Immune, Infectious Disease, Skin & Burns

Alterations in Health (Diagnosis)

• Skin infections may be bacterial (impetigo contagiosa, pyoderma, folliculitis, furuncle, carbuncle, cellulitis, staphylococcal scalded skin syndrome), viral (verruca, verruca plantaris, herpes simplex, varicella zoster, molluscum contagiosum), or fungal (tinea capitis, corporis, cruris, pedis/unguium, candidiasis). Bites and stings come from bees, fire ants, mosquitoes, flies, chiggers, ticks, mites, spiders, and scorpions. Infestations include scabies and lice.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Bacterial: contact with an infected person, congenital or acquired immunodeficiency, immunosuppression
• Fungal: geographic area
• Arthropod bites: dark clothing and exposed skin
• Scabies: continuous close personal contact; anyone can develop scabies or lice

Assessment — Expected Findings

• Impetigo contagiosa (Staphylococcus, Streptococcus): a reddish macule turns vesicular and ruptures readily, leaving moist erosion whose secretions dry into honey-colored crusts; it commonly itches and extends outward and by direct contact
• Verruca (warts, human papillomavirus): elevated, rough, gray-brown firm papules anywhere on the skin, single or grouped
• Verruca plantaris: flat warts on the plantar surface, sometimes surrounded by hyperkeratosis
• Herpes simplex type 1 and 2: cold sore or fever blister near mucocutaneous areas — lips, nose, buttocks, genitalia
• Scabies (Sarcoptes scabiei): intense itching especially at night, rash between the fingers and in popliteal folds and inguinal regions, thin pencil-like burrow marks with the mite visible as a black dot at the end of a grayish-brown burrow; infants show widespread involvement with pimples on the trunk
• Head lice (Pediculus humanus capitis): adult lice are small, grayish-tan, wingless, and hard to see; nits resemble dandruff but are firmly attached to the hair shaft
• Lyme disease stage 1, 3-30 days after the bite: red macular/papular lesion expanding into a red bull's-eye rash, with chills, fever, itching, headache, stiff neck, muscle weakness
• Lyme stage 2, 3-12 weeks after the bite: neurologic, cardiac, and musculoskeletal involvement with facial paralysis or weakness, muscle pain, fever, fatigue

Laboratory Tests

• Bacterial, viral, and fungal cultures; scabies confirmed by microscopic examination

Diagnostic Procedures

Nursing Care

• Assess the general condition of the affected area and look for associated or secondary infection
• Keep the child from scratching or touching the area, using distraction
• Teach proper hand hygiene and teach child and caregivers about the medications
• Impetigo: topical bactericidal or triple antibiotic ointment, with oral antibiotics if indicated, and cleansing with Burow solution
• Verruca: individualized destructive therapy — surgical removal, electrocautery, cryotherapy, laser, caustic solutions, curettage
• Verruca plantaris: apply caustic solution, wear insoles with holes to relieve pressure for 2-3 days, soak the area 20 min, and repeat until the wart falls off
• Tick bites: observe the child for 30 days; a single antibiotic dose for those meeting criteria and a 2-3 week course for confirmed disease
• Lyme antibiotics: doxycycline over age 8, amoxicillin or cefuroxime under age 8, and cefuroxime for penicillin allergy
• Provide cool baths or compresses and keep fingernails clean and trimmed

Medications

Therapeutic Procedures

Client Education

• Use good hand hygiene and take steps to prevent spread
• Do not share clothing, hats, combs, brushes, or towels, especially with fungal infections
• Do not squeeze vesicles
• Apply topical medications as prescribed and watch for adverse effects
• Avoid home remedies, which can worsen the infection
• Launder potentially contaminated clothing and bedding correctly, and seal items that cannot be washed in a tight bag for 14 days
• Disinfect combs, brushes, and hair accessories by boiling 10 min or soaking 1 hr in a lice-killing product

Interprofessional Care

Complications

Alterations in Health (Diagnosis)

