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14 Cards in this Set

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Categories of burns





Tissue destruction results from:


Protein denaturation

Ionization of cellular contents

Critical systems affected include







Characteristics of 1st degree burn

-superficial partial thickness (sunburn)

- Leaves skin pink or red

- dry


-slight edema

Characteristics of second degree burn

-deep partial- thickness destruction of epidermis and upper layers of dermis

- painful (sensitive to touch and cold air)

-Appear read or white, weeps fluid, blisters present

-Hair follicles intact (hair does not pull out easily)

-Very edematous

-blanching followed by capillary refill

-heals without surgical intervention

-usually does not scar

Characteristics of third degree burns

-Full-thickness; involves total destruction of dermis and epidermis

- skin can not regenerate

- requires skin grafting

- Underlying tissues (fat, fascia, tendon, bone) may be involved.

- Wound appears dry and leathery as eschatology develops

- painless

How to determine severity

Determined by extent of surface area burned

Rule of nines (for adults):

-head and neck 9%

-upper extremities 9% each

-lower extremities 18% each

-front trunk 18%

-back trunk 18%

- perineal area 1%

Lund and Browder chart

Stages of burn care

Stage 1: Emergent

-Begins at time of injury

-Concludes with the restoration of capillary permeability

-typically reverses 48-72 hours following the injury

-characterized by fluid shift from intravascular to interstitial and shock

-focus of care is to preserve vital organ functioning

Stage 2: Acute

- Occurs from beginning of diuresis to near completion of wound closure

- Is characterized by fluid shift from interstitial to intravascular

Stage 3: Rehabilitation

- Occurs from major wound closure to return to optimal level of physical and psychological adjustment (approx 5 years)

- Is characterized by grafting and rehabilitation specific to client needs

3 stages

Signs of inhalation burns

- Singed nasal hairs

- Circumoral Burns

- Conjunctivitis

- Sooty or bloody sputum

- Hoarseness

- Asymmetry of check movements with respiration’s and use of accessory muscles indicative of pneumonia

- Rales, wheezing, and ronchi denoting smoke inhalation

Signs of inadequate hydration


- disorientation

- decreased urinary volume and urinary sodium

- increased urinary specific gravity

Topical antimicrobial agents


- Usually uses with open method of wound care

- Painful; Causes mild acidosis

- Penetrates wound rapidly

Silver sulfadiazine (Silvadene)

- Usually used with open method of wound care

- Used to avoid acid-base complications

- Keeps eschar soft, making debridement easier

-penetrates wounds slowly

Nitrofurazone (Furacin)

- Used to prevent infections

-Interferes with bacterial enzymes

- Allergic contact dermatitis

- May see superinfections

-Monitor for signs of infection

Nursing plans and interventions for the Emergent phase

Efforts directed toward stabilization with ongoing assessment

Assist with admission care

-Extinguish source of burn

~Thermal: remove clothes

Immerse burn in tepid water

Apply sterile dressing

~Chemical: flush with water or

Normal saline

~Electrical: separate client

from electrical source

-Provide an open airway; intubation May be necessary if laryngeal edema is a risk

-Determine baseline data: vital signs, blood gases, weight

-Administer tetanus toxoid

-Initiate fluid & electrolytes: lactated ringer’s

-Insert NG tube to prevent vomiting, abdominal distention, and gastric aspiration

-Administer IV pain medication as prescribed

Monitor hydration status

-record urinary output hourly (normal range 30-100ml/hr)

-maintain IV fluids titrated to keep urine output WNL

- Accurately record I&O

- Weigh daily

- Observe for signs of inadequate hydration

Monitor respiratory functioning

- provide respiratory functioning

- Suction ET or nasotracheal tube

- Monitor ABGs

-Observe for cyanosis, disorientation

- Administer O2

- Encourage use of incentive spirometer, coughing, and deep breathing

Provide wound care

- Use strict aseptic technique

- Perform debridement and dressing changes according to client condition

- change dressings in minimum time; premeditate client, maintain sterile technique

-maintain room temp above 90*F humidified & free of drafts

- Monitor body temperature frequently; have hyperthermia blankets available

Assess for paralytic lieus

- absence of bowel sounds

- nausea and vomiting

- abdominal distention

Assist with management of pain

- Administer analgesics IV

- Teach distraction and relaxation techniques

- Teach use of guided imagery

Assess for circulation compromise in burns that constrict body parts. Prepare client for escharotomy

Nursing plans and interventions for the acute phase

Characterized by fluid shift from interstitial to intravascular (diuresis begins)

Provide infection control

-Maintain protective isolation of entire burn unit

- Cover hair at all times

- Wear masks during dressing changes

- Use sterile technique for hydrotherapy, dressing changes, and debridement

- Administer IV antibiotics if indicated

- live plants and flowers prohibited

Splint and position client to prevent contractures

-avoid use of pillows in cases of neck burns

Perform ROM exercises (painful)

-Administer pain meds immediately prior to performing ROM exercises

- Perform active ROM exercises for 3-5 minutes frequently during day

-mobilize active ROM exercises when up and about

Provide fluid therapy (May use colloids to keep fluid in vascular space)

- Monitor serum chemistries at all times

- Keep and IV site available; a saline lock is helpful

- Maintain Strict I&O

- Encourage oral intake of fluids

Provide adequate nutrition

- Provide high-calorie (up to 5000/day,) high-protein, High-carbohydrate diet

- Give nutritional supplements via NG feeding at night of calorie intake is inadequate

- Keep accurate calorie counts

- Administer all medications with milk or juice

- May require TPN

- weigh daily

Provide burn and wound care

- Cleansing per agency routine (daily or up to 3x/day) in hydrotherapy or shower

- Wet to dry dressing changes two to three times a day to remove necrotic tissue and debris

- Apply silver sulfadiazine (Silvadene) or mafenide acetate (Sulfamylon) to burn as prescribed

-cover (closed method) or leave open (open method,) according to agency policy or physician’s prescription

- Prepare client for grafting when eschar has been removed

- Prepare client for autografts (use of client’s own skin for grafting.)

- Use heat lamp to donor site following graft to allow the area to reepithelialize.

Nursing plan and interventions for the rehabilitation phase

Characterized by the absence of infection risk

Ongoing discharge plan occurs

Client may return home when the danger of infection has been eliminated

High-protein fluids with vitamin supplements are recommended

Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scarring and contractures