Hawassa university

College of medicine and health science

Psychiatric nursing

Group members

1.Abenezer Bezabeh …………….0156/14

2.Amanuel Seta…….…………….0348/14

3.Biniyam Teshale ………………0716/14

4.bizuayehu Samuel…………….0788/14

5.Daniel Nebiyu………………….0910/14

6.Esubalew Bafa…………………1204/14

7.Eminet Shumbe…………………

Burn injury
Burn is damage to the skin or other body parts caused by extreme heat, flame, contact with heated objects,
or chemicals .It is characterized by varying degrees of tissue damage, ranging from mild superficial burns
to severe deep burns that can affect multiple layers of skin and underlying tissues.

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 Burns can cause pain, swelling, redness, blistering, and in severe cases, can lead to complications such as
infection, scarring, and even life-threatening conditions like shock. Treatment for burns may involve first
aid measures, such as cooling the affected area, cleaning the wound, and applying appropriate dressings.
Severe burns often require specialized medical care, including fluid resuscitation, wound debridement,
and surgical interventions.

Classification of burn
Burns are classified into different degrees based on the severity and depth of tissue damage. The most
commonly used classification system for burns is as follows;

Type Layers involved Appearance Sensation

Superficial (first- Epidermis Red without blisters Painful

degree)

Superficial partial Extends into superficial Redness with clear very Painnful
thickness (second- (papillary) dermis blister. Blanches with
degree) pressure.

Deep partial thickness Extends into deep Yellow or white. Less Pressure and discomfort
(second-degree) (reticular) dermis blanching. May be
blistering.

Full thickness (third- Extends through entire Stiff and white/brown. Painless
degree) dermis No blanching

Fourth-degree Extends through entire Black; charred with Painless

skin, and into eschar
underlying fat, muscle
and bone

Table1.1 classification of burn(source Wikipedia)

 First-degree burns (superficial burns)

These burns affect only the outermost layer of the skin, called the epidermis. They are characterized by
redness, pain, and mild swelling. Sunburns are a common example of first-degree burns.

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  Second-degree burns (partial-thickness burns)

These burns involve both the epidermis and the underlying layer of skin, called the dermis. They can be
further divided into two subcategories:

 Superficial second-degree burns

These burns affect the upper layers of the dermis and are characterized by
blistering, severe pain, redness, and swelling.

 Deep second-degree burns

These burns extend deeper into the dermis and may appear white or pale. They can be less painful
compared to superficial second-degree burns but may still cause significant discomfort.

 Third-degree burns (full-thickness burns)

These burns extend through all layers of the skin and may involve underlying tissues such as muscles,
tendons, or bones. The affected area may appear white, blackened, or charred. Third-degree burns are
often painless because nerve endings are destroyed.

 Fourth-degree burns:

These burns are the most severe and extend beyond the skin into deeper tissues, such as muscles, bones,
or organs.

ESTIMATION OF BODY SURFACE AREA OF BURN

The total body surface area (TBSA) of a burn can be calculated with a Lund and Browder Chart, Wallace
Rule-of-Nines or the palmar method. An accurate estimation of a burn guides acute management, fluid
resuscitation, nutrition supplementation and prognosis.

-Appropriate burn charts for different childhood age groups should be used to accurately estimate the
extent of BSA burned. The volume of fluid needed in resuscitation is calculated from the estimation of
the extent & depth of burn surface.

The Rule of Nine

The Rule of Nines is a quick and approximate method used by healthcare professionals to estimate the
extent of burns in adults. It divides the body into regions representing 9% or multiples of 9% of the total
body surface area. The areas are assigned percentages as follows:

 Head and neck: 9%

 Each upper limb (arm): 9%
 Front of the chest: 9%
 Back of the chest: 9%
 Abdomen: 9%

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  Upper back: 9%
 Lower back and buttocks: 9%
 Each lower limb (leg): 18% (9% for the front and 9% for the back)

This method assumes that each body part represents a specific proportion of the total body surface area. It
is primarily used for quick initial assessment and to guide initial fluid resuscitation in burn patients.

The Lund and Browder Chart

The Lund and Browder chart is a more accurate and detailed tool for estimating BSA involvement in burn
injuries in pediatric patients. It takes into account the changing proportions of a child's body as they grow.
The chart divides the body into smaller regions, each with its own specific percentage of BSA.

The Lund and Browder chart assigns different percentages of BSA to different age groups, as follows:

- Newborns: The head represents 18% of the BSA, each lower limb represents 13.5%, and the trunk
represents 36%.

- Infants and toddlers: The head represents 18% of the BSA, each lower limb represents 14%, and the
trunk represents 36%.