• Contact dermatitis is an inflammatory hypersensitivity reaction when skin meets an irritant such as feces, urine, soaps, poison ivy, animals, metals, dyes, or medications. Diaper dermatitis follows prolonged contact with urine at increased pH, stool, friction, chemicals, soaps, or detergents. Seborrheic dermatitis (cradle cap, blepharitis, otitis externa) has an unknown cause and peaks in infancy and puberty. Atopic dermatitis is a form of eczema marked by pruritus and associated with allergy history; it is classified by age, lesion distribution, and appearance, and cannot be cured but can be well controlled. Acne vulgaris is the most common adolescent skin condition, involving pilosebaceous follicles of the face, neck, chest, and upper back; it is self-limiting and not dangerous but threatens self-image, with Cutibacterium acnes driving the inflammation.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Diaper dermatitis: diaper use, infrequent changing, excessive stooling
• Contact dermatitis: exposure to an irritant
• Atopic dermatitis: existing allergic condition and family history of atopy, previous skin disorder or current flare, exposure to irritants, genetic predisposition, geographic location
• Acne: genetic link, more common in males, typical during adolescence, hormonal fluctuations trigger flares
• Acne: cosmetics containing petrolatum and lanolin, cooking grease exposure in fast-food work, and a possible dietary link to high glycemic index foods and dairy

Assessment — Expected Findings

• Contact dermatitis: red bumps that can become moist weeping blisters, skin warm and tender, oozing, drainage, or crusts, skin becoming scaly, raw, or thickened
• Diaper dermatitis mild: scattered erythematous papules with minor irritation; moderate: erosions, maceration, extensive erythema, pain; severe: extensive glistening erythema, erosions, papules, pustules, nodules, pain
• Seborrheic dermatitis: thick adherent lesions with yellow scaly patches
• Atopic dermatitis: intense pruritus, erythema, vesicles and papules, weeping, oozing, crusting, scaling, lichenification, dry rough skin
• Atopic dermatitis: small diffuse areas of hypopigmentation, pallor around nose, mouth, and ears, bluish discoloration under the eyes, lymphadenopathy near affected areas
• Atopic dermatitis distribution: generalized on cheeks and scalp in infants; flexural areas (antecubital and popliteal fossae, neck) and wrists in children
• Acne: open comedones (blackheads) and closed comedones (whiteheads) on face, neck, back, and chest, with inflammation producing papules, pustules, nodules, or cysts, and a pattern of exacerbation and remission

Laboratory Tests

Diagnostic Procedures

Nursing Care

• Diaper dermatitis: change diapers frequently and remove soiled diapers promptly
• Cleanse the diaper area with a nonirritating cleanser or plain warm water using soft cloths or alcohol- and fragrance-free wipes
• Expose the affected area to air and apply a skin barrier such as zinc oxide, which should not be washed off at each change
• Contact dermatitis: remove the irritant and limit further exposure
• Poisonous plant exposure: flush the area with cold running water as soon as possible and wash clothes and shoes in hot water with detergent
• Apply calamine lotion, Burow solution compresses, or colloidal oatmeal baths, plus topical corticosteroid gel; oral corticosteroids for severe reactions or involvement of face, neck, or genitalia
• Seborrheic dermatitis: daily scalp and hair hygiene, gently scrub to lift scaly crusted patches, soften overnight with petrolatum or mineral oil, remove loosened crusts with a fine-tooth comb, and use a daily antiseborrheic shampoo containing sulfur and salicylic acid
• Atopic dermatitis: apply overnight wet wraps for severe pruritus by covering the area with water-moistened gauze then dry gauze on top
• Acne: discuss the disease process with the adolescent and family and stress adherence to the plan of care

Medications

• Hydroxyzine or diphenhydramine for allergic or medication reactions and severe pruritus — teach scheduled administration and supervise the child because of sedation
• Loratadine or fexofenadine as a nonsedating oral antihistamine preferred for daytime use
• Antibiotics for secondary infection — finish the full course
• Clotrimazole and other antifungal ointments for Candida albicans in diaper dermatitis
• Topical corticosteroids intermittently to control flares, chosen as low, moderate, or high potency based on the site, extent of involvement, and child's age; low potency is safe on the face
• Tacrolimus or pimecrolimus for children over 2 years, started at the beginning of an atopic dermatitis flare when the skin reddens and itches
• Benzoyl peroxide inhibits C. acnes and can bleach linens, towels, and clothing but not skin
• Topical and oral antibacterials such as clindamycin, azelaic acid, and dapsone inhibit C. acnes — monitor for allergic reaction

