1. PRESENTED BY SOUMYA SARA JOSEPH

2. 1. Name: Case No.3 2. MR No : 196537 3. Diagnosis: 15% Burn 4. Age: 2 YRS 5. Gender: Male

3.  GENERAL ASSESSMENT: Baby has fever, lethargic, dehydrated  SKIN: Dry, No blisters, No edema, Right side upper chest, left elbow, right thigh 1 st degree burn present, Dehydrated  HEAD AND NECK: No Deformities Found

4.  THORAX : Normally symmetrical in size  CARDIOVASCULAR: normal  GENITOURINARY: Diminished urine output

5.  GASTROINTESTINAL : Abdomen is soft, not distended  MUSCULO-SKELETAL : No deformities found  NEUROLOGY : Growth and development is normal according to Erikson’s psycho social stage

6. CHILD’S AGE MASTERED SKILLS 1 MONTH Lifts head when lying on tummy. Respond to sound. Stares at faces. 2 MONTHS Vocalizes: gurgles and coos. Follows objects across field of vision. Notices his hands. Holds head up for short periods. 3 MONTHS Recognizes your face and scent. Holds head steady. Visually tracks moving objects. 4 MONTHS Smiles, laughs. Can bear weight on legs. Coos when you talk to him. 5 MONTHS Distinguishes between bold colors. Plays with his hands and feet. 6 MONTHSTurns toward sounds and voices limits sounds roll over in both

7. CHILD’S AGE MASTERED SKILLS 7 MONTHSSits without support. Drags objects toward herself. 8 MONTHSSays ‘mama’ or ‘dada’ to parents. Passes objects from hand to hand. 9 MONTHSStands while holding onto something. Jabbers or combines syllables. Understands object permanence. 10 MONTHSWaves good bye. Picks things up with pincer grasp. Crawls well, with belly off the ground. 11 MONTHSSays ‘mama’ or ‘dada’ to the correct parent. Plays patty- cake and peek-a- boo. Stands alone for a couple of seconds.

8. CHILD’S AGE MASTERED SKILLS 12 MONTHSImitates others activities. Indicates wants with gestures. 13 MONTHS Stands without support 14 MONTHS Pull things out 15 MONTHSPlays with ball, Learns about 5 words, Can walk backward 16 MONTHSCan turn the pages a book, Has toddler temper

9. CHILD’S AGE MASTERED SKILLS 17 MONTHSVocabulary increases, Loves to play pretended games 18 MONTHS Loves to watch the pictures. 19 MONTHSLearns to use a spoon and fork, Runs, Throws ball 20 MONTHSCan take off own clothes with help, Can imitate actions 21 MONTHSCan walk up stairs, Keeping a toy in its place

10. CHILD’S AGE MASTERED SKILLS 22 MONTHSCan kick a ball forward, Imitates others behavior 23 MONTHSNames simple pictures in a book, Learns and uses about 50 words 24 MONTHSCan make short sentences

11. PATIENT HISTORY Past Medical History No past history of any medical illness Present Medical History Now baby is admitted with complaints of 20% Burns

13.  Tissue damage from excessive heat, electricity, radioactivity, or corrosive chemicals that destroys(denatures) proteins in the exposed cells is called a burn.  Generally, the systemic effects of a burn are a greater threat to life than are the local effects.

15. FIRST-DEGREE – only epidermis (sunburn) SECOND-DEGREE BURN – destroys entire epidermis & part of dermis – fluid-filled blisters separate epidermis & dermis – epidermal derivatives are not damaged – heals without grafting in 3 to 4 weeks & may scar THIRD-DEGREE OR FULL-THICKNESS – destroy epidermis, dermis & epidermal derivatives – damaged area is numb due to loss of sensory nerves

17. EPIDERMIS – The superficial portion of the skin – Composed of epithelial tissue. DERMIS – The deeper layer of the skin – Primarily composed of connective tissue

18. SUBCUTANEOUSOR HYPODERMIS – It consists of areolar and adipose tissue. – fat storage, an area for blood vessel passage, and an area of pressure sensing nerve endings.

