In this section
Definition of Terms
Children have a high risk of sustaining a burn injury due to their
physiological, psychological, and developmental differences.
Burn injuries have a
significant impact on paediatric patients and may affect a range of body
systems. The impact of these injuries on children and families is often long
lasting. As the injury itself and required treatment often causes distress,
pain and anxiety, appropriate management by nurses is essential in providing
family centered care.
Ongoing care requirements
are based on the size, depth, anatomical site and mechanism of injury.
To assist and support nursing
staff at The Royal Children’s Hospital to plan and deliver care to children
with burn injuries, across all departments including: Emergency, Paediatric Intensive
Care Unit, Inpatient Units, Theatres and Outpatients.
Burn injuries cause a significant insult on the body and a thorough ABCD
assessment, followed by full head to toe and focused assessment are vital to
ensure clinical issues/deterioration are identified early and appropriate
Assessment of the pediatric patient with a burn injury should occur on
admission, when the patient’s condition changes and regularly throughout care.
Detailed information regarding completion and documentation of ABCD,
head to toe and focused assessments can be located on the Nursing Assessment
Clinical Nursing Guideline.
Burns specific information is outlined below.
Assessment and monitoring of airway patency and breathing should be
carefully observed as patients at risk of inhalation burns can deteriorate up
to 72 hours post burn injury, particularly if they have:
burns in an enclosed space (at risk due to smoke inhalation)
or hoarseness of voice
distress/increased work of breathing
If inhalation burns are suspected high flow oxygen therapy via a Hudson
mask should be administered to the patient and changes/abnormal findings
reported to the treating team immediately for further assessment and management.
Children who sustain burns injuries are at increased risk of circulatory
compromise due to significant fluid loss and fluid shifts, these patients must
be closely monitored for:
- Signs and
symptoms of hypovolemia.
- Signs and
symptoms of hypothermia.
Other circulatory concerns include:
burns should be identified, monitored for circulatory compromise (neurovascular
observations nursing guideline) and the affected area elevated where ever possible.
the need for an ECG and continuous cardiac monitoring if the burn is of
Burn injuries are often associated with extreme amounts of pain and
discomfort due to damaged/loss of skin coupled with widespread oedema.
A detailed pain assessment must be completed upon arrival to hospital and
then continued at regular intervals (1-4 hourly minimum) throughout the
patient’s admission, prior to/during procedures as well as during outpatient
visits. Re-evaluation of pain, post pain management is vital to ensure
analgesia is adequate.
Detailed information regarding paediatric pain assessment can be located on
the Pain Assessment Nursing Clinical Guideline. Information regarding
procedural pain management can be located on the Procedural Pain Management Nursing Clinical
Assessment of the burn injury should occur on the initial presentation
to the Royal Children’s Hospital as well as prior to completing wound care throughout
the inpatient stay and outpatient visits. Burn injuries can take up to 10 days
to truly present the depth and extent of injury so frequent reassessment is
vital. As burn injuries heal accurate wound assessment will ensure wound
management is altered as needed to ensure appropriate wound care continues to
be delivered to the patient.
Wound assessment of a burn injury includes:
of Total Body Surface Area (TBSA) burnt, utilising the Lund Browder chart. Areas of erythema and superficial burns are not included in
calculations of TBSA.
of depth of burn injury
of wound healing.
Accurate documentation of wound assessment should be recorded.
Further information regarding wound assessment in a burn injury can be
located on the Burns Clinical Practice Guideline as well as the
Burns Unit: Clinical Information.
Further information regarding wound assessment and healing can be
located on the Wound Care Clinical guideline.
A thorough patient history should be collected on admission to hospital.
Specific information regarding the burn injury must be obtained from the
patient, family and first responders as this will inform ongoing treatment.
History taking should include:
- Time of
of injury: How the burn occurred/type of burn, including length of exposure and
estimated temperatures of heat source.