Therapeutic Procedures

Client Education

• Avoid bubble baths and harsh soaps
• Wear long sleeves and pants when exposure to irritants is likely and remove an offending agent immediately after contact
• Wash the face gently without scrubbing or abrasive cleansers
• Keep nails short and trimmed, and put gloves or cotton socks on the hands for sleeping
• Clothe young children in one-piece cotton outfits that are soft and cover the arms and legs
• Wash clothes and linens in mild detergent and repeat the wash cycle without soap
• Change diapers as soon as they are wet or soiled and watch for signs of infection

Interprofessional Care

Complications

• Bacterial infection through breaks in the skin from scratching — monitor for infection, keep nails short, cleanse with mild soap and water, give antipruritics and antibiotics, and teach avoidance of offending agents
• Psychosocial impairment from acne with stress, lowered self-esteem, and depression over appearance — monitor mood and behavior, encourage the adolescent to talk about feelings, support adherence, and have caregivers report mood changes
• Skin scarring from scratching or delayed acne treatment, either atrophic with tissue loss or hypertrophic such as keloids — managed with topical medications, injectable steroids, silicone dressings, punch excision, cryosurgery, dermabrasion, or microdermabrasion, with realistic reassurance that therapy improves appearance

Alterations in Health (Diagnosis)

• Vaccines stimulate antibody production against a specific disease using a killed or weakened form of the organism. The Advisory Committee on Immunization Practices sets the schedule. Preterm infants receive each vaccine at the same chronologic age as full-term infants. A catch-up schedule on the CDC website covers missed doses. Goals are to reduce or eliminate infectious diseases in the population and to prevent those diseases and their complications.

Health Promotion & Disease Prevention

• Hepatitis B: minimum age birth, 3 doses at birth, 1-2 months, and 6-18 months; at least 4 weeks between doses 1 and 2 and 8 weeks between doses 2 and 3; final dose no earlier than 24 weeks of age and at least 16 weeks after the first; withhold for preterm infants under 2,000 g if the mother is hepatitis B negative
• Rotavirus: minimum age 6 weeks, 2 doses of Rotarix (2 and 4 months) or 3 doses of RotaTeq (2, 4, 6 months); do not start the series at 15 weeks 0 days or older and give the last dose by 8 months 0 days
• DTaP: minimum age 6 weeks, 5 doses at 2, 4, 6 months, 15-18 months, and 4-6 years; at least 6 months between doses 3 and 4; dose 4 may be given as early as 12 months; dose 5 is unnecessary if dose 4 was given at 4 years or older and at least 6 months after dose 3
• Tdap: minimum age 11 years, one dose at 11-12 years then Td booster every 10 years; one dose in each pregnancy between 27 and 36 weeks regardless of prior timing; for wounds, give Tdap or Td if a minor clean wound and over 10 years since the last dose, or over 5 years for all other wounds
• Hib: minimum age 6 weeks, 4 doses (ActHIB, Pentacel, Vaxelis) at 2, 4, 6 months and a 12-15 month booster, or 3 doses (PedvaxHIB); use a different Hib product for the booster; only 1 dose is needed for unimmunized children 15 months or older
• PCV13: minimum age 6 weeks, 4 doses at 2, 4, 6, and 12-15 months; follow current dual-series guidance with PPSV23 for high-risk conditions

Assessment — Risk Factors

Assessment — Expected Findings

Laboratory Tests

Diagnostic Procedures

Nursing Care

• Obtain guardian consent before administration
• Give the vaccine information statement and review it with guardians and older children, documenting each VIS publication date
• Reassure caregivers that MMR is not associated with autism
• IM route: vastus lateralis for infants and young children, deltoid for older children and adolescents
• Subcutaneous route: outer upper arm or anterolateral thigh
• Choose needle size by route, site, age, and volume — adequate length reduces injection site swelling and tenderness
• Use comfort strategies to minimize discomfort
• Effectiveness is shown by development of immunity and by local reactions resolving without pain, fever, or swelling
• Anaphylaxis to any vaccine contraindicates further doses of that vaccine or any vaccine containing that substance

