Question | Answer |
Major Burn Injuries | Greater than 25% TBSA
Exception: Children under 10, adults over 40 = greater than 20%
Greater than 10% TBSA full thickness
Involve face, eyes, ears, hands, feet, perenium
Electrical burns
inhalation injury or major trauma
preexisting disease |
Moderate Burn Injuries | 15%-25% TBSA partial thickness
Exception: Children under 10, adults over 40 = 10%-20%
Less than 10% TBSA, full thickness
Burns with no concurrent injury
Burns in patients with no preexisting disease |
Minor Burn Injuries | Less than 15% TBSA
Exception: less than 10%
Less than 2% TBSA, full thickness
burns in patients with no preexisting disease |
Medical Management of Burn Phases | 1. Emergent - stop the burning process, NO ICE, rinse all chemicals off skin
2. Provide open airway -
3. Control bleeding
4. remove nonadherent clothing and jewelry
5. Cover victim with clean cloth or sheet
6. Transport to hospital |
Electrical burns result in... | cardiac arrest, requiring CPR or cardiac monitoring |
Primary priority in ALL BURNS | OPEN AIRWAY |
S/S of inhalation injury | singed facial hair, black-tinged sputum, soot in throat, hoarseness, neck or face burns. STRIDOR is LIFE THREATENING |
During Emergent Phase, patient should be monitored | q 30min to 1 hr |
Moderate to Severe burns treated with | 1. est airway& admin O2
2. Ringer's lactate. Amt dep %age of TBSA Weigh pt to ind fluid loss.
3. Foley Cath nn 30-50mL/h Out
4. NG prevent aspiration
5. Analgesics
6. maintain airway, fluids, monitor vitals
7. tetanus shot unless w/in 5 years ago |
Primary goals of Emergent Phase burn treatment (hrs 1-72 post burn) | Maintain respiratory integrity
prevent hypovolemic shock (which can lead to death) |
Acute Phase (72h after burn)
can last 10 days to several months | MAIN PURPOSE - Treat wound; prevent and manage complications
metabolism increases
fluid shifts back into circulation, therefore output increases and edema decreases |
complications of burns | infection - #1 cause of death after first 72 hours
heart failure, renal failure, contractures, paralytic ileus, Curling's ulcer - first sign usually vomiting bright red blood |
Burn Care Nursing Interventions | ***Prioritize airway, breathing, circulation
1. respiratory pattern
2. vital signs
3. circulation
4. intake & output
5. ambulation
6. bowel sounds
7. inspection of wounds
8. mental status |
assessment for infection | increasing erythema, odor, green or yellow exudate |
Monitor closely during acute phase | elevated creatine, BUN, electrolyte levels, serum potassium levels may rise sharply, DAILY NUTRITIONAL STATUS - increase protein, vitamins, calories, SKIN GRAFTS REQUIRE ADEQUATE NUTRITION |