- Children: The head represents 12.5% of the BSA, each lower limb represents 16%, and the trunk
represents 32%.

Pain score of burn

The Wong-Baker FACES Pain Rating Scale is often used to assess pain in children with burns. This is a visual
scale that uses pictures of faces to help children rate their pain on a scale of 0 to 10. The scale includes six
faces, ranging from a smiling face (no pain) to a crying face (worst pain). Children are asked to point to the
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face that best represents how much pain they are feeling. This scale is easy for children to understand and can
help healthcare providers assess the severity of the burn pain and determine appropriate treatment.

Management of burning injury

For the burn patient, the very first step is to immediately stop the burning process and remove burning or hot
items from skin contact. The primary survey assesses the A.B.C.s for life threats and the we can go for the
following.

1. Pain management

Prescription pain medications may be necessary for severe burns.

2. Wound care

Depending on the severity and extent of the burn, wound care may include debridement (removal of dead
tissue), cleaning, and dressing changes.

3. Antibiotics

If the burn becomes infected, antibiotics may be prescribed to treat the infection.

4. Tetanus shot

If the burn is caused by a dirty or rusty object, a tetanus shot may be necessary to prevent tetanus
infection.

5. Fluid replacement

If the burn is severe, fluid replacement may be necessary to prevent dehydration and shock.

6.Nutritional support

If the burn is extensive, nutritional support may be necessary to promote healing and prevent
malnutrition.

 Patients with burns of more than 20% - 25% of their body surface should be managed with
aggressive IV fluid resuscitation to prevent “burn shock." A variety of formulas exist, like
Brooke, Galveston, Rule of Ten, etc.4, but the most common formula is the Parkland Formula.
This formula estimates the amount of fluid given in the first 24 hours, starting from the time of
the burn.

The Parkland Formula

Four mL lactated ringers solution × percentage total body surface area (%TBSA) burned × patient's
weight in kilograms = total amount of fluid given in the first 24 hours.
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One-half of this fluid should be given in the first eight hours.

Maintenance Fluid
One of the primary objectives of maintenance parenteral fluid therapy is to provide water to meet
physiologic losses (insensible loss + urine loss)

For infants 3.5 to 10 kg the daily fluid requirement is 100 mL/kg.

For children 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10.

For children >20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20, up to a
maximum of 2400 mL daily.

Equations used

 FluidRate = DailyVol / 24

In our case
Abiyu Girma a 5years age male patient presented with second degree burn .

Assessment

Redness with clear blister,Blanches with pressure and its Very painfull.

25% BSA

 both foot.....4%

 hands.......2%

 Head(the face bilaterally )....6%

 Upper and lower back....13%

 he has a severe pain.

Management

 Antipain...PCM 250

...Morphine 0.1ml/kg

 Wound care
 Topical antibiotics...Nitrofurazone

 Resuscitation fluid
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 Since he got hypovolumic shock he adiminstered
20ml/kg fluid that means 20mlx16kg=320 ml and
additionally the resuscitation fluid = 4ml(c)x25%x16kg=1600ml/24h

And the daily maitenance

Since he is 16kg= the daily fluid requirement is 1000 mL + 50 mL/kg=1650ml/24h.

 he has NG tube

GCS in child
The Glasgow Coma Scale (GCS) is clinician-administered scoring system, designed to assess depth and
duration of impaired consciousness and coma arising from any medical condition. The Paediatric
Glasgow Coma Scale (also known as Paediatric Glasgow Coma Score or simply PGCS ) is the equivalent
of the Glasgow Coma Scale (GCS) used to assess the mental state of child patients. As many of the
assessments for an adult patient would not be appropriate for infant, the Glasgow Coma Scale was
modified slightly to form the PGCS. As with the GCS, the PGCS comprises three tests:

-Eye

-Verbal and

-Motor

The three values separately as well as their sum are considered. The lowest possible PGCS (the sum) is 3
(deep coma or death) whilst the highest is 15 (fully awake and aware person).

The PGCS examines hierarchical levels of functioning in three domains: Eye opening, Verbal response
and Motor response. There are four levels of eye opening, ranging from the lowest level, no eye opening,
not even in response to pain, through to the highest level, spontaneous eye opening.

Five levels of Verbal response range from no verbal response, not even in response to pain, through to
alertness, babbles, coos, words or sentences to usual ability. Six level of Motor response range from no
motor response, not even in response to pain, through to obeying commands.

Best eye response: (E)

4. Eyes opening spontaneously

3. Eye opening to speech

2. Eye opening to pain

1. No eye opening or response

Best verbal response: (V)

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5. Smiles, oriented to sounds, follows objects, interacts.

