Clinical Guidelines (Nursing)

Nursing management of burn injuries

  • Introduction

    Definition of Terms

    Assessment

    Management

    Companion Documents

    Links

    Evidence Table

    References


    Introduction

    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.

    Definition of terms 

    • Burns Multidisciplinary Team – consist of Burns Consultant/Fellow, Burns Clinical Nurse Consultant, Burns register/resident, Nurse Coordinator, Occupational Therapist, Physiotherapist, Dietitian, Play therapy, Specialist Clinics Team.
    • % TBSA – percentage of total body surface area burnt (not including erythema or superficial burns) calculated using the Lund Browder chart found under assessment in the Burns/Management of Burn Wounds Clinical Practice Guideline
    • Minor Burn – In paediatric burns a minor burn consider less than 10% TBSA
    • Major Burn – In paediatric burns a major burn considered more than 10% TBSA

    Assessment

    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 management initiated. 

    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.

    Airway and breathing:

    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:

    -       Sustained burns in an enclosed space (at risk due to smoke inhalation)

    -       Have facial burns

    -       Singed nasal hairs

    -       Facial swelling

    -       Blackened sputum

    -       Stridor or hoarseness of voice

    -       Respiratory 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.

    Circulation:

    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:

    -       Circumferential burns should be identified, monitored for circulatory compromise (neurovascular observations nursing guideline) and the affected area elevated where ever possible.

    -       Consider the need for an ECG and continuous cardiac monitoring if the burn is of electrical origin.

    Pain assessment:

    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 Guideline.

    Wound assessment:

    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:

    -       Assessment 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.

    -       Assessment of depth of burn injury

    -       Assessment 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.

    History:

    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 injury

    -       Mechanism 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

    -       Tetanus 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.

      Social history: 

    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 follow up. 

    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.

    Management

    First Aid:

    Completion of 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 wound care:

    -       The area of tissue damage should be cooled with cool running water for 20 minutes.

    -       Cooling for longer than 20minutes is not beneficial.

    -       Ensure the unburnt areas of the patient are covered and warm to prevent hypothermia.

    Further information regarding burn injury first aid including burns to the eye area and chemical burns can be found on the Burns Clinical Practice Guideline.

    Fluids:

    Burn injuries 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. 

    -       A Strict 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)

    -       Fluid resuscitation is required in patients who have >10-15% TBSA.

    -       Patients receiving fluid resuscitation should have two large bore Intravenous cannulas inserted

    -       Fluid resuscitation is calculated utilising the modified parkland formula. For further information regarding this please see the Burns Clinical Guideline.

    -       Intravenous maintenance fluid should be administered in conjunction with fluid resuscitation, if child is unable to tolerate oral fluids.

    -       An IDC is essential for patients receiving fluid resuscitation to allow close monitoring of fluid status and adjustment of IVT as necessary.

    -       Expected urine output is 1ml/kg/hr unless otherwise stated by the medical team.

    -       U&E’s should be monitored 8 hourly while patient is receiving fluid resuscitation.

    -       Fluid resuscitation rates may need to be adjusted to accommodate the patients fluctuating fluid status.

    Analgesia:

    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 trauma/post-traumatic stress. 

    -       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 necessary.

      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.

    Preparation for burns dressing:

    Preparation of patient and family

    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 change.

    -       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 and/or parents.

    -       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 dressing change. 

    -       It 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

    Assessment 

    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 assessment above).

    The child will require continuous ABCD monitoring and pain assessment throughout the procedure to ensure that analgesics provide are adequate and effective. 

    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.

    Pre medication/ Pain relief

    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 the procedure.

    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. 

    Options may include:

    -       Simple analgesia such as Paracetamol and NSAIDs

    -       Oral Analgesia such as Opioids (Oxycodone), Tramadol, Ketamine and Oral Sedatives such as Benzodiazepines e.g. Diazepam, Midazolam

    -       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).

    Staffing requirements

    To complete a burns dressing change in a safe and time efficient manner which minimises patient and family distress, staffing requirements must be considered. 

    • Simple analgesia: 1-2 nursing staff of which 1 is experienced in burns dressing changes.
    • Oral sedation agents: 2-3 nursing staff of which 1 monitors the patient, 1 is experienced in burns dressing and 1 staff member assists.
    • Nitrous Oxide: 2-4 nursing staff of which 1 is accredited in nitrous oxide administration, 1 is experienced in burns dressing and 1-2 staff members assists
    • IV agents: An Anaesthetist and Anaesthetic technician are required; 2-3 nursing staff of which 1 is experienced in burns dressing and 1-2 nursing staff members to assist

    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.