- Was first
aid completed, if so what type and for how long
status of the patient (if not up to date consider immunisation, see immunisation of inpatients nursing Clinical Guideline.
In addition to this information a detailed patient and family history
should also be obtained. Further information regarding this can be located on
the Nursing Assessment Nursing Clinical Guideline.
Non accidental injuries must be
considered when the history does
not match with the injury or inconsistencies with the history/story occur. Refer to medical staff & social
work. Victorian Forensic Paediatric Medical Service (VPFMS) can also be notified.
For further information regarding non
accidental injuries refer to the Child Abuse Clinical Guideline.
Burn injuries are traumatic
and life altering events which can significantly impact the patient and their
family. Early support from social work, contact with play therapists and chaplains
should be offered to the child, siblings and family. It may also be appropriate
to consider referrals to mental health/psychology.
Families from non-English
speaking backgrounds interpreters must be utilised throughout the admission and
Patients who live more than 100km away from the hospital, may be eligible for travel and accommodation assistance from the Victorian Patient Transport Assistance Scheme (VPTAS). Claim forms are available from the RCH’s Family Hub, clinic desks and Main Street Reception, or you can download the form here. Equivalent schemes are available in each state for interstate residents. For more information visit the Department of Health website.
first aid for a child who has sustained a burn injury is an important initial
aspect of care as it assists with pain relief as well as minimising the
progression of tissue damage. First aid
is effective for up to three hours post time of injury. If appropriate
first aid was not initiated and it is still within the 3 hour time frame post
burn injury, first aid should be completed as outlined below, prior to any
area of tissue damage should be cooled with cool running water for 20 minutes.
for longer than 20minutes is not beneficial.
the unburnt areas of the patient are covered and warm to prevent hypothermia.
information regarding burn injury first aid including burns to the eye area and
chemical burns can be found on the Burns Clinical Practice Guideline.
result in circulatory compromise secondary to fluid loss via damaged tissue,
widespread vasodilation as well as increase capillary permeability and fluid
shifts (third spacing). This can result in hypovolemia leading to burns shock.
Therefore it is vital that adequate fluid is administered to the patient in combination
with ongoing circulatory and fluid balance assessment.
Fluid Balance must be maintained at all times, including all intake (both
intravenous and oral) and strict measurement of all output (weigh nappies,
weigh pans/bottle, measure IDC)
resuscitation is required in patients who have >10-15% TBSA.
receiving fluid resuscitation should have two large bore Intravenous cannulas
resuscitation is calculated utilising the modified parkland formula. For
further information regarding this please see the Burns Clinical Guideline.
maintenance fluid should be administered in conjunction with fluid
resuscitation, if child is unable to tolerate oral fluids.
is essential for patients receiving fluid resuscitation to allow close
monitoring of fluid status and adjustment of IVT as necessary.
urine output is 1ml/kg/hr unless otherwise stated by the medical team.
should be monitored 8 hourly while patient is receiving fluid resuscitation.
resuscitation rates may need to be adjusted to accommodate the patients
fluctuating fluid status.
Burn pain can be extremely intense and distressing for
paediatric patients and can also be challenging to manage due to the individual
experience and its unique characteristics.
Initial and ongoing pain management is vital to ensure
patient comfort, maximise healing and minimise risk of mental
Initial pain relief should be
administered immediately following an accurate pain assessment, further
information regarding initial pain management can be located on the Burns
Clinical Practice Guideline.
Regular pain relief should be charted
and administered, consider a combination of Paracetamol and Opioids initially.
Recommended routes of administration of
analgesia include: oral, intravenous or intranasal. Intramuscular is not
recommended in patients with burn injuries.
Pre-emptive analgesia may be necessary
prior to re-positioning, physiotherapy and follow up outpatient appointments.
Reassessment and evaluation of pain
management is vital, referral to Children’s Pain Management Service may be
Burn pain experienced by patients is likely to increase
during procedures such as dressing changes. Management of pain during burn
dressing changes is discussed in detail below.