20. Stratified squamous epithelium – Avascular (contains no blood vessels) – 4 types of cells – 5 distinct strata (layers) of cells

21. Four Principle Cells of the Epidermis KERATINOCYTES – produce the protein keratin, which helps protect the skin and underlying tissue from heat, microbes, and chemicals, and lamellar granules, which release a waterproof sealant MELANOCYTES – produce the pigment melanin which contributes to skin color and absorbs damaging ultraviolet (UV) light

22. LANGERHANS CELLS – derived from bone marrow – participate in immune response MERKEL CELLS – contact a sensory structure called a tactile (Merkel) disc and function in the sensation of touch

24. From deepest to most superficial the layers of the epidermis are  – STRATUM BASALE (stratum germinativum)  – STRATUM SPINOSUM  – STRATUM GRANULOSUM  – STRATUM LUCIDUM (only in palms and soles)  – STRATUM CORNEUM

26.  Connective tissue layer composed of collagen & elastic fibers, fibroblasts, macrophages & fat cells  Contains hair follicles, glands, nerves & blood vessels  Two major regions of dermis – papillary region – reticular region

28.  (from steam, hot bath water, tipped-over coffee cups, hot foods, cooking fluids, etc.)  Contact with flames or hot objects (from the stove, fireplace, curling iron, etc.)  chemical burns (from swallowing things, like drain cleaner or watch batteries, or spilling chemicals, such as bleach, onto the skin)  Electrical burns (from biting on electrical cords or sticking fingers or objects in electrical outlets, etc.)  overexposure to the sun

29. When large part of the body burnt this will effect most systems of the body.

31. Burn area is too large Destruction of red blood cells Blood transfusion Bone marrow replacement

32. In case of burn Body becomes hyper metabolic

33. Burning of the skin Increase in capillary permeability Increase in blood vasculaturiture Decrease of Blood pressure Decreases blood flow and oxygenation to tissue Edema, shock and eventually death

34. Partial thickness burn Full thickness burn Only pain Nerve cell destruction no feeling Abnormal levels of circulating potassiumions Such as Cellular destruction, outward flow of K+ fluid in burn HYPERKALEMIA HYPOKALEMIA Transmission of messages in the nervous system work faster or Slower than normal or not at all

35. Airway obstruction Gross edema of the throat Increased rate of respiratory rate Pulmonary edema

36. Increased secretion of adrenaline and nor adrenaline Increased body temperature Increased cell metabolism

37. Increased inflammation Grater strain on lymphatic system Pitting edema

38. Excessive strain on Burns area removing the first Lymphatic system line of infection defense Decreased response Increased infection

39. Potential hypovolemic state Decrease in blood availability in the intestinal lining and liver Increases nutrients requires to support metabolism Repair of damaged cells

40. Increased fluid loss Decreased urine output Potential for kidney damage Poor perfusion

41. BOOKED BASE 1 ST DEGREE  Redness  Pain  Minor swelling 2 nd DEGREE  Severe pain  Blister+ and if it breaks the area wet looking with a bright pink to cherry red color  Redness 3 rd DEGREE  Little or No pain  Skin Dry, look waxy white, leathery, brown or charred

42. PATIENT MANIFESTED  Fever  Pain  Redness  Minor swelling

43.  Promoting comfort  Promoting fluid intake and maintain nutrition  Promoting pain relief and psycho logic adjustment  Promoting family knowledge  Prevention of infection  Monitoring And Prevention Of Complication  Promoting home and community based care

44. BOOK BASED 1ST & 2 nd DEGREE BURNS  Sterile dressings  Preventive Antiseptics  Preventive Antibiotics  Analgesics  Hydration- 3 RD DEGREE BURNS  Sterile dressing  Preventive Antibiotics  Preventive Antiseptics  Hydration  Transfusion  Skin grafting

45. FLUID CALCULATION FOR BURN PATIENT ACCORDING TO PARKLAND FORMULA 4 X TBSA ( %OF BURN ) X WEIGHT  ONE HALF OF THE REQUIREMENTS ARE GIVEN DURING THE FIRST 8 HRS  THE REMINDER IS GIVEN OVER THE NEXT 16 HRS