    Preparation of environment and equipment

    • Location of burns dressing change is dependent on the following: age of child, % TBSA burnt, sedative agent require and length of procedure to ensure patient safety and OH&S considerations for staff.
    • For children who have larger %TBSA burn injuries (>10%) consider using a treatment area where heaters can be utilised to minimise the risk of hypothermia. These heaters should be turned on prior to the dressing change commencing. (i.e. Platypus Burns Bathroom, Theatre, ED Resus)
    • Adequate preparation of the environment should be completed prior to the child being taken into the treatment room/bathroom.
    • Utilise the dressing trolley to prepare the products required, and consider the need for wound swabs.
    • Consider the need to organise:

    Burns dressing:

    Staff should adhere to the aseptic technique policy (RCH only) for all aspects of wound care outlined below.

    Removal of previous dressing

    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.

    Wound management

    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.

    Personal hygiene

    Ensure the patient’s personal hygiene is thoroughly attended to if the burns dressing change is occurring in the bath or shower.

    Application of burns dressing

    -       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.

    Burns dressings

     Additional products 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

    Specific body areas  

    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.

    Documentation

    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.

    Nutrition:

    Nutrition 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.

    Insertion 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. 

    Referral 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.

    Children with significant burn injuries are at risk of acute gastric ulceration and a H2 antagonist should be considered for these patients. 

    Management of Itch:

    Itching is a common issue in the healing phase of a burn injury.

    The following may assist in reducing itch:

    -       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™) may assist.

    -       Distraction will play a big role in patient comfort

    Scar management:

    Strategies to 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.

    Physiotherapy / occupational therapy – splinting & positioning:

    Physiotherapy (PT) and Occupational therapy (OT) may be necessary throughout both inpatient stay and outpatient management for patients who have sustained a burn injury. 

    Significant 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.

    It 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 reinforcement

    -       Consistency in care 

    Concerns regarding splinting and positioning regimes should be documented and reported back to PT/OT so as appropriate alterations to regimes can be initiated. 

    Discharge planning:

    The 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. 

    Children may be ready for discharge when

    • Pain is able to be appropriately managed at home
    • An appropriate plan for wound care and follow up has been made
    • Nutritional requirements are being met
    • Mobility, positioning and splinting are able to be managed at home
    • If needed pressure garments are tolerated

    The following should be discussed with the family and child prior to discharge

    • Pain management and itch plan, including plan for procedures (outpatients dressing changes)
    • Home care of burn wound
    • Nutritional requirements
    • PT/OT recommendations
    • Medical review
    • When to return to hospital – ED/Specialist Clinics 

    Companion documents

    • Nursing competency workbook – burns dressing, assessment, and fluid management of burns.

    • Burns Appendix1

    Links

    Evidence table

    The evidence table for this nursing guideline can be found here. 

    Complete evidence table document available at http://www.wch.org.au/nursing/governance

    References 

    1.     Australian New Zealand Burn Association. (2015). Retrieved August 3rd 2015, from http://anzba.org.au/about-anzba/

    2.     Bonham, A. (1996) Managing procedural pain in children with burns. Part 1: Assessment of pain in children. International journal of trauma nursing, 2 (3), 68-73.

    3.     Bonham, A. (1996) Procedural pain in children with burns. Part 2: Nursing management of children in pain. International journal of trauma nursing, 2 (3), 74-77.

    4.     Chan, M. & Chan, G. (2009). Nutritional therapy for burns in children and adults. Nutrition, 25, 261-269.

    5.     Church, D., Elsayed, S., Reid, O., Winston, B., & Lindsay, R. (2006). Burn Wound Infections. Clinical Microbiology Reviews. 19(2). Pg. 403-434.

    6.     Clifton, L., Chong, L. & Stewart, K. (2015). Identification of factors that predict outpatient utilisation of a plastic dressing clinic. A retrospective review of 287 paediatric burn cases. Burns, 41, 469-475.

    7.     Duffy, B., McLaughlin, P. & Eichelberger, M. (2006). Assessment, Triage, and Early Management of Burns in Children. Clinical Pediatric Emergency Medicine, 82-93.

    8.     Holland, C., DiGiulio, G. &  Gonzalez del Rey. Wound care and the paediatric patient.

    9.     Langschmidt, J., Caine, P., Wearn, C., Bamford, A., Wilson, Y. & Moieman, N. (2014). Hydrotherapy in burn care: A survey of hydrotherapy practices in the UK and Ireland and literature review. Burns, 40, 860-864.

    10.  Liao, A., Andreson, D., Martin, H., Harvey, J. & Holland, A. (2013). The infection risk of plastic wrap as an acute burns dressing. Burns.

    11.  McGarry, S., Elliott, C., McDonald, A., Valentine, J., Wood, F. & Girdler, S. (2014). Paediatric burns: From the voice of the child. Burns, 40, 606-615.

    12.  Selig, H., Lumenta, D., Giretzlehner, M., Jeschke, M., Upton, D. & Kamolz. (2012). The properties of an “ideal: burn wound dressing- What do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns, 38, 960-966.

    13.  Victorian Burns Unit. (2012). Burns Management Guideline. Retrieved August 3rd 2015, from http://www.vicburns.org.au/

    14.  Young, A. (2004). The management of severe burns in children. Current Paediatrics, 14, 202-207.

     

    Please remember to read the disclaimer.

     

    The 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.