Medications

Therapeutic Procedures

Client Education

Interprofessional Care

Complications

• DTaP mild: injection site redness, swelling, and tenderness, poor appetite, vomiting, low fever, drowsiness, irritability, anorexia
• DTaP moderate reactions: crying that cannot be consoled lasting 3 hr or longer, temperature reaching 40.6 C (105 F) or above, seizures with or without fever, and a shock-like state
• DTaP severe: acute encephalopathy, rare; encephalopathy within 7 days of a prior dose contraindicates further doses
• LAIV: allergic reaction, vomiting or diarrhea, nasal congestion and runny nose

Alterations in Health (Diagnosis)

• Communicable diseases spread by airborne, droplet, or direct contact transmission, and most are vaccine-preventable. Antibiotics and antitoxins reduce serious complications. Primary prevention means immunization; secondary prevention means limiting spread to others. Immunization is the single best method of prevention.

Health Promotion & Disease Prevention

• Conjunctivitis spreads by direct contact; viral requires contact precautions and bacterial requires standard precautions
• Viral conjunctivitis follows a viral infection, starts in one eye and spreads to the other, and clears on its own in 7-14 days; bacterial clears with topical antibiotics; allergic clears with allergy medication
• Infectious mononucleosis (Epstein-Barr virus) spreads in oral secretions, incubation 3-6 weeks; healthy carriers shed the virus in saliva for life and people with mono transmit for weeks
• Fifth disease spreads through respiratory secretions and blood product transfusion, incubation 4-14 days and up to 21, most contagious in the 5 days before the rash, droplet precautions
• Mumps spreads by direct contact with respiratory droplets, incubation 14-21 days, contagious 1-2 days before symptoms until 5 days after they begin
• Pertussis spreads by direct or indirect contact with respiratory secretions and freshly contaminated articles, incubation 1-3 weeks, most contagious during the catarrhal stage before paroxysms begin

Assessment — Risk Factors

• Prior communicable disease history and recent exposure to a known case
• Not immunized or behind on immunizations
• Immunocompromised status and chronic illness
• Crowded living conditions, poor sanitation, poor nutrition
• Poor oxygenation and impaired circulation

Assessment — Expected Findings

• Conjunctivitis: pink or red sclera, swollen conjunctiva, excessive tearing; bacterial adds yellow-green purulent discharge and morning eyelid crusting, viral produces watery discharge
• Fifth disease prodrome: several days of fever, runny nose, headache
• Fifth disease rash lasting 7 days to several weeks: red slapped-cheek facial rash on days 1-4, then symmetric maculopapular red spots spreading proximal to distal on the extremities over a week, with a secondary itchy rash possible elsewhere including the soles
• Measles prodrome 3-4 days before the rash: mild to moderate fever, cough, runny nose, red eyes, sore throat
• Measles: Koplik spots (tiny white spots) in the mouth 2 days before the rash, then a red or reddish-brown rash starting on the face and moving downward with a fever spike
• Mononucleosis: fever, fatigue, sore throat, swollen lymph glands, poor appetite, headache, elevated WBC with atypical lymphocytes, splenomegaly, hepatic involvement
• Mumps: painful swollen parotid glands, fever, muscle aches, earache worsened by chewing, fatigue, poor appetite
• Pertussis catarrhal stage: runny nose, congestion, sneezing, mild fever, mild cough; paroxysmal stage begins in 1-2 weeks with violent rapid coughing fits and a whooping sound

Laboratory Tests

• CBC, electrolyte panel, and mono spot test for infectious mononucleosis

Diagnostic Procedures

Nursing Care

• Give an antipyretic for fever but never aspirin, because of Reye syndrome risk
• Give antipruritics for severe itching and analgesics for pain
• Offer preferred fluids and nutritious foods and promote rest with naps as needed
• Provide quiet diversional activities, dim the lights for photophobia, and keep the child out of the sun
• Notify the school or daycare and arrange for schoolwork at home; report communicable diseases to the health department
• Skin care: calamine lotion for topical relief and keep the skin clean and dry to prevent secondary infection
• Bathe the child in tepid water

Medications

• Diphenhydramine hydrochloride and hydroxyzine control pruritus

Therapeutic Procedures

Client Education

• Good hand hygiene prevents spread
• Complete the full antibiotic or antiviral course
• Cover the nose and mouth when coughing or sneezing
• Wash bed linens daily in mild detergent
• Immunocompromised individuals should seek care promptly if symptoms develop
• Include adolescents in decision-making

