Ministry of Education
Jazan University
College of Nursing
Adult Care Nursing 2 -practice
Level 8
Assignment
Nursing care of patient with burn
wounds
Prepared by:
Yasmin Alhafaf 202102583
Nujood Essa Jaber 202102850
Yara Altherwi 202103650
Arwa hakami 202103673
Jana Mahdi 202103931
Submitted to [Link]
Burns are avery specific type of injuries of the skin involving the
two layers: the thin, outer epidermis and the thicker, deeper dermis.
86% of burns are caused by thermal injury, while about 4% are
electrical and 3% are chemical. Burns are classified as first-, second-,
or third-degree, depending on how deep and severe they penetrate
the skin's surface.
First-degree (superficial) burns burns affect only the epidermis, or
outer layer of [Link] Second-degree burns involve the epidermis
and part of the dermis layer of skin andThird-degree burns destroy
the epidermis and dermis. Burn injury of the skin is characterized by
the damage to skin tissue. They can result in significant
disfigurement, physical impairment, and psychological problems.
Prevention of burn is considered the best strategy to reduce the
overall burden of burns.
Type of burn
First-degree burns cause minimal skin damage. They are also called
“superficial burns ”because they affect the outermost layer of skin.
Signs of a first-degree burn include:redness minor inflammation, or
swelling pain dry, peeling skin occurs as the burn [Link] this
burn affects the top layer of skin, the signs and symptoms disappear
once the skin cells shed. First-degree burns usually heal within 7 to
10 days without scarring. You should still see your doctor if the burn
affects a large area of skin, more than three inches, and if it’s on your
face or a major joint, which include:knee ankle foot spine shoulder
elbow forearm. First-degree burns are usually treated with home
care. Healing time may be quicker the sooner you treat the burn .
Nursing management for first degree of burns: Immediately immerse
the burn in cool tap water or apply cold, wet compresses. Do this for
about 10 minutes or until the pain subsides. Apply petroleum jelly
two to three times daily. Do not apply ointments, toothpaste or butter
to the burn, as these may cause an infection.
Second - degree Burns
This type of burn affects both the epidermis and the second layer of
skin (dermis). It may cause swelling and red, white or splotchy skin.
Blisters may develop, and pain can be severe. Deep second-degree
burns can cause scarring .
Nursing management:
First aid-:
Immerse in cold water / wet pack .
Do not break blisters.
Ensure the unburnt areas of the patient are covered and warm to
prevent hypothermia.
Promoting Gas Exchange and Airway Clearance -.
-Fluid Resuscitation.
Relive pain : given analgesic as order -.
-Prevent infection :by dressing the wound and Provide a clean and
safe environment .
Provide psychologic support
Third-degree burn
They cause the most damage, extending through every layer of skin:
epidermis, dermis and fat.
Third-degree burns can be life-threatening and often require skin
grafts. Skin grafts replace damaged tissue with healthy skin from
another of the uninjured part of the person’s body. If the person does
not have enough skin available for a graft at the time of injury, a
temporary source of graft can come from a deceased
donor .Treatment also includes extra fluids (usually given
intravenously, with an IV) to keep blood pressure steady and prevent
shock and [Link] surgery, these wounds heal with
severe scarring and contracture. There is no set timeline for complete
spontaneous healing for third-degree burns.
Nursing management:
-Assess circumstances surrounding the injury: time of
injury ,mechanism of burn, whether the burn occurred in a
closed space, the possibility of inhalation of noxious chemicals,
and any related trauma.
-Monitor vital signs frequently; monitor respiratory status closely;
and evaluate apical, carotid, and femoral pulses particularly in areas
of circumferential burn injury to an extremity.
-cardiac monitoring if indicated (eg, history of cardiac or respiratory
problems, electrical injury.)
-Check peripheral pulses on burned extremities hourly; use Doppler
as needed.
-Arrange for patients with facial burns to be assessed for corneal
injury.
-Assess neurologic status: consciousness, psychological status ,pain
and anxiety levels, and behavior.
-Assess patient’s and family’s understanding of injury and treatment.
Assess patient’s support system and coping skills.
-Preparing the patient for the operation if there is a need for the
operation
-Provide analgesics as doctor order .
-Administer anti microbial as doctor order .
-Administer fluids to prevent shock and electrolytes imbalance
-Following aseptic techniques to prevent infection
In the end, the burn injury must be treated well and should not be
underestimated, otherwise it will cause infection. There are some
common mistakes in the treatment of burns, such as putting
toothpaste, honey, flour, or ice, and this is wrong behavior, which
makes the burn injury worse .Doing first aid correctly facilitates and
speeds up the healing process. Here are some of the first aid in case
of burn injury:
First degree burns:
* Cooling the burn to help soothe the pain by placing the burnt area
under running tap water of moderate cold for 10 to 15 minutes to
relieve the pain.
* Remove accessories (such as: rings, watches, or belts), if any, or
remove shoes or any clothing gently and quickly, before the area
swells.
* Cover the burn area with a wet bandage or a clean, cool cloth, to
reduce the risk of infection.
* Take a pain reliever if necessary to relieve pain.
* Seek help immediately if the burn is severe and extends to large
areas, or if you notice signs of infection such as increasing pain,
redness, and swelling .
* Do not try to touch the bubbles resulting from the burn.
* Do not apply any ointments, butter, toothpaste or other remedies
to the burn.
* Do not use ice directly on the burnt area.
In the event of a second-degree burn:
As in the first class, but:
* Cover open blisters with a dry, sterile bandage .
* And go to the doctor
don't:
* Remove burnt clothes stuck to the skin .
Cover the burn with an adhesive bandage.
* Putting large burn areas in cold water to avoid trauma to the
injured person.
* Putting thin cotton on the affected area, which may irritate the
skin.
In the event of a third-degree burn:
You should immediately call 911 and take the following measures
until it arrives:
* Check the patient's vital signs, such as breathing.
* Protecting the injured person from harm, by keeping him away
from flammable materials, smoke or heat sources.
Raise the affected area above the level of the heart if possible.
Cover the burn area with a damp bandage or a clean, cool cloth.
Don't!!
* Don't Remove burnt clothes stuck to the skin .
* Don't Putting large burn areas in cold water to avoid shock to the
injured (sudden drop in body temperature).
Don't Cover the burn with an adhesive bandage .
Don't Applying any ointments, butter, toothpaste, or other remedies
to the burn.
* Don't Putting thin cotton on the affected area, which may irritate
the affected area.
Reference
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