Chapter 52.

Nursing Care of the Child with a Traumatic Injury

Terms:
1. Allografting - transfer of body tissue between two genetically dissimilar individuals
2. Autografting - transplantation of tissue from one part of the body to another in the same individual
3. Contrecoup injury - an injury resulting from a blow to one side of the skull that causes the brain to rebound and then injure the
opposite side
4. Debridement - the removal of foreign material from a burn or wound
5. Drowning - asphyxiation because of submersion in a liquid
6. Escharotomy - a surgical incision into the head crust that forms over a burn
7. Heterografts - tissue from another species (such as a pig) used as a temporary skin covering
8. Near-drowning - a state in which a person has survived drowning
9. Otorrhea - discharge from the external ear
10. Plumbism - lead poisoning
11. Rhinorrhea - discharge from the nose
12. Stupor - lethargy and unresponsiveness

Poisoning
Condition Signs & Symptoms Management
Salicylate Poisoning *Hyperpnea, hyperpyrexia *Treatment
-toxic condition caused by *DHN 1. Induce vomiting
ingestion of salicylates, most *Hyperventilation A. If unconscious, gastric lavage
often in the form of Aspirin *Loss of consciousness B. It conscious:
*Causes stimulation of the *Lethargy Give syrup of Ipecac 1/2 hour after ingestion
respiratory center; alteration of *Vomiting Administer activated charcoal after ipecac syrup
CHO and lipid metabolism; *Metabolic Acidosis Administer saline cathartics
respiratory acidosis; increased *Bleeding, if chronic ingestion 2. IV fluids: F/E electrolytes including NaHCO3
O2 consumption and CO2 3. Vitamin K if bleeding
production; inhibition of 4. Monitor I & O
platelet aggregation and 5. Place on a cooling blanket
prothrombin production, 6. Monitor ABG results
bleeding tendencies 7. Monitor neurologic status
*toxicity begins at 150-200 8. Anticonvulsants may be given
mg/kg 9. Peritoneal dialysis in severe cases
*peak effects: 2-4 hours;
duration: 8 hours
Lead Poisoning (Plumbism) -abdominal colic *Preventive measures through education, proper housing,
-Most common between 9 -constipation supervision of children
months and 3 years of age, -anorexia, vomiting *Goal of treatment: reduce concentration of lead in the blood and
usually from eating lead chips - weight loss soft tissues by promoting excretion and deposition in bones
from peeling paint or sucking -pallor, fatigue A. Dimercaprol
on objects with lead-based -clumsiness. Irritability B. Vitamin D, Calcium and Phosphorus
paint -loss of coordination
-Lead is absorbed through GIT -Ataxia, seizure
and pulmonary system; -lead line on teeth
deposited in the bones, soft -insomnia, joint pains
tissues; excreted via feces, -increased blood lead level
urine, sweat A. Normal: <40mcg/100ml of
-toxic effects due to enzyme blood
inhibition: enhanced by low B. Treatment needed 60 mcg or
dietary iron and Ca intake higher
C. Brain damage occur 80 mcg

BURNS
Burns - cell death due to an exposure to extreme heat
Classifications
Layer Presentation Healing
st
1 degree - Epidermis Redness (Erythema) 3-7 days
Partial 2nd degree - Epidermis + Dermis Blister/most painful Average 21 days (Nursing management: cover
the area
3rd degree - Skin + Subcutaneous Charcoal-colored skin Skin grafting
(Edema + eschar) *common 1. Autograft - patient is the donor
is compartment syndrome 2. Xenograft (Heterograft) - animals; cow/pig
Full thickness 3. Allograft - cadaver
4th degree - skin + SubQ + Painless Amputation/skin grafting
muscles + bones

Assessment:
(Rapid) TBSA - Total Body Surface Area
Roles of Nines: used for 9 years old and above
Head (including neck) - 9%
Each arm - 9%
Anterior Thorax - 18%
Posterior Thorax - 18%
Each leg - 18%
Perineum - 1%
Total of 100%

Major Burns = ≥25% TBSA or sites (head, neck, thorax)

Systemic Complications: (major Burns)

