Urgent! Case study of the child with a burn

[vague111]

I have a case study and I need your tips for these two questions.

My answers are general and I don't think I got the point.

Here is a senario.

Charge Nurse Report: We floated you over from the burn unit to care for Kim Danner who's 11 and ½ years old. She's the middle Danner child. Since the burn unit is full and we needed a burn RN to care for her as she was the last person removed from the wreckage because she was blocked in by her brother that was paralyzed, and unfortunately by that time a grass fire stated from the sparks of the accident under and near the vehicle. She was sitting in the center of the backseat. She has a second-degree burn on her anterolateral left side stretching from her nose to her perineal region. It also spreads out halfway across her chest. It covers about 25 % of her total body area. We thought that her left eyebrow and eyelashes were singed but it turned out to be soot that washed right off. We turned her room into an isolation room, and put her in it because it the farthest away from the other patients and the staff areas. As soon as a bed opens up in the burn unit, we'll transfer her over.

Kim has no medical history other than a tonsillectomy at 8 years old. Her vitals are T 37.0, HR 106, R 24, and BP of 90/64. She has sinus tachycardia. Lungs are clear with sats around 98 on room air. Her voice is a little scratchy. Hourly urine outputs have been around 45 ml/hr, and dark-brown. Her bowel tones are slightly hypoactive. She has a high protein tube feeding running through a Dobhoff tube, 45 ml/hr. She has a PICC in her right arm with LR running at 80ml/hr. The skin around the burns is grossly edematous. The wound gets washed gently BID with mild soap, no scrubbing. Loose skin flaps are cut off, but blisters are to be left intact. Then it's covered with Silvadene gauze, then surgical netting.

Kim has been on a fentanyl PCA, with a basal rate of 10-20 mcg/hr and a bolus for her wound care. The debridements are terribly painful otherwise. Today we are starting to switch her over to Oxycontin BID with Oxycodone for breakthrough. If you can get her pain to a level of "2", she seems to be OK.

Here are two questions and my answers.

1. Why do burn patients have such significant pain?

Pain is inevitable during recovery from any burn injury. Burn pain travels through peripheral receptors to central detection via nociceptive tracts. The inflammatory response of the burn injury exacerbates the pain responses during dressing changes. The outstanding features of burn pain are its intensity and long duration. Furthermore, necessary wound care carries with it the anticipation of pain and anxiety.

1. Factors contribute to the patient's pain experience

- The adequacy of the health care provider's assessment of the pain.

- The appropriateness and adequacy of pharmacologic treatment of pain

- The appropriateness and adequacy of pharmacologic treatment of pain

- The multiple procedures involved in burn care (e.g. wound care, rehabilitative exercises).

- The appropriate evaluation of the effectiveness of pain relief measures.

2. Types of burn and causes of pain

- Partial-thickness burns: Nerve endings are exposed, resulting in excruciating pain with exposure to air current.

- Full-thickness burn: Although nerve endings are destroyed, the margins of the burn wound are hypersensitive to pain, and there is pain in adjacent structure. Healing of full-thickness burns creates significant discomfort as regenerating nerve endings become entrapped in scar formation.

3. Types of burn pain

- Background or resting pain: Pain that exists on a 24-hour basis.

- Procedural pain: Pain caused by manipulation of the wound bed during dressing changes or range-of-motion exercises.

- Breakthrough pain: Pain occurs when blood levels of analgesic agents decrease below the level required to control background pain.

2. Considering her age, are there any other pain interventions that you would consider?

Overview

The patient is 11 and ½ years old. Therefore, she can understand the relationship between an event and pain, have a more complex awareness of physical and psychologic pain such as moral dilemmas and mental pain. She may be able to describe intensity and location with more characteristics and to describe psychologic pain. The predicted behavioral response is to pretend comfort to project bravery, or to regress with stress and anxiety. She might attempt to maintain her composure during painful or invasive procedures because school-age children tend to believe they need to be brave.

Intervention

- To reduce the stress of burn dressing procedures, give her as many choices as possible. Children with some perceived control tend to demonstrate less maladaptive behavior.

- The child's anxiety and fear often will be reduced if the nurse explains what is

going to happen and demonstrates how the procedure will be done. Children

who have understanding of the procedure also demonstrate less maladaptive

behavior.

- Ask her to give a history of painful procedures with reactions.

- Assess how she copes with and manages pain. The child with several past pain experiences may not exhibit the same types of stressful behaviors as the child with few pain experiences.

- Identify what works best to reduce her pain.

- Identify the parent's and child's preferences for analgesic use and other pain interventions

[Wave Watcher]

When working with children you can find out what they like to watch on tv....distraction can work well when they are in pain....it takes their mind off what is going on and focuses on what brings them pleasure. Including any toys/stuffed animals/hobbies/music, arts and crafts to keep their minds occupied.

[vague111]

Thank you for your contribution with your precious experience.

[vague111]

Can anybody give me more comments?

[hsienko]

gate control pain theory might be worth looking at, also for #2 non pharmacologic interventions could be a possibility, no not a makeup set, but coloring, video games, or reading a story could reduce anxiety with a secondary effect of reducing reported pain.

[xtxrn, ASN, RN]

Watch that scratchy voice. If she had soot on her face, there may be soot in her respiratory tract.....BIG concern. Get sats w/all vs. (unless you just focus on the pain).

Also, I'd be reporting the dark brown urine with continuous IV fluids going. Sounds like she may not be getting enough.

But- to get into the ideas re: critical thinking, be sure to look at all information you get- and think about why it's being reported.

[nurseprnRN, BSN, RN]

dark brown urine post burn can be a signal of other bad things going on in the kidneys-- (look at her mechanism of injury)-- i'd look that up and learn what you need to do about it.

[ImThatGuy, BSN, RN]

I didn't read all of that, but with a burn clear the airway, assure respiration and circulation (escharotomy anyone?), fluid balance, thermoregulation, prevent/treat infection, high calorie/high protein nutrition, pain management, and start scraping off the sluff.

[xtxrn, ASN, RN]

Are the highlighted questions in the OP the only questions you have to deal with on this care plan?

[bols27]

I'm with Grn Tea, that dark brown urine is a classic presentation of myoglobinuria, particular attention needs to be paid to her I/O to make sure she isn't having a renal insufficiency issue. And with a burn "from the nose..." and a scratchy voice I would also be concerned with her airway.