MORENO, GIA M BSN 3E

SIGNS AND SYMPTOMS

II. PATHOPHYSIOLOGY AND MANAGEMENT Signs and symptoms of a burn depend upon the
A. Diagram degree of severity.

-First-degree burns: skin redness, peeling, mild to

moderate pain, and tenderness, and blistering
ETIOLOGY
may occur.
Causes -Second-degree burns: including a greater degree
-Dry Heat: open flame, most common, brief of blistering and more intense pain.
exposure high temperature
-Moist Heat: hot liquids and steam. Scalding injuries -Third-degree burns include a loss of color of the
-Contact burns: hot metal, tar, grease leads to full- skin as it turns white. Loss of sensation is an
thickness injury. Space heater, iron, molten metals associated symptom with third-degree burns.
-Chemical injury: skin contact, inhaled, swallowed.
Severity of injury depends on duration of contact,
concentration, amount and action of chemical
-Electrical injury: Burns when electrical current
enters body. Small looking outside large damage
inside. DIAGNOSTIC EVALUATION/TOOLS
-Radiation injury: Exposure to large doses of -ABCDE assessment, ABG, CBC, Urinalysis,
radioactive material. Electrocardiography, Fiber-optic bronchoscopy
NURSING DIAGNOSIS: Ineffective airway
clearance related to increased congestion in the
airway passages secondary to smoke inhalation
as evidenced by diminished breathing and
presence of abnormal breath sounds.

DISEASE PROCESS

Burn injury is a result of heat transfer from

one site to another. Tissue destruction results from
MANAGEMENT SPECIFIC TO THE SIGNS AND
coagulation, protein denaturation, or ionization of
SYMPTOMS
cellular contents. The skin and the mucosa of the
upper airways are sites of tissue destruction. Deep
Independent (Nursing):
tissues including the viscera, can be damaged by
1.Monitor patient’s vital signs.
electrical burns or by prolonged contact with a heat
2. A head-to-toe assessment is performed, focusing on
source. Disruption of the skin can lead to increased
the signs and symptoms of concomitant illness,
fluid loss, infection, hypothermia, scarring,
associated injury, or developing complications.
compromised immunity, and changes in function,
Dependent:
appearance, and body image. The depth of the injury
1. Administer medications as prescribed.
depends on the temperature of the burning agent
2. Provide with oxygen therapy as prescribed.
and the duration of contact with the agent.
Collaborative:
1.Monitor chest x-rays and laboratory findings in
collaboration with other health care professionals.
IF NOT TREATED IF TREATED

PROGNOSIS
If left untreated, it would likely
become a fatal disease that leads
to a lot of complications which
would rapidly result in a
decreased life expectancy.
MEDICAL
- Administer medications.
- Provide with oxygen therapy.
-Initiate fluid resuscitation.
SURGICAL
-Debridement and allograft placement on the stage 3 burns PROGNOSIS

Bacterial infection, which may If treated, most first- and

lead to a bloodstream infection
(sepsis); Fluid loss, including low
blood volume (hypovolemia);
Dangerously low body
temperature (hypothermia);
Breathing problems from the
intake of hot air or smoke; Scars
or ridged areas caused by an
overgrowth of scar tissue
(keloids); Bone and joint
problems, such as when scar
tissue causes the shortening and
tightening of skin, muscles or
tendons (contractures).
NURSING
Promoting Gas Exchange and Airway Clearance second-degree burns heal
over two to three weeks.
-Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, Depending on the burn
and carboxyhemoglobin levels. severity, you may have some
-Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for scarring, which may fade over
hypoxia. time. People recovering from
-Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed third-degree burns need
nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or physical and occupational
respiratory secretions.
therapy to maintain joint
-Report labored respirations, decreased depth of respirations, or signs of hypoxia to
mobility and improve
physician immediately; prepare to assist with intubation and escharotomies.
-Monitor mechanically ventilated patient closely. function.
-Institute aggressive pulmonary care measures: turning, coughing, deep breathing,
periodic forceful inspiration using spirometry, and tracheal suctioning.
-Maintain proper positioning to promote removal of secretions and patent airway and
to promote optimal chest expansion; use artificial airway as needed.