3. Local response
1. cellular damage and fluid movements - edema
2. fluid leaks into interstitial spaces, fluid lost to air
3. fluid is lost to circulating volume (the "oliguric" phase)
4. burn damages tissue
4. Multi-systemic response and potential complications
1. cardiovascular: dehydration- "burn shock"
2. pulmonary: respiratory distress, possible post-inhalation injury, ARDS, aspiration pneumonia, pulmonary edema
3. GI: ischemia - decreased bowel sounds, possible ileus, Curling's ulcer
4. GU: decreased fluids, increasing BUN and creatinine
5. metabolic: increased basal metabolic rate, vital signs
6. neuroendocrine: increased ADH and aldosterone
7. CNS: possible encephalopathy, seizures, coma, altered LOC
8. integumentary: burned, infection, scar tissue formation and poor healing
9. anemia: associated with major burns
   
5. Burn injuries differ in children
1. thinner skin, so tissue damage is more severe
2. fluid volume changes faster than cardiovascular system can respond
3. relatively large surface area increases risk for losses of fluid and heat
4. increased risk for dehydration and acidosis due to: diarrhea, insensible fluid loss, and because child's body requires higher proportion of water than adult's
5. immature immune system increases risk of infection
6. long term: scars mature more slowly and keloidsmore severe
6. Findings
1. superficial (first degree) burn: localized pain, dry surface, blanches with pressure, redness, possible blister
2. partial thickness (second degree) burn: open wound, very painful, denuded skin; blistered, moist
3. full thickness (third degree) burn
1. tough, leathery, dull dry, with variable pain (often severe).
2. color: brown/tan/black/red: dependent on severity)
3. may be life threatening; may affect many body systems
4. full thickness (fourth degree) burn
1. wound dull and dry
2. ligaments, tendons, bone may be exposed
   
7. Management: priority is to stop the burning process 
1. superficial: cleanse with solutions, debride loose debris or necrotic tissue, add antimicrobial ointment, and dressing (fine mesh or occlusive), tetanus prophylaxis, mild analgesic
2. care of full thickness burn
1. maintain ABC: airway, breathing, circulation
2. weigh client and provide fluids and electrolytes. Use Parkland formula for burn shock
3. remove constrictive clothing or jewelry.
4. cover the burn: prevent infection, heat loss, and further deterioration
5. provide sufficient nutrition and calories to prevent negative nitrogen balance and meet body demands
6. provide adequate pain control
7. antibiotic therapy
8. tetanus prophylaxis
   
3. care of the child with a burn wound
1. aseptic technique
2. pre-medicate for pain before any dressing change
3. debridement: surgical, enzymatic, hydrotherapy
4. cleanse wounds with mild solutions, then cover with antimicrobial
5. skin grafts (temporary, permanent): allograft and autografts
6. donor site, usually covered with xeroform dressing - (nursing does NOT change this dressing)
7. long term: Jobst pressure stockings and body wraps, support surfaces, range-of-motion activities
8. Concerns in burn cases

c.                  acute: airway status, pain, shock, infection, fluids

d.                 long-term: nutrition, pain control, contractures, wound healing, keloid formation, psychological, body image and self esteem

10. Pediatric Hematology

Blood Components(illustration 1  illustration 2)

1. Erythrocytes
1. Carry oxygen to cells and move carbon dioxide back to lungs.
2. Average life span: 120 days
3. Hemoglobin: the iron component of RBCs
4. Blood typing (illustration)
1. persons with type A can receive type A or type O blood
2. persons with type B can receive type B or type O blood
3. persons with type O can receive only type O blood
2. Leukocytes increase with infections or inflammation:
   
3. Plasma proteins
1. Include albumin and globulins
2. Measuring plasma proteins helps assess nutritional status
4. Platelets
1. Small fragments of cells
2. Life span eight to ten days
3. Essential to blood clotting/coagulation
   

Disorders of Red Blood Cells

5. Sickle cell anemia (SCA) (illustration 1  illustration 2)
1. Etiology: autosomal recessive disease; 1 in 12 African-Americans carries the trait, while 1 in 375 is affected with sickle cell disease
2. Pathophysiology
1. trigger - RBC's shape becomes sickled and clump -
2. generalized microvascular occlusion (vaso-occlusive crisis)
3. Findings
1. result from
1. obstruction caused by sickled RBCs
2. RBC destruction
2. hypoxia
3. organ dysfunction (spleen, liver, kidney) due to ischemia and infarction
4. painful episodes
4. Therapeutic management
1. aims of therapy
1. to prevent sickling phenomenon
2. to trust medical emergency sickle cell crisis
2. hydration
3. oxygen
4. analgesics
5. antibiotics
6. folic acid
7. prophylaxis with penicillin recommended
5. Concern: sickle cell crisis
   
6. B-Thalassemia
1. Definition: inherited blood disorder characterized by deficiencies in rate of production of specific globin chains in hemoglobin
2. Etiology: autosomal recessive disorder, also known as Cooley's anemia
3. Pathophysiology: abnormal, chronic production and destruction of RBC's resulting in insufficient amounts of normal circulating hemoglobin
4. Findings
1. severe anemia, pallor
2. microcytic RBC's
3. impaired growth
4. splenomegaly
5. Management
1. chronic transfusion therapy to maintain hemoglobin of ten gm/dl
2. referral for chelation counseling