Burn injuries are responsible for about 1, 80, 000 deaths per year globally and majority of them occurs in low and middle income countries (World Health Organization 2018). They pose a huge number of challenges to the healthcare professionals for properly managing the situations due to a number of facts.
The assessment of the spectrum of burn injuries has to be done first where the nursing individuals have to assess the burns which may range from simple first-degree burns that have no sequel to that of third degree burns which are seen to have a hypermetabolic response (Morton et al. 2017). Usually, in case of severe burn injuries, initial management of the wounds is seen mainly to focus on the early recognition of the potential airways, circulatory compromise as well as potential resuscitation.
In order to manage successfully burns in children, health care professionals should have proper knowledge about pathophysiology, epidemiology, initial resuscitation, associated injuries, social concerns for child and many others (Gauglitz and Williams 2015). This assignment will thereby show the sequential procedure of burn management from recovery approach for the concerned child named Zyhnab. Psychosocial care of the children and ethical and legal considerations will be also discussed in the paper in details.
Airway management
Zaynab is a five-year child who has faced second-degree burn on her upper arms and chest. These types of the burn are quite serious as the damage extends beyond the uppermost layer of the skin. These types of burns are seen to cause a blister in children that become extremely sore and red with time (Bi et al. 2017). Superficial partial thickness burns are not only painful but also have blisters with a brisk capillary refill (Gandhi et al. 2010). These burns are mainly seen to comprise of the epidermis along with the superficial parts of the dermis (Heyneman et al. 2016). They are mainly seen to heal within 1 to 3 weeks without causing any type of scarring. The airway must be assessed, and if the professionals find it necessary, the airway can be secured (Morton et al. 2017).
Initial management of the burn would require an evaluation of the potential airway compromise, ventilation and oxygenation. The chief aspect of the airway management for Zaynab would be to rapidly secure the airway before considering overt airway closure (Kishikova, Smith and Cubison 2014). The management of difficult airway can be addressed with the help of video laryngoscopes, fiberoptic intubation, and laryngeal mask airway (LMA) – guided intubation (Richtsfeld and Belani 2017).
However, the route of tracheal intubation is to be individualized as per the need of the patient. Ventilator strategies for managing hypoxia and ARDS (Acute Respiratory Distress Syndrome) in the patient might be challenging. For Zyanba, the ideal process would be a lung-protective ventilation strategy with the help of low-tidal volumes, positive end-expiratory pressure, and permissive hypercarbi.
The rationale is that is if effective in minimizing the impact of lung injury which is ventilator induced. Pediatric Rapid Sequence Intubation (RSI) would be a useful tool that is a sequential process of preparing, sedating and paralyzing the patient for facilitating safe and emergency tracheal intubation. Research indicates that RSI is beneficial for providing optimal conditions for emergent intubation (Kerrey et al. 2015). Pediatric rapid sequence intubation can be fixed in Zaynab by making her conscious and using neuromuscular block. Secondly, good preparation needs to be done for safe induction and step needed to be taken in case the intubation fails. Choice of induction agent and neuromuscular blocking agent are also important (Kerrey et al. 2012).
Maintenance of homeostasis
Care should also be taken so that the patient does not remain in an environment that is hypothermic. The patient should be treated in a warm environment by giving warm fluids (Pruskowski et al. 2017). Fluid resuscitation can be applied to Zaynab is the professional finds that burn involves more than 10 to 12% of the total body surface area. Researchers are of the opinion that about 3 to 4 mL of a warmed crystalloid solution should be given such as the Hartman solution.
This should be given for about per kg per percent of the TBSA in the preliminary 24 hours (Gandhi et al. 2010). 50 % of the volume is given in the first 8 hours experienced researchers are also of the opinion that for children under 30 kg of weight can be administered with glucose containing maintaining fluid which are called half normal saline with 5 % glucose (Haberal, Abali and Karakayali 2010). As Zaynab is a five year old child, he can be administered with similar fluid (McGarry et al. 2014).
Surgical intervention
According to Vincent et al. (2016), urgent surgery for a pediatric patient suffering burn is to be considered beneficial is the patient has suffered vascular injury or if there is a risk of compartment syndrome. In case these conditions are absent, surgical intervention can be carried out normally after the team has prepared for the same. In such a case, the surgery is to be carried out within 72 hours of the burn (Von Keudell et al. 2015).
Definite surgical management for Zaynab would include excision, grafting and reconstruction. Burn reconstruction process would have the aim of covering the burn wound and restoring the body functions. Preservation of esthetics would also be an objective of the surgical process. Further, the reconstruction is to be completed in different phases, and this would depend on the severity of the burn that the patient has suffered (Rowan et al. 2015).
The use of skin grafting and early excision would allow for initial acute coverage of the burns. In addition, there would be a reduction in the infected tissue severity and necrosis (Rowan et al. 2015). As opined by Hop et al. (2014) early excision and proper skin grafting is beneficial for reduced cost of hospital care, reduced the length of stay at the hospital, and reduced rate of chances of mortality.
Pain management
A prominent factor for poor pain management is the inadequate pain assessment. Therefore it is crucial for using the proper measurement tool for gauging the severity of the pain. The tool that can be used in the present case for Zaynab is the FLACC tool (Face Legs Activity Cry and Consolability). The same is a behavior assessment tool which is useful for validating pain (Crellin et al. 2015). The effectiveness of the assessment tool has been widely discussed in the literature.