Interprofessional Care

Complications

• Fifth disease: arthralgia and arthritis that resolve on their own, seen most often in adult females
• Mononucleosis: ruptured spleen, encephalitis, Guillain-Barre syndrome
• Mumps: orchitis, encephalitis, meningitis, oophoritis, mastitis, deafness, myocarditis, arthritis, hepatitis
• Pertussis in infants and children: seizures, apnea, pneumonia, ear infection, encephalopathy, hemorrhage, weight loss, hernia, and death; in teens and adults: rib fracture, syncope, pneumonia, weight loss, and loss of bladder control
• Rubella: complications are generally rare, but maternal infection during pregnancy causes fetal birth defects including deafness, heart defects, cognitive deficits, and liver and spleen damage
• Rubeola: ear infection, pneumonia, encephalitis, laryngitis, death
• Varicella: pneumonia, bleeding problems, bacterial skin infection, encephalitis

Alterations in Health (Diagnosis)

• Acute otitis media is infection of the middle ear structures and one of the most common acute childhood illnesses. Otitis media with effusion is fluid in the middle ear without infection. Most cases stem from eustachian tube dysfunction and many clear spontaneously within days, but repeated infections can impair hearing and speech.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Children's eustachian tubes are shorter and more horizontal than adults'; incidence peaks in the first 24 months and declines after age 5
• Bacterial triggers: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
• Viral triggers: respiratory syncytial virus, influenza; also allergies and enlarged adenoids
• Higher incidence in winter and spring
• Daycare or exposure to large groups of children
• Secondhand smoke exposure
• Cleft lip and/or palate, Down syndrome
• Incomplete childhood immunizations

Assessment — Expected Findings

• Recent upper respiratory infection with acute behavior change
• Frequent crying, irritability, fussiness, inconsolability
• Tugging or rubbing the ear and rolling the head side to side
• Ear pain, loss of appetite, nausea, vomiting, fever, lethargy
• Acute otitis media: bulging inflamed tympanic membrane, purulent material in the middle ear or draining from the canal, decreased or absent movement on pneumatic otoscopy, head and neck lymphadenopathy
• Chronic disease brings hearing difficulty and speech delay
• Otitis media with effusion: feeling of ear fullness, opaque tympanic membrane with decreased movement, transient hearing loss

Laboratory Tests

Diagnostic Procedures

• Pneumatic otoscope lets the provider visualize the tympanic membrane and middle ear and assess membrane movement
• Pull the pinna down and back under 3 years, up and back over 3 years

Nursing Care

• Analgesics are the priority action for pain
• Provide comfort measures and diversional activities
• Position the child upright
• Manage fever

Medications

• Acetaminophen or ibuprofen for analgesia and fever
• Antibiotics: amoxicillin, amoxicillin-clavulanate, or azithromycin orally for 10 days, or IM ceftriaxone for three doses
• Antibiotics are recommended over 6 months of age for severe symptoms — increased pain or temperature above 39 C (102.2 F) — lasting more than 2 days, and for children 6-23 months with bilateral disease
• Benzocaine ear drops relieve pain

Therapeutic Procedures

• Management depends on physical findings, age, and history
• AAP recommends watchful waiting for 2-3 days before antibiotics in children 2-12 years with uncomplicated, nonrecurrent disease
• Myringotomy with tympanostomy tube placement for repeated episodes, done as outpatient surgery under general anesthesia, sometimes by laser
• A small incision in the tympanic membrane allows tiny plastic tubes to equalize pressure and reduce effusion; postoperative pain is uncommon and mild if present

Client Education

• Finish the entire antibiotic course and watch for allergy such as rash or difficulty breathing
• Feed the child upright when bottle- or breastfeeding
• Apply antibiotic ear drops as prescribed and use comfort measures
• Limit exposure to secondhand smoke and to people with respiratory infections
• Seek care at the first sign of infection such as behavior change or ear tugging
• Keep immunizations current

Interprofessional Care

Complications

• Hearing loss and speech delay — assess and monitor for deficits, refer for audiology testing, and arrange speech therapy if needed

