BSN III-D

OBJECTIVES
General Objectives:
Specific Objectives:
OVERVIEW
OF THE
DISEASE
 BURN

A burn is an injury to the tissues of the body.

It is defined as damage to the skin caused
by excessive heat or caustic chemicals.
Classification
- first degree: only involves epithelial layer. Often very
painful but resolves with no residual scarring. Skin is red
and painful but blisters are not present
- - second degree: involves epithelium and part of dermis.
Pain and scarring vary according to depth of burn. In
superficial second-degree burns damage is limited to
epidermis and uppermost part of dermis.
Deep second-degree burns spare only the deepest
portion of dermis
- - third degree: full thickness. Usually painless due to
destruction of cutaneous innervation. Leads to scarring.
Usually dry and have milky white or tanned leather
appearance
 Other classifications
 A description of the traditional and current
classifications of burns.
Nomenclature Traditional Depth Clinical findings
nomenclature

Superficial First-degree Epidermis involvement Erythema, minor pain, lack of

thickness blisters

Partial thicknessSecond-degree Superficial (papillary)Blisters, clear fluid, and pain

— superficial dermis

Partial thicknessSecond-degree Deep (reticular) dermis Whiter appearance, with decreased

— deep pain. Difficult to distinguish from
full thickness

Full thickness Third- orDermis and underlyingHard, leather-like eschar, purple

fourth-degree tissue and possibly fascia,fluid, no sensation (insensate)
bone, or muscle
 Assessment of extent

Area % BSA
Body surface area
Head 9
(BSA) involved can
be estimated from Each upper 9
limb
Lund & Browder chart Each lower 18
Wallace rule of nine limb
Front of 18
trunk
Back of trunk 18
Perineum 1
 Criteria for referral to burns unit

> 10% BSA in child

> 15% BSA in adult
Inhalation injuries
Burns involving the airway
Electrical burns
Chemical burns
Special areas - eyes, face, hands
 Escharotomy
 Deep circumferential burns of
torso can impair respiration
 In a limb can reduce distal
vasculature
 In both situations escharotomies
should be considered
 No anaesthetic is required
 Burn should be incised into
subcutaneous fat
 Release of underlying soft tissue
should be ensured
 On chest should be performed
bilaterally in anterior axillary line
 Bleeding may be significant and
transfusion may be required
 Special situations

 Respiratory burns
 Smoke inhalations should
be suspected if:
 Explosion in enclosed
environment
 Flame burns to the face
 Soot in mouth or nostrils
 Hoarseness or stridor
 Intubation may be
required
 Blood
carboxyhaemoglobin
levels can give indication
of extent of lung injury
 Electrical burns
 Most electrical burns are flash burns
and are superficial
 Do not occur by electrical conduction
 Flash from an electrical burn can reach
4000 ºC
 Low-tension burns are usually small
but full thickness
 High-tension burns usually have an
entry and exit wound
 Current passes along path of least
resistance (e.g. blood vessels, fascia,
muscle)
 Extent of tissue destruction can often
be underestimated
 High-tension burns can be associated
with cardiac arrhythmias
 Myonecrosis and myoglobinuria can
also occur
 Chemical burns
 Commonest acids involved are
hydrochloric, hydrofluoric and
sulphuric
 Acid burns may penetrate
deeply down to bone
 First aid treatment involves
liberal irrigation with running
water
 Calcium gluconate may be
useful in hydrofluoric acid
burns
 Commonest alkalis are sodium
hydroxide and cement
 Again can cause deep-dermal
or full-thickness burns
 Personal Data

Age: 41
Birthday: April 4, 1967
Sex: Female
Civil Status: Married
Present Health History
Past Health History
Drug
Study
 Pharmacological Dosage Adverse Nursing
Name of Drug Mechanism Indica- Reaction Responsi-bilities
tion and
prepara-
tion

1.Amoxicillin Inhibits cell-wall synthesis For skin 500 mg. Nausea, -Before giving
during bacterial and and TID vomiting meds. Assess pt.
multiplication soft tissue diarrhea & for any allergic
skin rashes reaction.

2.Mefenamic acid For pain 500 mg. Diarrhea,drow -Monitor pt.

q 4 prn siness - Instruct pt. to
take meals after
taking drugs

3.Tegretol To stabilize neuronal For 200 mg. Dizziness, -Watch for

membranes and limit epilepsy BID fatigue, worsening of
seizures act by either drowsiness, seizures
increase efflux or skin reactions, -monitor pt.
decrease influx of Na ions nausea &
across cell membrane in vomiting
the motor complex during
generation of nerve
impulses
4.Silver Inhibits cell wall For the wound Apply TID Skin -Clean first the
sulfadiazine synthesis during reaction e.g wound &
bacterial itching remove dead
multiplication skin or other
debris

5.Omepr-azole Binds to an enzyme Prevention of 20 mg. 1 cap Headache , -Assess pt.

on gastric parietal relapse of OD diarrhea, routinely for
cells in the presence duodenal ulcer constipation, epigastric or
of acidic gastric pH, abdominal abdominal
preventing the final pain, pain
transport of hydrogen nausea, Administer
ion into the gastric vomiting doses before
lumen. preferably in
the morning
6.Fluc- Inhibits the for treatment 50 mg. Hypersensensi -Monitor pt.
lox action of of skin QID tivity sp. Skin -note for skin sensitivity
bacteria infection rashes
causing
infection

7.Carvedil-ol Inhibit NE- For 25 mg. ½ Dizziness, -monitor v/s of the pt.
induced hypertensi-on OD headache, -watch for any sign and
depolarization tiredness, symptoms
in the artery nausea,
but not vein abdominal
pain, diarrhea,
constipation &
vomiting

8.Nifedipi-ne Calcium beta Treatment of 5 mg. SL Headache, -monitor v/s

blocker essential stat tiredness, &
hypertension dizziness
Nursing
Care
Plan
Nursing Care Plan
Assessment Nursing Planni- Intervention Rationale Evaluation
Diagnosis ng

S:”Nahihirapan -Risk for -At the end >emphasize/ >prevents

akong gumalaw infection r/t of the model good hand cross-
kasi dumidikit altered body nursing washing contamination,
and damit ko sa defenses as interventio technique for all reduces risk
sugat kaya sya evidenced by n, pt. will individual coming acquired
sumasakit” as presence of demonstrat in contact with infection.
vervalized by the broken skin e client. >prevent skin-
pt. and traumati- technique to-skin surface
zed tissue to contact e.g
O:-with slight prevent/red touching of
uce risk of others hand
facial grimace
infection into
The affected site of
the body
>reccomenduse of
mask, & gloves
during direct wound >prevents exposure
wound care and to infectious
provide sterile or organism
freshly bed linens.
>examine wounds
daily,note
/document
appearance, odo, or
quantity of drainage >identifies presence
of healing and
provides detection
of burn-wound
infection. Infection in
partial-thickness
burn may cause
conversion of

>
burn to full >goal met;
thickness injury seen S.O
>monitor v/s performing
including proper hand
>provides washing before
temperature info.for and after
baseline contact to the
data;frequent pt.
temp.elvation
indicates that >’’naghuhugas
the body is na ako ng
responding to a kamay kasi
new infectious para maiwasan
ang
process.
pagkakaron
inpeksyon”as
>reduces verbalized
>provided clean, number of
well ventilated pathogen
environment presented
Presented
to: Ms. Jennifer Rosales RN

Presented
by: Karen Joy M. Sereno
Mechelle Rentoy
Joseph Villanueva
Richard
BSN III-D