Pain management would be a crucial component of care for Zaynab, and since pain is a major part of burn injury, it is to be given special care. Depression and anxiety are known to be confounding components in the burn. The forms of pain that are to be taken account of are baseline pain and procedure-related pain versus background pain. High dose of opioid would be useful for managing pain and morphine would be the best-suited drug. A dose of 0.1mg/kg is to be initially administered to the patient. The combination of opioid and benzodiazepine might also prove to be effective (Gamst-Jensen et al. 2014). If the patient shows a haemodynamically stable condition with minimal evidence of respiratory depression, the dose can be increased in case the patient suffers further pain.
Psychosocial care of children in hospital
Burn injuries have been denoted to be a trauma that lasts for a considerable time period in pediatric patients. Healthcare professionals confront different psychosocial issues when providing treatment to a pediatric patient suffering burn injuries (De Sousa 2010). According to McGarry et al., (2015) treatment of the patient with burn injury would need to include recovery of the optimal function of the individual to be physically and psychologically fit. The goal of psychosocial care for Zaynab would consider restoration of life beyond functional restoration.
Pediatric burns and the role of family support have been well documented in the literature. Family members play a crucial role in the rehabilitation and long-term care for the patient (Li et al. 2017). Members of the family must be helpful to a great extent so that the best interests of the child are supported, and the child feels safe and secured (Procter 2010).
Identification of the vulnerabilities of the family member and psychosocial strengths are important for developing the treatment plan facilitating child care (McGarry et al. 2014). In the present case, it has been found that Zaynab’s mother is insensitive towards her, and does not provide her with empathy and affection when she cries. In this case, the responsibility would be to counsel the patient’s mother regarding the importance of providing care to the child.
Educating the patient’s mother would be a fundamental part of delivering psychosocial care (Horridge Cohen and Gaskell 2010). This would ensure that Zaynab’s mother participates in the care delivery process and engages in informed care decisions. Education and counseling would take place in a suitable environment for promoting adequate outcomes (Tegtmeyer et al. 2018). The process would commence with an assessment of the psychological needs of the individual. Any interpersonal differences are to be sorted out for facilitating this process.
As per the framework developed by National Burns Care Review Committee, a Coordinator of psycho-social rehabilitation would need to address the needs of the patient. It is the role of this professional to provide with the appropriate interventions. Further, a trained psychotherapist is to be involved in the care of Zaynab (Guest, Griffiths and Harcourt 2018).
The role would be to consult with the patient’s family for inter-disciplinary therapeutic interventions. In this case, parental inadequacy has led to the probable neglect of the child. She has further chances of complications during recovery due to family dysfunction. In such a case, an honest discussion with the child’s parents would be pivotal. In the early phase of care for the patient, apart from functional physical recovery, the focus is to be given to coping strategies for managing self-esteem, body image and social identity. As the patient faces the stressful process of adaptation, coping strategies are to be taught for promoting self-esteem. This would require considerable energy and time, and a positive motivation is to be instilled within the patient.
The hospital must consult with external agencies for ensuring that the care process for Zaynab is comprehensive. Planned contact with community agencies such as social support group would provide the required care. Inter-agency work would also focus on consultation with a visiting care worker. When involved in the care process, the care can be piecemeal, and no particular care professional would bear the responsibility of keeping track of the psychological help required that impinges the treatment provided by the primary burn team (Shah and Liao 2017).
Legal and ethical issues
The provision of appropriate, accessible and equitable care for a burn injury care is to be governed by ethical and legal principles. As per the NHS legislation, informed consent is mandatory prior to treatment and as per the Gillick Competent, children under the age of 16 can provide consent to their own treatment is they have enough competence and intelligence and understands the implications of the treatment provided. In other cases, the parents are required to provide the consent (NHS 2017).
As Zaynab is a five year old patient, the child is not eligible for signing the consent form. However, it is noted that the child’s biological father is not present and her mother is also detached from her care process. As per the NHS legislation, the person with parental responsibility must be having the capacity for giving consent. In case the parent refuses to agree to a certain treatment, the decision can be overruled since the treatment is to the best interest of the patient.
In case of Zaynab, consent cannot be taken from his step-father as he is not the biological father of the child. In this condition, the most obvious step would be to convince Zaynab’s mother regarding the necessity of treatment and the risk to her life if treatment is delayed.
As suggested by the RCPCH (2010) the healthcare professionals are required to demonstrate competency in child safeguarding and protection. This would include identification of maltreatment and abuse. In the present case, Zaynab is reported to have suffered deep scratches on the lower torso and bruising on the inner aspect of her upper thigh, which is indicative of abuse.
The initial action would be to fist inform Zaynab’s parents about the injury and confirm signs of sexual abuse by means of appropriate clinical test and examination. Then after obtaining permission from the child’s mother, the case is to be reported to National Society for the Prevention of Cruelty to Children for taking appropriate actions for safeguarding the child.
Maintaining the privacy of the patient and confidentiality of information are the ethical implications for practice. Patient information is to be shared with relevant individuals who have direct involvement in the care process of the patient. Further, guidelines for surgical care and anaesthetic care are to be abided by the professionals (Runciman, Merry and Walton 2014).
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