Perioperative Care Of A Five-Year-Old Burn Victim: Evidence-Based Essay.

A five year old girl, Zaynab, is brought to theatre from the Emergency Department for a second degree scalding burns (5% body surface area) on upper arms and chest. Her mother and her stepfather accompany her and the stepfather reports that Zaynab has spilled her body with a hot soup while playing close to the dining table during their lunch. The child’s mother seems withdrawn in the anaesthetic room and does not offer the child much comfort when she starts to cry. You have noticed also some deep scratches on Zaynab’s lower torso and bruising on the inner aspect of her upper thigh, but she is otherwise healthy.

With reference to current research and evidence based guidelines, discuss Zaynab’s likely perioperative care in relation to:

• From a Surgical or Anaesthetic or Recovery perspectives discuss the treatment of burns injury in children and young people (30%)
• The psychosocial care of children and young people in hospital, including their safe transfer to the care of others (40%)
• Legal and ethical issues

The treatment of traumatic injury in children

Should include: maintenance of airway and homeostasis (fluid balance, temperature etc), pain management, timing of surgical intervention, guidance from Royal Colleges and specific reference to the case study.

Legal and ethical issues:

Should include legal discussion of consent, parental responsibilities and rights, dealing with suspected abuse etc. and ethical obligations of the practitioner

Operating department practitioner (ODP) perspectives

Burn is an injury mainly caused by thermal energy. Scald is a burn caused by contact with hot liquid or steam. Few burns can be managed by simple management; however, few of the burns require complex treatment comprising of surgeon, STP, ODP and anaesthetic. In UK hospitals burn admission rate is 0.29 per 1,000. In UK approximately 250,000 people get admitted to hospitals and approximately 300 burn related deaths occur (Cleland, 2012; Kemp et al., 2014). In this essay, perspective of different professionals like ODP, STP and anaesthetic in management of burn is discussed. Psychological and legal aspects in care are also discussed.

Due to burn injury, Zaynab might be experiencing fluid replacement. It might have resulted in cardiovascular instability and respiratory insufficiency in her. For the speedy recovery of Zaynab, early excision of dead or necrotic tissue is required. It would be helpful in the reducing chances of wound colonization and systemic sepsis (Ong et l., 2006).

ODP and doctors need to assess amount of blood loos prior to surgery. Based on the assessment of blood loss, surgeon and surgical theatre practitioner (STP) can plan suitable vascular accessibility, invasive monitoring and can request for suitable blood products. Surgeon and STP need to access history of Zaynab and perform physical examination to evaluate additional requirements during surgery. Physical evaluation would be helpful in evaluating degree of burn injury, respiratory tract evaluation, existence of inhalation injury resuscitation, vascular disturbance, existing resuscitation aids and Zaynab’s response to it and tolerance to enteral feeding (Yeung et al., 2013). Prior to surgery, surgeon and ODP need to manage vascular disturbance by reducing edema and bloodstream infection. ODP need to maintain temperature and the humidity of theatre room for paediatric patient specifically to prevent a hypothermic and fluid loose. It can be helpful in maintaining homeostasis. Edema can be reduced by pressing on the swollen area hence accumulated fluid can be taken out (Allorto et al., 2016). Bloodstream infection can be prevented by administrating suitable antibiotic. Surgeon, STP and ODP need to identify whether intravenous route can be used to insert catheter in Zaynab. Surgeon, STP and ODP need to identify whether peripheral or central catheter can be used in Zaynab. Moreover, the urinary catheter is very crucial to monitor the fluid outcome of the in burn paediatric patient. In addition, ODP should prepare all surgical instruments for burn patients such as dermatome and special equipment as well as the special dressing. ODP and STP need to assess this preoperative assessment which cab be helpful in reducing complications during surgery procedure. Dexmedetomidine can be used because it can induce sedation and analgesia, however it would not produce respiratory depression (Rode and Heimbach, 2013).

