Burn is an injury caused by chemical, electrical, radiation energy and scalding ASSESSMENT: 1st Degree Partial Thickness -only

the superficial epedermis is affected characterized by erythema, dryness and pain. 2ND Degree Partial Thickness- The entire epidermis and portion of dermis are affected characterized by erythema, blistered and moist -extremely painful 3rd Full Thickness- The skin layers, epidermis and dermis are affected and may include adipose tissue, fascia, muscle and bone. - skin becomes dry - There is no pain because of the destruction of the nerve endings.

Classification of Burn

Assessment and Deviation from Normal

Chemical Burn

Electrical Burn

Radiation Burn

Scalding

Symptoms
Blisters Pain Peeling skin Red skin Shock (watch for pale and clammy skin, weakness, bluish lips and fingernails, and a drop in alertness) Swelling

Diagnostic Tests

Biopsy refers to removing and studying sample tissue. Thermography is the term for studies of burn temperature.

Treatment
Minor Burn Injury -Soak the burn in cool water for 15 minutes. -Apply cool cloth to the burn for a few minutes each day. -Apply topical antibiotic to the burn to prevent infection if necessary. -If necessary, take over-the-counter pain medication to control pain. -If burn pain, redness, swelling persists or if there are signs of infection see a physician.

Major Burn Injury

Skin graft surgery If the body will not be able to heal the injury by itself, skin grafts will be needed. The specifics of skin graft surgery depend on the location and severity of your burns.

Nursing Diagnosis
Impaired Skin Integrity related to burn injury

Risk for Imbalanced Nutrition less than body requirements due to increased metabolic needs following burn injury.

Nursing Intervention: Impaired Skin Integrity related to burn injury

During the first 24-48 of injury continually assess the injury for evidence of adequate perfusion, edema and depth of injury. Check capillary refill, pulses (via palpation or Doppler ultrasound) every hour or as ordered. Rationale: Carefully assessment and reassessment of the wound bed and surrounding tissue can help determine the level of injury. Closely assessing the burn during the first 2448 hours also helps determine the type of wound therapy, topicals, dressings and if grafting or escharotomies are needed.

 Change burn dressing using the topicals and dressing materials ordered, at the prescribed frequency. Rationale: Reinforcing a dressing is important so that the drainage does not contaminate other areas of the patients room. A complete dressing change may not be necessary or in fact frequent disturbing of the wound bed may be harmful to the wound and healing process. With each dressing change maintain sterile technique. Rationale: Infection is the biggest risk that compromises wound healing.

 With each dressing change observe the burn area for evidence of healing Rationale: Evidence of poor wound healing may indicate the burn is becoming infected or the patients nutritional status needs to be improved.

Risk for Imbalanced Nutrition less than body requirements due to increased metabolic needs following burn injury.

Nursing Intervention:

Request a consult with registered dietician when patient is admitted to assess nutritional status as soon as possible, develop nutritional goals and nutritional plan. Encourage the patient to eat a balance diet, but emphasize that protein is essential to wound healing and recovery. If the patient has burns on their face, hands, or mouth; try modifications to their food to make the food easier and more palatable to ingest. Consult with PT/OT as needed to implement strategies to help the patient eat and gain a sense of independence with eating.

 Check patients weight per unit recommendations. Some units do weekly, twice weekly or daily weights for at risk or high-risk patients. Check laboratory work per dietary or unit protocol. Keep accurate I+O and/or calorie counts. Consider the need for tube feeding or TPN if patient cannot take in the nutrients needed by mouth.