Description
Characteristics of BurnThe depth of a burn injury depends on the type of injury, causative agent, temperature of the burn agent, duration of contact with the agent, and the skin thickness. Burns are classified according to the depth of tissue destruction: Show
Extent of Body Surface Area BurnedHow much total body surface area is burned is determined by one of the following methods:
CausesMost burns result from preventable accidents. Thermal burns, which are the most common type,occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries. Gender, Ethnic/Racial, and Life Span ConsiderationsPreschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart (Lund-Browder Chart) for children that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and in particular, young adult males ages 20 to 29 years of age, followed by children under 9 years of age. Individuals older than 50 years sustain the fewest number of serious burn injuries. The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of
flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of Most adults are victims of house fires or workrelated accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat. Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child Burns 167 experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. No specific gender and ethnic/racial considerations exist in burns. Gerontologic Considerations
Primary Nursing DiagnosisIneffective airway clearance related to airway edema OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level Medical ManagementMINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection. MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special
training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition.Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine ormafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze. The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered, through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place. Nursing Management: Emergent/Resuscitative PhaseAssessment
Promoting Gas Exchange and Airway Clearance
Restoring Fluid and Electrolyte Balance
Maintaining Normal Body Temperature
Minimizing Pain and Anxiety
Monitoring and Managing Potential Complications
Nursing Management: Acute/ Intermediate PhaseThe acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage. Assessment
Restoring Normal Fluid Balance
Preventing Infection
Monitor culture results and white blood cell counts.
Maintaining Adequate Nutrition
Promoting Skin Integrity
Relieving Pain and Discomfort
Encourage patient to use analgesic medications before painful procedures.
Promoting Physical Mobility
Strengthening Coping Strategies
Supporting Patient and Family Processes
Monitoring and Managing Potential Complications
Nursing Process: Rehabilitation PhaseRehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important. Assessment
Nursing Diagnoses
Collaborative Problems/Potential Complications
Promoting Activity Tolerance
Improving Body Image and Self-Concept
Monitoring and Managing Potential Complications
Teaching Self-care
EvaluationExpected Patient Outcomes
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Nursing DiagnosisImpaired Physical MobilityMay be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Nursing DiagnosisKnowledge DeficitMay be related to
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Nursing DiagnosisDisturbed Body ImageMay be related to
Possibly evidenced by
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Nursing DiagnosisFear/AnxietyMay be related to
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Nursing DiagnosisImpaired Skin IntegrityMay be related to
Possibly evidenced by
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Maintain wound covering as indicated
Prepare for/assist with surgical grafting or biological dressings:
Nursing DiagnosisImbalanced NutritionMay be related to
Possibly evidenced by
Desired Outcomes
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Nursing DiagnosisIneffective Tissue PerfusionRisk factors may include
Desired Outcomes
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Nursing DiagnosisAcute PainMay be related to
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Desired Outcomes
Nursing Interventions
Nursing DiagnosisRisk for InfectionRisk factors may include
Desired Outcomes
Nursing Interventions
Which burn injuries are brought to the emergency department (ED)?A patient is brought to the emergency department with the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines.
Which drug is prescribed for a client with a burn injury?Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse? A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect?
Does the location of an electrical burn determine its severity?Rationale: The severity of electrical burns depends on the type and duration of the current and amount of voltage. Location is not important in determining possible severity. Location is not important in determining possible severity. A nurse sees a patient get struck by lightning during a thunder storm on a golf course.
When does systemic response occur to a burn injury?• Systemic response occurs once a burn is greater than 30% of total body surface area • Different burn mechanisms lead to different injury patterns • Identification of non-accidental burn injury is important
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