Recovery perspective

There can be occurrence of respiratory insufficiency in Zaynab due to higher metabolic state and increased production of carbon dioxide (Buckley et al., 2011). Hence, it is necessary to maintain homeostasis. Respiratory insufficiency can be effectively managed by using Laryngeal mask airways in Zaynab (McCall et al., 1999). These masks proved successful in numerous patients with burn. These masks can be useful in improving oxygen saturation in Zaynab. During intrahospital transportation of Zaynab having mechanical ventilation, minimum of two anaesthesia personnel need to be present there (Mackie et al., 2009). There can be agitation in Zaynab during intrahospital transportation. Hence, anaesthesia, analgesia and muscle relaxant need to be given to Zaynab. There might be delayed or no gastric emptying in Zaynab due to infection, sepsis, opioid consumption and intestinal edema. Methylnaltrexone can be used to improve gastric emptying in Zaynab. It is evident that burn related pain is undertreated in case of burn patients. However, pain need to be managed effectively in burn patients because it can affect speedy recovery of Zaynab. Untreated pain lead to depression and anxiety in Zaynab. Pain due to burn might be mostly of neuropathic pain nature. It is evident that neuropathic pain is opioid resistant. Hence, other pain-relieving drugs need to be administered for Zaynab prior to surgery (Crellin et al., 2015; Alharbi et al, 2012). There should be prior administration of sedative and anxiolytic agents because these agents can reduce pain and fever due to burn. Premedication can also be useful in the relieving physiological and psychological adverse effects in Zaynab. There might be more fluid loss due to burn which can disturb homeostasis. Hence, Zaynab should be administered with fluid through nasojejunal tube approximately two hours prior to surgery (Klein et al., 2007). Wounds due to burn need to be treated with either short or long acting topical antiseptic agents (Coetzee et al., 2012).

Anaesthetic perspective: Anaesthetic drug should be selected for Zaynab based on her hemodynamic and pulmonary status. Due to change in the haemodynamic characters in Zaynab, there can be alteration in the pharmacodynamic and pharmacokinetic characters of anaesthetic drugs. Due to change in the pulmonary status, volatile anaesthetics cannot be used in burn patients like Zaynab. Hence, ODP and STP need to select admixture of intravenous and inhaled anaesthesia in Zaynab. Myoglobinuria and hypovolemia can be developed in patients with burn. These patients can be at risk of renal injury due to use of anaesthesia like sevoflurane use with a CO2 absorbent. In burn patients, there can be greater volume of distribution, hence there would be more volume requirement of anaesthetic agent through intravenous route (Bittner et al., 2015). ODP and STP should assist in preparing sedation plan which comprises of spontaneous ventilation and minimal depression in respiration, until patient is ready for receiving intravenous anaesthesia. As a result, respiratory tract functioning can be maintained normally. Routine anaesthesia monitoring is necessary because there might be blood loss during surgical procedure. Maintenance of anaesthesia can be achieved through isoflurane or ketamine (Fuzaylov and Fidkowski, 2009).

Anaesthetic perspective

Psychological intervention need to be carried out in burn patients to improve their body image and self-esteem and reduce depression and anxiety. Social comfort also need to be provided for these patients. Patients need to be rehabilitated in such a way that their return to society should be with minimal physical changes and with normal abilities and functioning (Kilburn and Dheansa, 2014). Psychological intervention is required for both patient and their family members because family members also might be mentally disturbed due to burn scars on the patient. While providing psychological intervention, needs of the patient and family members need to be considered. Emotional and behavioural stability need to be given to the patients and their family members because improved emotional and behavioural stability can be helpful in the reducing depression and anxiety and improving adherence to the treatment (Bakker et al (2013)). Most of the burn patients might not wish to adhere to treatment because of loss of hope for recovery. In such cases, psychological counselling is necessary. Psychological problems in the burn patient and their family members can have long term effect. Hence, continuous psychological intervention is required for these patients. Psychological intervention to the burn patients need to be provided based on the developmental stage of the patient. Since, Zaynab is five years old, different growth and development theories relevant to her age should be considered while providing psychological intervention to her. These theories include psychoanalytic theories, learning theories and cognitive development theories. Children of Zaynab start distinguishing themselves from other children, hence appropriate psychological theory need to be implemented to psychological intervention (Neaum, 2013).

