Caring for Client with Burns

A 34-year old male is brought to emergency department after being rescued

form
house. By the time the fire and rescue team arrived, he had suffered major
burns and excessive smoke inhalation. He has burns to his anterior chest, face,
neck,
right arm and right leg. The burned area appears white, leathery, with no blister.
These are his vital signs:
Pulse rate: 180 bpm
Blood pressure: 65/40 mmHg
Respiratory rate: 40 breaths/ min
Oxygen saturation: 95%
Two large bore intra venous lines were inserted and fluids were administered
through
each. His vital signs stabilized and he was then transported to the Burn unit
Questions
1. What is a major burn?
Major burn is the serious injury or damage to the skin and other
tissue of our body that underlying on the skin and cover the
surface area
2. What
are the
the major burns

specific
patient?

things to consider in the assessment of

By using the extent of burn or total body surface area (TBSA)

affected by burn
3. How do you assess a burn wound?
-The rule of nine
- Lund and browder charts
4. What is the best classification for this burn in term of depth of burn?
Third degree burn ( full thickness )
5. What is percentage of Total Body Surface Area (TBSA) for this client using rule
of nine?

Anterior chest= 9%
neck=4.5%

Right leg=9%

Face and

Right arm=4.5%
Total=27%
6. Why the blood pressure of the client was so low and his heart rate was so high
upon arrival at the emergency department?
His heart rate was so high because of hypovolemic shock that
occurs to him. His blood or fluid in his body loss that may cause the
heart impossible to pump a sufficient amount of blood to the body. The
heart failure occurs can decrease the cardiac output that cause the
hypotension to the patient
7. Why was it important to immediately administer intravenous fluids to this
client?
-To prevent the burn shock occur
-To maintain circulatory volume as it is important for normal
cardiac output, rebal perfusion and tissue perfusion
-To provide metabolic water for body
8. Using Parkland formula, how much fluid should the client receive for the first 8
hours after burn injury? The client weighs 60kg. (Show your steps of calculation)
Parkland formula
24hr fluid requirement= 4ml X kg X %TBSA burn
24hr fluid requirement= 4ml X 60kg X 27%
=3240 ml
12hr fluid requirement= 3240ml/2
= 1620ml
9. Formulate 2 nursing diagnosis of the client and then develop the nursing care
plan for the client.
-Impaired gas exchange related to smoke inhalation as evidence by patient heart
rate increase up to 40 breaths per minute
-Fluid volume deficit related to increase capillary permeability as evidence by
low blood pressure below than normal range which is 65/40 mmHg

Assessment
Subjective:
Patient heart
rate is 40
breaths per
minute
Objective:
Patient look
pale

Assessment

Diagnosis
Impaired gas
exchange
related to
smoke
inhalation as
evidence by
patient heart
rate increase
up to 40
breaths per
minute

Planning/Goal
Patient will be
able to breath
normally
about 12-20
breaths per
minute within
4 hours

Intervention
-Assess
patients
condition to
ensure patient
in comfort
-Provide the
humidified
oxygen to
reduce the
breath of
patient to
normal
-Report depth
of respiration
for the
preparation of
intubation
-Maintain
proper
position of
patient to
promote
optimal chest
expansion

Evaluation
Patient
breaths back
to normal
about 12-20
breaths per
minute

Diagnosis

Planning/Goal

Intervention

Evaluation

Subjective:
Patient blood
pressure is
65/40 mmHg

Objective :
Patient look
discomfort

Fluid volume
deficit related
to increase
capillary
permeability
as evidence
by low blood
pressure
which is 65/40
mmHg

Patients
blood
pressure will
be back to
normal range
within 6 hours

-Monitor vital
signs to
ensure the
blood
pressure is
normal
- Note and
report signs of
hypovolemia
to ensure
patient s fluid
volume is in
normal range
- Maintain IV
lines and
regular fluids
at appropriate
rates
as prescribed
to promote
patient body
fluid level in
adequate
range
-Monitor
patient
position to
prevent
contrectures

Patient blood
pressure back
to normal
range