Video Case Study - Caring for Pediatric Patients With Burn Injuries

Nurse Lawrence works in a pediatric rehabilitation facility and is caring for Abigail, a 2-year-old who was admitted to the facility from a burn unit after being treated for an accidental scalding injury that resulted in partial- and full-thickness burns.

In collaboration with the registered nurse, RN Miley, Nurse Lawrence goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Abigail’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Lawrence recognizes important cues, including Abigail’s vital signs, which are temperature 98.6 F or 37 C, heart rate 88 beats per minute, respirations 18 breaths per minute, blood pressure 96/52 mmHg, and oxygen saturation 100 percent on room air.

Next, Nurse Lawrence uses the Face, Legs, Activity, Cry, and Consolability, or FLACC scale, and determines Abigail’s pain rating is 5 out of 10 according to her behavioral cues.

Next, Nurse Lawrence analyzes these cues. He reviews the electronic health record, or EHR, with RN Miley, and they note an order for sterile dressing changes, and that Abigail is prescribed a topical antimicrobial to be applied to her burns.

They also see that she’s been prescribed medication for pain management and that she received her last dose four hours ago.

Nurse Lawrence recalls that a scald is a type of thermal burn caused by hot liquids or steam, and he knows that toddlers, like Abigail, are at high risk for these types of burns as they start to become more mobile and explore their environment.

He recalls that partial-thickness burns involve the epidermis and part of the dermis layers of the skin, and that full-thickness burns involve both the epidermis and the entire dermis.

This destroys the network of immune cells that reside in the epidermis and the physical barrier the skin provides against microorganisms.

He further understands that the risk of infection is increased because the wound exudate is easily colonized by bacteria and the vascular supply to the burned tissue is impaired.

Nurse Lawrence realizes that Abigail needs management of her burn injuries to promote skin integrity and prevent infection.

Now, using the information they've gathered, Nurse Lawrence and RN Miley choose a priority hypothesis of impaired skin integrity.

Then, together they generate solutions to address Abigail’s impaired skin integrity that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Abigail’s burns will show no signs of infection at the end of the shift.

Nurse Lawrence then takes action to implement these solutions. He knows it’s been four hours since Abigail’s last dose of pain medication and her dressings will need to be changed soon.

He also knows that providing pain medication prior to dressing changes makes it easier to tolerate the procedure, so he prepares the dose of the pain medication and re-enters Abigail’s room.

Then, he proceeds to administer the pain medication using safe medication administration principles. One hour later, Nurse Lawrence and RN Miley return to Abigail’s room.

RN Miley assesses Abigail’s pain level to be 1 out of 10 according to the FLACC scale; and Nurse Lawrence puts on Abigail’s favorite music to provide distraction before they remove the soiled dressings.

Together, they look closely at each wound and note partial- and full-thickness burns distributed in a spatter pattern on Abigail’s right shoulder, arm, torso and thigh (IMG 5-6) that are in various stages of healing.

Next, they check the wounds for changes that could indicate infection, and they note that there’s no increased drainage, foul odor, wound discoloration, or increased thickness of the wounds.

Then, Nurse Lawerence and RN Miley gently cleanse her wounds using strict aseptic technique, apply the prescribed antimicrobial to the sterile dressings, and apply the dressings to her wounds.

Lastly, Nurse Lawrence sits with Abigail and helps her to choose high-protein food and snacks from the menu to promote wound healing.

At the end of the shift, Nurse Lawrence evaluates the outcomes of his actions. He takes Abigail’s vital signs, which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respiratory rate 20 breaths per minute, blood pressure 94/50 mmHg, and pain level is a 0 out of 10 using the FLACC scale.

He checks Abigail’s dressings and notes that no increased drainage or foul odor are present. Alright, as a quick recap… Nurse Lawrence recognized and analyzed cues related to Abigail’s impaired skin integrity, and in collaboration with RN Miley, prioritized hypotheses and generated solutions to address this problem.

Nurse Lawrence and RN Miley then implemented pharmacologic and nonpharmacologic measures and evaluated Abigail's outcomes and compared them to the expected outcome.

Since Abigail’s burns showed no signs of infection at the end of the shift, they determined the plan of care was successful.