Alterations in Health (Diagnosis)

• HIV infects CD4 T lymphocytes, impairing and destroying immune cells and progressively weakening immune function. Adolescents 13-20 years are managed following adult HIV/AIDS content.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Perinatal transmission or ingestion of breast milk from a person with HIV
• Exposure to blood products or body fluids containing the virus
• Sexual assault
• Risky behaviors such as unprotected sex and IV substance use
• Existing sexually transmitted infections
• Lack of awareness of risk factors and transmission routes

Assessment — Expected Findings

• Immunologic staging by CD4 count under 12 months: stage 1 is 1,500 cells/microliter or more, stage 2 is 750-1,499, stage 3 is under 750
• Ages 1-5 years: stage 1 is 1,000 or more, stage 2 is 500-999, stage 3 is under 500
• Age 6 and older: stage 1 is 500 or more, stage 2 is 200-499, stage 3 is under 200
• Clinical category N is not symptomatic — no HIV-attributable findings or only one mildly symptomatic condition
• Category A is mildly symptomatic, including recurrent sinusitis
• Severely symptomatic disease includes opportunistic infections such as pulmonary candidiasis

Laboratory Tests

Diagnostic Procedures

Nursing Care

• Encourage a balanced high-calorie, high-protein diet with nutritional supplements, and give total parenteral nutrition if prescribed
• Provide good oral care and report abnormalities for treatment
• Keep the skin clean and dry
• Assess pain and manage it with nonpharmacologic methods plus NSAIDs, acetaminophen, opioids, muscle relaxants, or lidocaine-prilocaine cream
• Prevent infection with standard precautions and good hand hygiene
• Teach the child and family to avoid people with colds and infections
• Encourage immunizations including pneumococcal and annual influenza vaccines
• Monitor CBC, WBC, and liver function on antiretroviral therapy, which can raise ALT, AST, bilirubin, MCV, HDL, and total cholesterol

Medications

• Antiretrovirals act at various points of the HIV life cycle to inhibit viral reproduction and slow disease progression
• Combination therapy is used to prevent resistance, and treatment is lifelong
• Nucleoside reverse transcriptase inhibitors — zidovudine, didanosine, stavudine, lamivudine, abacavir — suppress viral DNA synthesis
• Non-nucleoside reverse transcriptase inhibitors — delavirdine, efavirenz, nevirapine, doravirine, etravirine, rilpivirine — bind viral DNA for direct inhibition
• Trimethoprim-sulfamethoxazole prophylaxis for every infant born to an infected parent until HIV infection is ruled out

Therapeutic Procedures

Client Education

• Take medications on a regular schedule without missed doses; the illness is chronic and treatment is lifelong
• Watch for adverse effects and use strategies to lessen them
• Call the provider for headache, fever, lethargy, warmth, tenderness or redness at joints, or neck stiffness
• Practice safe handling of needles and syringes
• Discuss transmission routes with adolescents including sexual transmission and IV substance use, and confirm they understand safer sex practices

Interprofessional Care

• Social services for access to health care and medications
• Dietitian for nutritional support

Complications

Alterations in Health (Diagnosis)

• Thermal, cold, chemical, electrical, and radioactive agents destroy skin layers and underlying tissue. Thermal burns follow exposure to flame, hot surfaces, or hot liquids. Chemical burns follow contact with acids, alkalis, or organic compounds, including household and industrial cleaners. Electrical burns occur when current passes through the body and can destroy tissue, cost organ function, and require amputation. Burn depth is graded superficial, superficial partial thickness, deep partial thickness, full thickness, and deep tissue extension.

