BURNS

By Victoria S. Brioso-Ang

Directions: Do reading assignments and

complete powerpoint slides
 The Skin
• Identify the 3 layers of the skin

a)

b)

c)
 The Skin
• Identify the specific areas and functions:

a)
b)
c)
d)
e)

f)
 The Skin
• Identify the functions of the skin as they
pertain to the pictures:
Causes of Burns
 Extent of Damage Depends on:
• T____

D________

S____ – most v___________ areas:

Classification of Burns
Classification of Burns
 Superficial Burn

• Example?
• Tissue layer damaged?
• Blister?
• Pain?
Partial Thickness : Superficial vs Deep

• Example?
• Tissue layer damaged?
• Blister?
• Pain?
 Full Thickness

Example?
Tissue layer damaged?
Blister?
Pain?
Classification of Burns

First degree burn

Partial-thickness

Second degree burn

Superficial & Deep
Partial-thickness

Third degree burn

Full-thickness
Risk for Death from Burns
 Phase 1: E_______/R__________
• Begins:
• Ends:
• Focus:
• What’s happening?
•Fld status?
•Urine output?
•Serum Protein?
•Type of shock?
•Serum Potassium?
•Serum Sodium?
•Respiratory system?
•ABG result? Protein Sodium
 Phase 2: Acute Stage
• Begins:
• Ends:
• Focus:
• What’s happening?
•Capillary permeability?

•Blood volume?

•Renal function?
 Phase 3: Rehabilitative
• Begins:
• Ends:
• Focus:

Wound h________
Increase s________

Emotional s________ Increase f________

Minimize d_________
Burn: Fluid Status
Other Labs:
 Priority: Airway Injury
• Why? Can progress to rapid o_________ in a
s______ time
• Symptoms: progressive h__________, brassy
c______, difficulty s________, drooling, audible
w________, d________, c________, s________
• Damage can occur from t_______ heat injuries or
c________ inhalation
• C_______ m________ poisoning is the l_______
cause of d________ associated with fires
 Carbon Monoxide Poisoning
• Released during c___________ in a fire
• I_________ causing CO poisoning
• C_________, o_________, t_________
• Attraction for hemoglobin 200 times greater than
o_________
• Leads to t_______ hypoxia

Physiologic
Effects of CO Poisoning

Iggy, 6th ed, p 530,

Table 28-4
 Nursing Care: Respiratory
Assessment Nursing Diagnosis Nursing Interventions
Airway patency
(face burns?) Ensure patency
Ineffective (intubation,
Mouth, nose, Breathing tracheostomy)
pharynx Pattern
(singed hair?)
HOB at least 45
degrees,
Oxygen status Humidified
oxygen

Breath sounds Encourage

cough,
deep breathe,
ICS use
 Nursing Care: Cardiovascular
Assessment Nursing Diagnoses Nursing Interventions

Decreased CO
VS, HM, Adm fluids,
heart rhythm, osmotic diuretics,
pulses inotropic agents

Fluid status
Begin IV fluid and
Deficient fluid electrolyte
volume replacement
Circulatory status

Ineffective
peripheral Elevate extremities
Capillary refill
tissue
perfusion
 Nursing Care: Skin
Assessment Nursing Diagnoses Nursing Interventions

Impaired Skin Warm room,

Head to toe
Integrity Cover w/
blankets
Size of burns Risk for Wound care
(TBSA) Ineffective and dressing
Thermoreg changes

Depth of burns Prevent

infection

Infection Administer
Risk for tetanus
Infection prophylaxis
Rule of Nines
An adult client was burned as a result of
an explosion. The burn initially affected
the client’s entire face, and the upper
half of the anterior torso, and there were
circumferential burns to the lower half of
both of the arms. The client’s clothes caught
on fire and the client ran, causing subsequent
burn injuries to the posterior surface of the
head and the upper half of the torso. Using
the rule of nines, what would be the extent
of the burn injury?
 Priority: Risk for Infection
Identify nursing interventions depicted by pictures:

IV
Ab
 Nursing Care: Gastrointestinal
Assessment Nursing Diagnosis Nursing Interventions

Bowel sounds Keep NPO

Imbalanced
Nutrition:
Nausea, vomiting, < body req
abd distention Administer H2-
antagonists

Stool for evidence of

bleeding
Adm nutrition
support as ordered
Emesis for evidence
of bleeding
 Nursing Care: Other “Systems”

Assessment Nursing Diagnoses Nursing Interventions

Acute Pain Encourage ROM

Urine output, BUN, Chronic Pain
Creatinine

Adm pain med prn

Specific gravity
Collaborative care
Pain Support groups
Disturbed
Body Image
Management

*bedside *yes sedation

*no anesthesia *yes analgesia

*operating room
*general anesthesia
 Eschar
What is an eschar?

What happens when the eschar from a burn

is circumferential…or in the chest area?
Therapeutic Procedures
Debridement

Dressings
 Surgical Management
• Escharotomy & Fasciotomy
 Identify nursing care to the graft site:

1.
2.
3.
4.
5.
6.
7.
 Scenario
• A nurse is caring for a client who sustained burns to 35%
of his total body surface area. Of the burns, 20% are full
thickness. The burns are on the client’s arms, face, neck,
and shoulders. The client’s voice seems hoarse and he
develops a brassy cough.
1. What might these clinical findings indicate?

2. What should be the next action taken?

3. Is this an urgent concern?