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Extent/Degree First Degree

Assessment of Extent Pink to red : slight edema, which subsides quickly Pain may last up to 48hours Relieved by cooling Sunburn is a typical example

Reparative Process In about 5 days, epidermis peels, heals spontaneously. Itching and pink skin persist for about a week. No scarring Heals spontaneously. If it doesnt become infected w/in 10days-2weeks

Second Degree

Superficial: Pink or red;blisters form (vesicles);weeping,edematous, elastic. Superficial layers of skin are destroyed; wound moist and painful Deep Dermal: Mottled white and red; edematous reddened areas blanch on pressure. May be yellowish but soft and elastic-may or may not sensitive to touch;sensitive to cold air.

Takes several weeks to heal Scarring may occur

Takes several weeks to heal Scarring may occur

Extent/Degree Third Degree

Assessment of Extent Destruction of epithelial cellsepidermis and dermis destroyed Reddened areas do not blanch with pressure. Not painful; inelastic; coloration varies from waxy white to brown; leathery devitalized tissue is called eschar. Destruction of epithelium, fat, muscle and bone.

Reparative Process Eschar must be removed. Granulation tissue forms to nearest epithelium from wound margins or support graft. For areas larger than 3-5cm, grafting is required Expect scarring and loss of skin function Area requires debridement, formation of granulation tissue and grafting

Minor Burns Partial thickness burns are no greater than 15% of TBSA in the adult

Moderate Burns Partial thickness burns are deep and are 15% to 25% of TBSA in the adult

Major Burns Partial thickness burns are >25% of TBSA in the adult

Full thickness burns are < 2% of the TBSA in the adult


Burn areas dont involve the eyes, ears, hands, face, feet or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 y.o The client has no preexisting medical condition at the time of the burn injury No other injury occurred with the burn

Full thickness burns are 2% to 10% of the TBSA in the adult


Burn areas dont involve the eyes, ears, hands, face, feet or perineum There are no electrical burns or inhalation injuries The client is an adult younger than 60 y.o The client has no chronic cardiac, pulmonary, and endocrine disorder at the time of the burn injury No other complicated injury occurred with the burn

Full thickness burns are >10% of the TBSA in the adult


Burn areas involve the eyes, ears, hands, face, feet or perineum The burn injury was an electrical or inhalation injuries The client is older than 60 y.o The client has chronic cardiac, pulmonary, and endocrine disorder at the time of the burn injury Burns are accompanied by other injuries