Health Promotion & Disease Prevention

• Provide adequate supervision and establish a safe play area
• Store hot liquids, electrical cords, and anything dangling where a child cannot reach

Assessment — Risk Factors

• Abuse or neglect
• Inadequate supervision

Assessment — Expected Findings

• Determine which agent burned the child (electrical, chemical, moist heat, dry heat, ionizing radiation), how long contact lasted, and which body area was involved
• Younger children sustain deeper injuries because their skin is thinner
• Extent measured as total body surface area using age-related charts and expressed as a percentage
• Severity depends on age, causative agent, body area, and burn extent and depth
• American Burn Association grading — minor: partial thickness under 10% TBSA, usually outpatient; moderate: partial thickness 10-15% TBSA and full thickness 2-10% TBSA, treated at a hospital with burn expertise; major: partial thickness over 20% TBSA, requiring a burn center

Laboratory Tests

• Major burns: CBC, electrolytes, BUN, ABGs, random glucose, liver enzymes, urinalysis

Diagnostic Procedures

Nursing Care

• On-site: stop the burning process and remove the child from the source
• Lay the child flat and smother flames by rolling them in a rug or blanket, or roll the child slowly if nothing is available
• Remove clothing and jewelry that conduct heat
• Apply tepid water soaks or run water over the injury — never ice, which risks hypothermia
• Flush liquid chemical burns with a large volume of water for extended cooling
• Assess airway patency, cover the burn with a clean dry cloth to prevent contamination, and transport for evaluation
• Phases of management: acute/emergent-resuscitative focused on shock and respiratory complications, management focused on preventing infection and closing the wound, and rehabilitative focused on preventing scarring complications after wound closure
• Airway is the priority — give humidified 100% oxygen as prescribed, monitor respirations and oxygen saturation, check ABGs and carbon monoxide level
• Prepare to intubate if stridor, nasal flaring, drooling, or respiratory distress appear, and prepare for escharotomy with full-thickness chest burns to allow ventilation

Medications

• Topical agents for partial-thickness burns — silver sulfadiazine (inhibits bacterial growth), mafenide acetate, collagenase (santyl), bacitracin — applied to a cleansed, debrided area with sterile gloves
• Topical prepackaged mesh gauze dressings protect the wound, improve comfort, speed healing, and reduce dressing change frequency
• Morphine sulfate IV for analgesia, sometimes premedicated before dressing changes — monitor for respiratory depression and discuss dependency risk with prolonged use
• Midazolam, fentanyl, propofol, and nitrous oxide for sedation and analgesia given IV just before a procedure
• Nitrous oxide and oxygen mixture is a short-acting analgesic gas that relieves anxiety and raises the pain threshold during procedures

Therapeutic Procedures

• Open method leaves the wound uncovered with a topical antimicrobial
• Modified method applies antimicrobial to thin gauze or net secured over the wound
• Occlusive method impregnates gauze with antimicrobial or applies it directly, then layers gauze secured with gauze or net
• Temporary skin coverings promote healing of large partial-thickness burns and need repeated surgical application
• Allograft (homograft) from human skin covers partial and full thickness wounds, with rejection possible 14 days after application
• Xenograft from porcine skin covers partial-thickness wounds but does not vascularize, so it must be changed every few days

Client Education

• Continue range-of-motion exercises and physical therapy to prevent contractures
• Assess the wound for infection and perform wound care at home
• Home safety: cover electrical outlets, supervise bathing, keep irons out of reach, and teach the danger of playing with matches
• Avoid sun between 1000 and 1400, wear protective clothing, and use sunscreen
• Growth and weight delays are possible for up to 3 years after a burn, and bone remodeling risk is increased
• Arrange interprofessional referrals for care after discharge

Interprofessional Care

• Refer to nutrition, social support, respiratory therapy, occupational and physical therapy, and individual and family counseling as prescribed

Complications

• Direct thermal injury with face and lip burns damages the tracheobronchial tree after inhaling heated gases and toxic combustion products, and can be delayed 24-72 hr — wheezing, increased secretions, hoarseness, wet rales, singed nasal hairs, laryngeal edema, carbonaceous secretions
• Carbon monoxide injury occurs in enclosed spaces, causing mental status change and dyspnea — maintain airway and ventilation with 100% oxygen
• Pulmonary injury from inhaled fumes, vapors, gases, and smoke — maintain the airway with intubation or sometimes tracheostomy and give oxygen
• Hypertrophic scarring from collagen deposition during healing appears raised — apply uniform pressure, fit custom pressure garments, continue physical therapy, give cetirizine or diphenhydramine for itching, and massage and moisturize scars as prescribed
• Wound sepsis, since burn wounds are a growth medium for bacteria — disorientation is an early sign, followed by spiking fever, decreased bowel sounds, tachycardia, tachypnea, thrombocytopenia, oliguria, and leukopenia