1. Hemodynamic Instability - begins immediately when there is injury in blood vessel wall
2. Respiratory Dysfunctions - carbon monoxide poisoning (pathognomonic sign: cherry-pinked face/skin)
 Nursing Priority: O2 supplement of 100% via tight fitting non-rebreather mask
3. Organ Failure - Due to hemodynamic instability
4. Hypermetabolic response - due to physical injury
Implications:
A. Increased metabolic acid - metabolic acidosis (↓pH, ↓HCO3)
Drug of Choice: Sodium Bicarbonate (NaHCO3)
B.↑ Calorie Requirements (Normal1,800 - 2,100/day)
-6,000 - 8,000/day (TPN)
Diet: ↑Calorie, ↑CHON, ↑CHO, ↑Fats, ↑Vitamins
5. Sepsis/immune dysfunctions
*↑Risk: infection
A. Priority: reverse isolation
B. Strict aseptic technique
C. Antibiotic (broad spectrum)
Silvadene - Silver Sulfadiazene - common
6. Pain
*Analgesics: Morphine SO4 dosage: 2mg/hour until pain goes away
7. Emotional Trauma

5 stages of Burns
1. Emergent Phase - actual exposure
2. Shock phase - first 24-48 hours
*Movement: Plasma to interstitial
*F/E imbalances
A. Hemoconcentration
B. Hyponatremia
C. Hyperkalemia
D. Hypovolemia
E. Decrease urine output
 F. Metabolic acidosis
3. Diuretic / fluid remobilization phase
Occurs 2-5 days after burn
Movement: interstitial to plasma
F/E imbalances:
A. Hemodilution
B. Hypernatremia
C. Hypokalemia
D. Hypervolemia
E. Increased urine output
F. Metabolic acidosis
4. Rehabilitation/covalescent phase - begins when diuresis is completed

Phases of Burn Care Priorities:

1. Emergent phase / shock phase
Priorities:
A. First Aid (RACEE)
Rescue patient
Alarm
Contain the fire
Extinguisher
Evacuate
B. Prevention of shock/respiratory distress
C. Detection and treatment of injuries
D. Wound assessment and care

2. Diuretic phase or Fluid Remobilization phase

Priorities:
A. Wound care and closure
 B. Prevention or treatment of complication
C. Nutritional support
3. Rehabilitation phase
Priorities:
A. Prevention scars and contractures
B. Physical, occupational and vocational rehabilitation
C. Functional and cosmetic reconstruction
D. Psychosocial counseling

Treatment: (drugs)
1. Antibiotics
2. Analgesics
3. NaHCO3
4. Vitamin supplements
5. Anti-PUD
6. Stool softeners
7. Anti-cholinergic
8. Anti-scar (Contractubex)

Other Treatments:
1. Fluid replacement
2. O2 supplement
3. Procedure :
A. skin grafting: post-operative Nursing management: elevate affected part to decrease edema and promote
venous return (note: do not cover the grafted site)
B. Amputation: post-operative: best position: elevate affected part
Note: if AKA, elevate on the first 24 hours post op, then flat on bed to prevent hip contractures
Nursing Care:
1. O2 supplement
 2. Reverse isolation
3. Watch for complications

Common complications:
A. Respiratory dysfunction - common cause of death
B. Infection - 2nd cause of death
Antibiotics
Strict Aseptic technique
Wound care - wound irrigation (PNSS) - common solution
Daikin’s Solution - mixture of Sodium Hypochloride (unstable solution)
-best time to prepare - the time you will use it
-irrigate the wound immediately after Daikin’s solution by PNSS
-Do not soak the wound with the solution
C. Metabolic Acidosis
D. Pain
E. PUD - stress ulcer
F. Shock
G. Organ Failure
H. Contractures - prevented by positioning properly
1. Best position: Anatomical position
I. Compartment Syndrome
1. Elevate
2. Inform Physician
Treatment:
A. Hydrotherapy - common complication: Hypothermia (earliest); Infection (late)
B. Escharotomy
C. Fasciotomy
J. Scar - Prevention: anti-scar stocking
Best time to wear stockings: a week after wound is healed (completed)
23 hours per day
16-18 months, maximum of 2 years