There is high possibility of development of stigma related to shame and abuse in the burn children. Hence, psychological counselling need to be given to the children and their parents to eliminate this stigma. Rimmer et al., (2014) demonstrated that children with burn injury exhibited separation anxiety and approximately 28 % children exhibited school avoidance. These characters in the children can be managed by integrated intervention through psychologist, social workers and school teachers. Anxiety can be develop in patients with burn due to far of abuse. Psychiatrist should assess the level of anxiety in the children and should recognize physical symptoms related to the anxiety. Anxiety can be of different levels like mild, moderate, severe and panic. Assessment of anxiety at the earlier stage can be helpful in planning appropriate intervention (Karaçetin et al., 2014; De Sousa, 2012). Making children to express their anxiety can be helpful to provide relevant counselling. However, in most of the children psychiatrist can’t expect to get anxiety expression from the children (McGarry et al., 2014). Hence, it is necessary to recognize physical symptoms for anxiety in children to provide relevant intervention. Depression is associated with anxiety due to injury and there is positive correlation between the depression and social avoidance (NHS, 2016).  Low self-esteem can be evident in the children with burn injury and this self-esteem is related to depression, hopelessness and feeling of scholastic incompetence. Hence, parents of Zaynab need to be provided with counselling for self-esteem, dignity and depression. However, medication for depression and anxiety should be avoided in children due to its long lasting side effects. Aggressive recreational therapy need to be implemented in Zaynab at acute stage of depression and anxiety to avoid long term consequences.

Psychological intervention

Point of ODP need to exhibit support to Zaynab because due to procedures like isolation techniques, occlusive dressings and immobilization patient might feel isolated. In case of Zaynab also, she might be feeling isolated because she didn’t receive comfort from her mother. Play therapy in the form of non-verbal support can be used for the children. Distraction therapy need to be implemented in children of Zaynab age (Brown et al.,2014). Co-operation of child in performing painful and difficult procedures can be effectively improved by using distraction therapy. Different types of distraction therapies are available. It is highly impossible that each distraction therapy can produce positive effect on every child. Hence, suitability of distraction therapy need to be assessed before application of therapy (Koller and Goldman, 2012).

Different professionals like doctors, ODPs, nurses, pharmacist, psychiatrist, social worker and occupational therapist need to be incorporated for the safe care on children to the society. However, there were a burse on Zaynab groin which might she exposed a sexual harassment. In this situation ODP should write a report if there is any (HCPC, 2014). Children should be mentally and physically fit to go to the society. Family members of the children need to be incorporated in the decision making for the transfer of the children to the other facility or the society. Needs and requirements of the children and their family members required to be considered during transfer process. Arrangements should be made for the children to take treatment form the outside agencies. Appointments for the future visits to the hospitals should be fixed so that children should not wait in the long que along with other patients (Apkon and Friedman, 2014; Gray et al., 2016).

Legal and ethical issues:

Consent is the integral part of the medical practice and it is necessary to fulfil the requirements of the law. Barrier for providing nursing intervention for the children can be eliminated by taking consent form the parents (Woolley, 2011). Gillick devised rules for taking consent while providing nursing intervention to the children. The United Nations Convention of Children’s Rights defined child, those who are under age of 18. Childhood is considered as the developmental stage and domestic laws for the children need to be followed according to their developmental stage. With respect to their developmental stage, views and wishes of the children in accessing medical intervention need to be considered. Gillick competent child defined that consent need to be taken for the child below age 16 years. However, these children need to be mature and intelligent enough to understand risk and benefits of the medical examination and treatment. Decision making competence of children should not be solely based on the puberty, however intelligence and maturity need to be considered while considering children’s decision. However, in children competence to consent need to be decided based on the severity of the health condition. Nurses need to be competent enough to assess the child’s Gillick competence so that children’s rights are respected. According to district and midwifery council (NMC), nurses are accountable for taking consent while providing care to the children (Griffith and Tengnah, 2012).

Nurse need to give respect to the child patient as an individual, obtain consent prior to providing treatment, protect and preserve confidential information, work in collaboration with other team members, preserve professional knowledge and competence, be reliable and responsible and need to identify and minimize risks to the child patients. In case of burn patients, it is not ethical to display photographs of burn patients in the public domain without taking consent from the patient or family members (Runciman, 2017). Nurses need to follow standards mentioned in the Nursing and Midwifery Council contained in the Code: Standards of conduct, performance and ethics for nurses and midwives. The Health and Social Care Act 2008; Regulations 2010 (regulation 18) stated that district nurse need to identify person who can take parental responsivity. This parental responsivity person need to take consent related to medical examination and treatment on behalf of children. According to Children Act, 1989, Section 4A; step parent also can take responsibility of consent for medical intervention. In case of Zaynab also her step parent can take responsibility of consent for medical intervention (Griffith, 2013).

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