Once dressings have been applied and wound healing is
progressing, patients are more comfortable and may require less analgesia.
Burn dressing changes can produce feelings of anxiety and distress in
both patients and their families. It is very important that both patients and
families are physically and emotionally prepared and well informed regarding
the procedure and the pain management options.
- Families/primary care givers should be
given a thorough explanation of the procedure, where appropriate pictures could
be used to visualise the procedure along with orientation to the treatment
room/bathroom to be used.
- Involve the parents where possible when
providing an age appropriate explanation of the procedure to the patient.
- Optimising the parent’s role may assist in
reducing both the child’s and parents anxiety during the procedure. Involving
them in distraction and support of the child may be useful. However not all
families will want to be involved and staff should be sensitive to parents who
choose not to be present.
- Referral to play therapy prior to the
procedure may assist in explaining and preparing the patient for the dressing
- Play therapy are also able to empower the
child to identify distraction techniques, as well as provide support and
distraction throughout the procedure. For older children distraction techniques
should be discussed with the child. Distraction should be utilised by staff
- Where possible and appropriate children
should be given the opportunity to choose whether they want to participate in
wound care for example assisting to remove dressings.
- Consider the benefit of social work support
for patients and parents who may require additional support before or after a
may be hard to distinguish between a patient’s pain and anxiety associated with
burns dressings, good communication with family prior to and during the
procedure will assist in this.
For further information, staff
and families can access reducing children’s discomfort during tests and
procedures kids health info factsheet.
Children who are planned to undergo a burns dressing change should have
an ABCD assessment completed along with pain assessment prior to the dressing
change commencing. This will assist the nurse in ensuring appropriate
pre-emptive analgesia is selected for the patient (see ABCD / Pain
The child will require continuous ABCD monitoring and pain assessment
throughout the procedure to ensure that analgesics provide are adequate and
The child’s personal hygiene requirements should also be assessed at
this time as this will assist the nurse in identifying children who should be
bathed (bath/shower) prior to having a new dressing applied.
Children who may require bathing (bath/shower) include those with large
% TBSA burns, those whose dressing prevent them from bathing/showering on a
daily basis and may be age dependent.
Burns dressing changes can be painful and distressing for children, it
is an individual experience, however burns with larger % TBSA, those that
contain partial thickness burns and any that require extensive debridement are
likely to be more painful.
Nursing staff should assess the child’s pain prior to the procedure
commencing and pre-emptive analgesia should be administered. Staff should
re-evaluate the effectiveness prior to the procedure commencing and throughout
Choice of analgesia is an individual process and staff should take into
account the % TBSA, depth, amount of debridement required as well as the pain
tolerance, distress and past experience of the child. Review of
analgesia/sedation requirements for previous dressing changes is essential.
The Children’s Pain Management Service (CPMS) may also be utilised to
assist in planning procedural pain relief for burns dressing changes.
- Simple analgesia such as Paracetamol and
- Oral Analgesia such as Opioids (Oxycodone),
Tramadol, Ketamine and Oral Sedatives such as Benzodiazepines e.g. Diazepam,
- Intravenous Sedation/Analgesics including
infusions, PCA or intermittent bolus (Morphine/Fentanyl/Ketamine)
- Nitrous Oxide (refer to the procedural
sedation ward and ambulatory care clinical procedure (RCH only)
- Anaesthetics may be involved to provide
sedation (Ketamine/Propofol) and continuous monitoring of the patient.
A combination of the above
options may be ordered and utilised to provide pain relief. Note for patients
receiving an anaesthetic or Nitrous Oxide the need for administration of
medications with analgesic effects should be considered to assist in pain
management post burn dressing change. Further information regarding this can be
located on the Procedural Sedation – ward and ambulatory care procedure (RCH only) or through consultation with CPMS or comfort kids.
