, even those with minor injuries. However, this may not be convenient if the nearest center is far from the child’s home. In any case, burn center staff will always answer questions from practitioners in need of advice or assistance. Do not hesitate to use this resource.
ANNUAL NAPNAP CONFERENCE San Antonio, Texas March 1 l-l 4, 1992
VOLUNTEERS Volunteers
are
needed
37
Bona& L. A., & Frank, D. H. (1987). Pathophysiology of the burn wound. In B. M. Achauer (Ed.), Marsqment ofthe burnedpatient (pp. 22-45). Norwalk, Conn.: Appleton and Lange. Jay, K. M., Bartlett, R. J., Danet, R., & AIIyn, P. A. (1977). Bum epidemiology: A basis for burn prevention. Journal of Trauma. 17, 946947. McCaffery, M. (1979). Nursing management ofthe patient with pain. Philadelphia: J. B. Lippincott. Schneider, R. M., & Simonton-Thorne, S. (1987). Treatment of joints and scars. In B. M. Achauer (Ed.),Managrrnent ofthe burned patient (pp. 223-241). Norwalk, Conn.: Appleton and Lange. Uchiyama, N., & German, J. (1987). Pediatric considerations. In B. M. Achauer (Ed.), Management of the burned patient (pp. 223241). Norwalk, Conn.: Appleton and Lange. Warden, G. D., Kravitz, M., & Schnebly, A. (1981). The outpatient management of moderate and major burn injuries. Journal ofBum Care and Rehabilitation, 2, 159- 161.
CONCLUSION
13th
Exchange
REFERENCES
burns are sensitive to sun and sunburn more severely than normal skin. Sunburns result in exaggerated hypertrophic scar formation. n
Management
to serve
NEEDED as monitors
or mod-
erators for the educational sessions at the 13th Annual NAPNAP Conference to be held in San Antonio, Texas, March 1 l-14, 1992. The theme will be “NAPNAP: Advocates for Healthy Children.” The Texas Chapter of NAPNAP is serving both as the host chapter, providing information about attractions and services in the area, and as volunteer coordinator. If you are interested in serving as either a monitor or moderator or if you have questions about these jobs, please contact Becky Morrison, 2515 Norsworthy Dr., Dallas, TX 75228, (214) 879-6102 (w), (214) 328-2339 (h).