48. LUND AND BROWDER CHAT IS USED TO DETERMINE TO EXTENT OF BURNS IN CHILDREN BECAUSE IT IS BASED ON AGE, THUS COMPENSATING FOR CHANGES BASED ON GROWTH

49. ACUTE  Infection  Curling’s ulcer (Stress) { TBSA>20%}  Acute gastric dilation { TBSA>20%}  Renal failure  Respiratory failure  Post burn seizures

50.  Hypertension  Central Nervous system dysfunction  Vascular Ischemia  Anxiety and complex pain  Anemia and malnutrition  Constipation and fecal impaction  Alteration in mood secondary to hospitalization

51. LONG TERM COMPLICATION  Growth and development delays secondary to malnutrition, hospitalization, complexities of injury and recovery  Developmental regression  Scarring, disfigurement, and contractures  Impact of psychological trauma

52.  Decreased cardiac output related to fluid loss and hyper metabolic state  Risk for infection related to altered skin integrity, decreased circulation, and immobility  Acute pain related to burn wound and associated treatments  Risk for injury related to paralytic ileus and stress

53.  Imbalanced physical mobility related to dressings, pain, and contractures  Imbalanced nutrition, less than body requirements related to hyper metabolic state and poor appetite  Disturbed body image related to pain, scarring and disfigurement  Fear and anxiety related to pain, treatments, procedures and hospitalization

54. ASSESSMENTDIGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATION SUBJECTIVE Child’s mother says that he is touching the skin and crying OBJECTIVE  Irritable cry  Tachycar dia  Not active Acute pain related to burn wound and associate d treatment s After 6 hours of nursing management Pain reduced and baby is active to perform activities 1.Assessed the pain scale frequently and pain management given as per pain scale such as pharmacological and non pharmacological 2.Administered analgesics (supp.voltaren 25mg) before each burn care and dressing 3.Promoted sleep with sedatives (fenistil drops) 4.Changed the position frequently and done range of motion exercises 5.Provided diversional therapies 1.It provides objective measurem ent 2. Helps to reduce the pain and decreases anxiety for burn care 3.Insomnia can increase pain perceptio n 4.It reduces the joint stiffness and prevent 5.Helps less focus on pain After 6 hrs of nursing management goals partially met and the mother verbalizes that baby has no cry and active to perform daily activities and adequate relief from pain

55. ASSESSMENTDIGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATION OBJECTIVE Temp : 37.4 c PR : 110/mt RR: 22/m t Risk for infection related to altered skin integrity, decreased circulation, and immobility Prevention of infection 1.Checked vital signs every 4hourly 2.Used standard precautions while doing dressing and burn care 3.Don’t put iv cannula in burned area 4.Kept burn dressing wet 5.Administered Inj.Augmentin 300mg iv q8hrly as per order 1.Increased temperature is a sign of infection 2.Reduces the risk of wound contaminati on 3.Reduces the risk of wound contaminati on 4.Helps to reduce the bacteria introduced to the burn site 5.To help to clear the infection immediately The child is free of infection during healing process

56. ASSESSMENTDIGNOSISPLANNINGIMPLEMENTATIONRATIONALEEVALUATION OBJECTIVE Temp : 37.4 c PR : 110/mt RR: 22/mt Decreased cardiac output related to fluid loss and hyper metabolic state The child will maintain adequate intake and output 1.Monitored vital signs and capillary refilling time 2.Advised to give more oral fluids 3.Administered IV Fluid Dextrose ½ normal saline at 50ml/hour 4.Monitored intake and output 5.Checked daily weight 6.Monitored serum electrolytes 1.To check any hypovolem ic shock 2.For proper hydration 3.For proper hydration 4.Risk for fluid overload during hydration and for edema in the tissues at the burn site 5.To check weight gain or loss 6.To check electrolyt e imbalance The child maintained adequate intake and output

58.  Brunner & Suddarth’s. Test book of Medical Surgical Nursing. 12 th Edition.  Lippincott Manual of Nursing Practice. 9 th Edition.(Page No:1765)