Pain Assessment should occur continuously throughout the procedure by
observing the behaviour and comfort level of the child as well as using an
appropriate pain assessment scale.
If analgesia and sedative agents prescribed are not providing effective
pain management/sedation then the procedure should be paused until appropriate
analgesia/sedation is available and pain is manageable. Escalation to the
children’s pain management service on pager 5773 or Burns resident on pager
4021 can occur at any stage throughout the procedure.
As the patients burn injury heals analgesia and sedative agents
utilised throughout the procedure should start to be slowly weaned with the
support of CPMS, medical teams and senior nursing staff.
All sedative agents should be administered in line with the Sedation
and Procedural Sedation Ward and Ambulatory Areas Procedure (RCH only).
To complete a burns dressing change in a safe and time efficient manner
which minimises patient and family distress, staffing requirements must be
Additionally allocating the role of distraction and non-pharmacological
pain management techniques should be considered and assigned to either a
parent, play therapist or additional staff member as appropriate.
All roles must be designated prior to commencement of dressing change
and the patient should remain in line of sight to staff at all times. For
further information refer to the Sedation and Procedural Sedation Guideline
Ward and Ambulatory Care Areas Procedure (RCH only).
Burn injuries which have a large TBSA percentage and patients with
reduced mobility may require increased staff numbers to assist in dressing
changes. For further information refer to the High Dependency and Special
Nursing Care guideline.
Staff should adhere to the aseptic technique policy (RCH only) for all
aspects of wound care outlined below.
Removal of the previous dressing should
not damage the healing burn wound and should be as atraumatic as possible.
The use of an adhesive remover, normal saline or water will assist with gentle
removal of previous dressings.
Clean the wound using a soft wipe with water, normal saline, pH neutral
soap or cetrimide (please note cetrimide is not to be used on face or scalp).
Enough pressure should be applied to debride the damaged skin and remove
exudate, loose skin and slough.
Please note if wound swab is required eschar, debris and topical
antibacterial agents should be removed prior to specimen collection. These can
be removed with sterile water or normal saline. A moistened swab may be
beneficial, particularly if swabbing dry areas on the burn injury. If the area
has been cleansed with antiseptic agents (i.e. cetrimide) then this must be
rinsed off and allowed to dry so as not to affect bacterial growth.
Debridement of any blisters present allows for wound bed assessment and
appropriate dressing application.
The wound and surrounding skin should be dry before application of the
dressing. If the patient has had a bath, pat dry the surrounding skin with
clean towels or gauze. Cling wrap could also be utilised to protect the burn if
there is an anticipated delay in application of new dressing.
Ensure the patient’s personal hygiene is thoroughly attended to if the
burns dressing change is occurring in the bath or shower.
- A thorough wound assessment should occur
with every dressing change and will determine the appropriate dressing required
(see wound assessment above).
- Dressings should cover all area where
tissue damage has occurred but not unburnt skin as maceration may occur.
- When taping a dressing consider the
sensitivity of skin and the age of the child. The dressing should be secured
but taping not excessive.
- A crepe bandage/tubifast assists with
securing dressings as well as absorbing some excess fluid. They also add
pressure to support with scar management.
- Oedema is common in the initial days post
burn, therefore tight circumferential bandages should not be applied. Elevation
of the limb in the immediate days post injury will limit swelling.
- Dermal burns produce a large amount of
exudate in the initial few days and changing of the outer bandage or tubifast
may need to occur. Where possible retaping/securement of the dressing should
occur unless a dressing change is scheduled.
may be utilised on burns wounds at the discretion of medical and nursing staff.
For further information regarding the above and additional
products please refer to the wound care guideline.
Facial Burn’s Care:
Facial burns may require regular wound care including
cleansing followed by application of paraffin cream. Parents should be
encouraged to be involved in providing this care.
If dressings are utilised on the face balaclavas can be made
from tubifast and used to secure dressing products.
Additional information can be located on the Burns on the
Face Kids Health Info fact sheet.
