Kategoriak: All - pain - metabolic

arabera natasha brember 9 hours ago

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Burns

Burns are injuries to the skin or tissues resulting from heat, electricity, or other sources, and their severity can vary significantly. Nursing interventions are crucial for managing burns, focusing on fluid administration, wound care, and pain relief.

Burns

Burns

Nursing Asessments: (treatment, 2023)

Exposure
skin inspection

apply cling wrap to burn

remove all non-adhered clothes and jewelry

temperature: if less than 35.5 provide blacnkets and warm the patinet
Disability:
Assess pain

if indicated, provide analgesia

Conducte a GCS score, pupillary response and limb strength

if reduced level of consciouness, consider shock or hypoxaemia

Circulation:
Look out for signs of shock

hypotension

abnormal skin colour

tachycardia

check blood pressure and pulse and cardiac rhythm
colour and warth of skin, ensure patient stays warm due to risk of hypoxia
perfusion and capillary refill
Breathing
severe burns: apply oxygen through non-rebreather mask
maintain O2 sats
Auscultate chest: listen for chest sounds like stridor to see if their is anything inhaled
respiratory rate: assist ventilation if required
Airway
evidence of airway burn: give humidified oxygen via non-rebreather. Be quick with oxygen as airway injuries can worsen overtime. Consider and prepare for intubation
Patency: maintain the airway patency
Postion:
comfot for the patient. patients with head and neck burns should be head up to reduce swelling

Acute presentations in a deteriorating patient

Changes in perfusion
skin: warm, red and tender with little to no sensation
pulse pressure:
capillary refill increased
burns with trauma
mid-deep dermal or full thickness burns
hoarse voice
cough
sore throat
strior
singed faical hairs
inhalation, facial or mouth burns
reduced conscious state
clincial manifestions on each presentations *

What causes burns

electrical burns
deep tissue damage

potnetial for internal organ damage

lead to cardiac arrest or arrythmias

chemical burns
cause more severe tissue damage

pain, redness, tissue necrosis

Thermal burns
causes redness, blistering and swelling

ranges from superficial to fullthickness burns

inhalation injuries

Nursing Inteverventions (Zwierello et al, 2023)

Overall nursing interventions:
Assess pain:

administer pain relief

after reciving a burn, patient is going to be in alot of pain, if patient is consious ask patient to rate thier pain out of 10 and document it

wound:

apply cling wrap on the new burn after cleaning it

remove necotric tissues to prevent any infections

Becuase the extent of the burns can cause a severity of fluid loss

fluid: administer IV fluids

Prority assessments:
fluid balance: assess urine output
Circulation: monitor bp, hr and capillary refill
Airway: check for soot in air way, strider present

Management

State wide interventions: (Alfred Health, 2025)
The Alfred Health Victoria Adult Burns service provides statewide burns care, offers clinical practice guidelines, long term follow up and rehabilitation

provides resources and guidelines for burns assessment and management

minor burn care can be completed without being in hospital and clinics with the appropriate wound management

Burn prevention: education and awareness

Pharmacological interventions (uptodate, 2025)
hyperglyceamia can occur after a burn

check BGL

may require medications like metformin

might require high flow oxygen
Fluid resuscitation: required IV to prevent dehydration and organ failure
Antibitotics and antimicrbiols to prvent and treat wound infections
Analgestics: combination of pain relief
immediate management: first aid provided at the scene. By conducting first aid on the scene can prevent burns from getting severly worse, howver depends on the extent of the injury to what first aid is completed. (McCann et al, 2022)
Chemical burns: patient to be removed from contaminated clothing, irrigated with running water to remove chemical from burn. Irrigated fro 45 mins- 1 hr (McCann et al, 2022)
Warm the patient: by warming the patinet is can prevent the possibility of hypothermia (McCann et al, 2022)
Cover the burn with non-adhernt dressing such as cling wrap. (McCann et al, 2022)
Running under cool water: to be completed for 20 mins even up to 4 hours after injury. this way the tissue damage is arrested and wounds wouldnt be as deep as it could of been (McCann et al, 2022)

Types of burns (nationwide children's, 2022)

Other
infection
shock
dehydration
Inhalation injuries
stridor
coughing
difficualty breathing
Full thickness burns:
blisters: epidermis & dermis destroyed no blisters
colour: white/charred/black
sensation: no sensation
appearance: white waxy charred, no blisters, no cappliary refill
pathology: involves epidermis, dermis destroyed
deep dermal burns:
colour: white/pale pink/ blotchy red
circulation: sluggish capillary refill
Sensations: decreased sensations
Appearance: blotchy red or pale deeper dermis
pathology: involves epidermis and significant part of dermis
superficial dermal thickness burns:
colour: pink
circulation: hypomanic, rapid capillary refill
Sensation: tender and painful, increased sensation
Appearance: pale pink, smaller blisters, wound base blaches with pressure
Pathology: involves dermis and epidermis
Superficial epidermal burns:
colour: red and warm
circulation: normal
Sensation: might be painful
Appearnace: dry and red, no blisters
Pathology: expidermis only

What is a burn

burns falls under the shock category. Shock is a complex life threatening condition that comes from circulatory failure. As a result of severe burns, the body falls into a state where it is unable to deliver sufficient oxygen to the cells and tissues (Blumlein & Griffins, 2022)
multi-organ failure: (Jeschke et al, 2020)

immune suppression (uptodate, 2025)

leads to patients being more susceptible to causing infections

increases risk of sepsis

imbalances in fluid

loss of fluid increases capillary permability

can lead to hypovalemia

overall damages kidney and heart

severe burns can lead to infection (feng et,al, 2028)

increase risk of sepsis

bodys reaction to infection is damges its own tissues and organs

tissue hypoperfusion:

burn injuries lead to increased capillary permermibility

lead to decrease in BP, and impaired tissue perfusion

severe burns causes a significant loss of fluid

fluid loss leads to decrease in intravascular volume

Results in hypoxia: as a result of poor oxygen supply via circulation

burns can cause a build up of fluid in the burn area which can restrict oxygen delivery

large burns can lead to hypovolemia, impairing oxygen delivery to tissues

severe burns can damage blood vessels

burns are a injury to the skin or tissue caused by heat, electricity or other sources. Burns vary in severity.
Systematic Response:

Metabolic changes: metabolic rate increases up to three times its orignial rate (the royal childrens hospital melbourne, 2024)

Respiratory changes: cause bronchoconstricton occurs (the royal childrens hospital melbourne, 2024)

Cardiovascular changes: capillary permeability increased, loss of fluids in intestinal compartment. Myocardial contractibility is decreased. Results in hypotension (the royal children's hospital Melbourne, 2024)

Local response:

Zone of hyperaemia: outermost zone tissue perfusion increased (the royal childrens hospital melbourne, 2024)

Zone of stasis: decreased tissue perfusion, tissue is potentially salvageable (the royal childrens hospital melbourne, 2024)

Additional impacts: - prolonged hypotension - infection risk - oedema

Zone of coagulation: irreversible tissue loss due to coagulation (the royal childrens hospital melbourne, 2024)