4. Cries but consolable, inappropriate interactions.

3. Inconsistently inconsolable, moaning.

2. Inconsolable, agitated.

1. No verbal response.

Best motor responses: (M)

6. Infant moves spontaneously or purposefully

5. Infant withdraws from touch

4. Infant withdraws from pain

3. Abnormal flexion to pain for an infant (decorticate response)

2. Extension to pain (decerebate response)

1. No motor response

Any combined score of less than eight represents a significant risk of mortality.

The PGCS is commonly used in emergency medical services.

Properties PURPOSE

The Pediatric Glasgow Coma Scale (PGCS) was created for children too young to talk, adjusting motor
and verbal response criteria in relation to developmental stages from babies < 6 months of age to age 5
years.

SCORING

If a child is unable to speak as a result of damage to the speech centers of the brain (dysphasia), then a 'D'
should be placed in the appropriate space on the assessment tool (Appleton and Gibbs 1998; Shah 1999).

If a child has a tracheostomy or an endotracheal tube in situ, a 'T' should be marked in the appropriate
space on the assessment tool (Aucken and Crawford 1999 ; Fischer and Matthieson, 2001 ). CHECK!!
Page 35 (Tate, 2010).

SCORE INTERPRETATION

Eye Opening

Score Age 1 Year or Older Age 0-1 Year

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  4 Spontaneously Spontaneously

 3 To verbal command To shout

 2 To pain To pain

 1 No response No response

Best Motor Response

Score Age 1 Year or Older Age 0-1 Year

 6 Obeys command

 5 Localizes pain Localizes pain

 4 Flexion withdrawal Flexion withdrawal

 3 Flexion abnormal (decorticate) Flexion abnormal (decorticate)

 2 Extension (decerebrate) Extension (decerebrate)

 1 No response No response

Best Verbal Response

Score Age >5 Years Age 2-5 Years Age 0-2 Years

5 Oriented and converses Appropriate words Cries appropriately

4 Disoriented and converses Inappropriate words Cries

3 Inappr words; cries Screams Inappr cry/scream

2 Incomprehensible sounds Grunts Grunts

1 No response No response No response

 Score 13–15: May indicate mild dysfunction, although a person with no neurologic disabilities
would receive a GCS of 15.Score 9–12: May indicate moderate dysfunction.

 Score 3–8: Is indicative of severe dysfunction.Patients who are intubated are unable to speak, and
their verbal score cannot be assessed. They are evaluated only based on eye opening and motor
scores, and the suffix T is added to their score to indicate intubation.

In intubated patients, the maximum GCS score is 10T and the minimum score is 2T. The GCS is
often used to help define the severity of TBI. Mild head injuries are generally defined as those
associated with a GCS score of 13-15, and moderate head injuries are those associated with a
GCS score of 9-12. A GCS score of 8 or less defines a severe head injury. These definitions are
not rigid and should be considered as a general guide to the level of injury.
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  Finaly in our case the patient name called Suni Shumbe has been assessed as follows

Eye oppening Verbal response Motor response

2 2 5

So,her GCS is 9/15 Moderate dysfunction

What Is Pneumonia?

Pneumonia is an infection of the lungs. Normally, the small sacs in the lungs are filled with air. In
someone who has pneumonia (nu-MOH-nyuh), the air sacs fill up with pus and other fluid.

What Causes Pneumonia?

Viruses, like the flu or RSV (respiratory syncytial virus), cause most cases of pneumonia. Kids with
pneumonia caused by a virus usually have symptoms that happen over time and tend to be mild.Less
often, bacteria can cause pneumonia. When that happens, kids usually will become sick more quickly,
starting with a sudden high fever, cough, and sometimes fast breathing. Types of bacterial pneumonia
include pneumococcal pneumonia, mycoplasma pneumonia (walking pneumonia), and pertussis
(whooping cough).

The signs and symptoms of pneumonia may include:

 fever
 cough
 chills
fast breathing
 breathing with grunting or wheezing sounds
 vomiting
 chest pain
 belly pain
 being less active
 loss of appetite (in older kids) or poor feeding (in babies)

Fast breathing was found to be the most useful sign predicting pneumonia in all age groups. Cut-
off points

 60 breaths/min for infants including neonates,

 50 breaths/min for children aged 12-35 months, and
 40 breaths/min for children aged 36-60 months indicated presence of pneumonia.

In our case the patient named Kirubel Endale aged 9 month has been assessed as

His RR is 66 so,it is fast breath and indicates pneumonia

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