Hand Burn’s Care:
Any dressing applied to fingers, should ensure fingers are
taped individually. Initially fingers which have circumferential burns should
be dressed with the finger tips exposed to monitor neurovascular status. Once
oedema has decreased the finger tips can be enclosed in the dressing.
Referral to hand therapy is vital.
A summary post dressing
change should be documented including: pain relief/ sedation and effect,
non-pharmacological techniques and effect, parental involvement, wound
assessment, dressing product utilised, staff present (including allied health,
interpreter etc.) and plan of ongoing care. See Nursing Documentation Clinical Guideline for further information.
plays a vital role in burn healing, minimising complications of care and
meeting the increased metabolic demands associated with paediatric patients
with burns. A diet high in protein, calcium, energy and micronutrients (in
particular Zinc and Vitamin C) has been shown to be most beneficial for wound
healing. Children should be encouraged to eat and drink foods high in these
nutrients and nutritional supplements such as Sustagen™ may also be required.
of a nasogastric tube and commencement of enteral feeds should be considered
for children who sustain significant burn injuries and/or facial burns and are
unable to tolerate adequate oral intake. Where possible feeds should commence
within 6 - 8 hours of the burn injury.
to the Burns Team Dietician is recommended for all patients with significant
burn injuries, facial burns, infants as well as patients who are not tolerating
adequate oral intake.
with significant burn injuries are at risk of acute gastric ulceration and a H2
antagonist should be considered for these patients.
Itching is a common issue in
the healing phase of a burn injury.
The following may assist in
- Advise child and parent to avoid
scratching - short finger nails will assist in this.
- Consider use of antihistamines i.e.
Periactin or Certizdine
- Avoid overheating the child
- Fragrance free moisturiser (Sorbolene™)
- Distraction will play a big role in
reduce scar development post burn injury include:
- Regular bathing and showering
- Fragrance free moisturiser (Sorbolene™)
should be applied at least twice daily to healed skin.
- Pressure therapy in the form of tubifast,
tapes, pressure garments and silicone may be prescribed by Physiotherapy (PT)
or Occupational therapy (OT). It is often recommended that garments are worn
continuously except during personal hygiene. Nursing staff should monitor for
pressure areas when such garments are in use and report concerns back to PT/OT.
(PT) and Occupational therapy (OT) may be necessary throughout both inpatient
stay and outpatient management for patients who have sustained a burn injury.
burn wounds and those over joints are at high risk of contracture development.
This can have an impact on both growth and mobility. Prevention of contractures
needs to occur early and to assist in this PT and OT will prescribe patients
with a splinting and positioning regime. To aid PT/OT in assessing the
patient’s burn injury and range of movement it is often beneficial for them to
attend changes of dressings.
is vital that these regimes are adhered to by nursing staff. Paediatric
patients may find the splints and positioning regimes uncomfortable and
distressing. It is important to educate both patient and family that the
position of comfort is likely to result in contractures. Strategies to support
splinting and positioning regimes include:
- Regular and pre-emptive analgesia
- Play therapy, distraction and rewards
(i.e. sticker charts)
- Ongoing education and positive
- Consistency in care
regarding splinting and positioning regimes should be documented and reported
back to PT/OT so as appropriate alterations to regimes can be initiated.
decision for a patient to be discharged should have involvement from the burns
multidisciplinary team and family meetings may be beneficial for planning
purposes. Early discussion regarding discharge may facilitate a smoother
transition home for the family.
may be ready for discharge when
following should be discussed with the family and child prior to discharge
The evidence table for this nursing guideline can be found here.
evidence table document available at http://www.wch.org.au/nursing/governance
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Please remember to read the disclaimer.
development of this nursing guideline was coordinated by Kate Glassford, RN, Stacey Richards, Nurse Educator, Undergraduate Nurses,
and approved by the Nursing Clinical Effectiveness Committee. Updated December 2015.