Non-Modifiable Factors: Male Elderly :

Children )

EXTENSIVE BURNS
Energy transfer from a heat source to the body Results to

Modifiable Factors: Thermal (Residential Burns) Electrical Burns (Contact with Faulty Electrical Wirings) Chemicals (Contact, Ingestion) Radioactive( Sunburn)

Facial burn, mucosal burn, voice changes, rapid breathing, panting

Loss of skin barrier Wound Grafting Superficial partial thickness Deep partial thickness Full thickness

Inhalation of superheated air & noxious gas

Upper airway injury (Inhalation greater than 150C of direct heat)

Severe upper airway edema

Involves the epidermis

Involves the epidermis & upper portion of dermis

Involves all layers of the skin

Inhalation below the glottis

Inhalation of carbon monoxide

Dilation of adjacent intact vessels

Destruction of underlying tissue Platelets & electrolytes adhere in the endothelium

Redness

Pain that last up to 48 hrs.

Inflammation

Capillary permeability

Tissues & RBC death

Perfusion to injured area

Nerve endings damaged

Muscle damage Abnormal Inflammatory response Inability to prevent water loss

CBC Edema Painless Myoglobin is release

Fluid localize to the burn site

Fluids & protein moves from vascular to interstitial spaces

Blood concentrates & hematocrit rises

Temperature

Blister formation

Sluggish blood flow Vascular volume GFR Body compensates Renal Blood flow Urinalysis

Pressure on small blood vessels & nerves

Excreted by the kidney

Neutrophils, immunoglobulins, lymphocytes

Hypothermia r/t loss of skin microcirculation & open wound

BP

CO

Continuous fluid loss

Anemia Dark urine

Immunosuppression

Risk for sepsis Debridement

IV Fluid replacement Withdrawal of fluid from undamaged extracellular spaces Constriction of vessels Oliguria Infection

thirst

Urinary indwelling catheter

Pulse rate

O2 delivery

LEGEND:
Fluid volume deficit r/t permeability & evaporative losses from the burn wound GI Complications

Pathophysiology

Medical Management

Absence of intestinal peristalsis (Paralytic ileus)

Cell necrosis of gastric mucosa

Signs & Symptoms Surgical Management Diagnostic Test

Gastric distention

Gastric bleeding

Nausea & Vomiting Bloody Vomitus

Complications
Black/ Coffee ground stool

Nursing Diagnosis