Burns: ASSESSMENT Flashcards
Burn Assessment Risk Factors
Risk for Death from Burns (3)
- Age greater than __?__years
- Burn involves greater than __?__ TBSA
- __?__ injury
- Age > 60 years
- Burns involves greater than 40% of TBSA
- Inhaltion Injury
Burn Assessment Risk Factors
__?__adults are at higher risk for damage to __?__tissue, muscle, connective tissue, and bone because __?__.
Older adults have a higher risk for complications from burns because of
__?__. examples (2)
Older adults are at higher risk for damage to subcutaneous tissue, muscle, connective tissue, and bone because their skin is thinner.
Older adults have a higher risk for complications from burns because of chronic illnesses (e.g., diabetes mellitus, cardiovascular disease).
Burn Assessment: Subjective Data
- Report of burn agent __eg__(4)
- Duration of __?__
- Area of the__?__ in which the burn occurred
- Report of burn agent (dry heat, moist heat, chemical, electrical, ionizing radiation)
- Duration of contact
- Area of the body in which the burn occurred
Burn Assessment: Objective Data/PHYSICAL FINDINGS
ASSESS DEPTH OF INJURY
(5) AREAS OF INVOLVED
- SUPERFICIAL
- SUPERFICIAL PARTIAL THICKNESS
- DEEP PARTIAL THICKNESS
- FULL THICKNESS
- DEEP FULL THICKNESS
Burn Assessment: Objective Data/PHYSICAL FINDINGS
- SUPERFICIAL
- SKIN CHARACTERISTICS (5)
- SENSATION/HEALING (3)
- EXAMPLE (1)
ASSESS DEPTH OF INJURY
(1/5) AREAS OF INVOLVED
- SUPERFICIAL: Damage to epidermis
- SKIN CHARACTERISTICS:
Pink to red, tender, no blisters, mild edema, and no eschar
- SENSATION/HEALING (3) Painful, Heals within 3 to 6 days, No scarring
- Examples: Sunburn
Burn Assessment: Objective Data/PHYSICAL FINDINGS
- SUPERFICIAL PARTIAL THICKNESS
- SKIN CHARACTERISTICS (4)
- SENSATION/HEALING (3)
- EXAMPLE (2)
ASSESS DEPTH OF INJURY
(2/5) AREAS OF INVOLVED
- SUPERFICIAL PARTIAL THICKNESS: Damage to entire epidermis and some parts of the dermis
- SKIN CHARACTERISTICS:
Pink to red, blisters, mild to
moderate edema, and no eschar
- SENSATION/HEALING (3)
Painful, Heals within 10 to 21 days, No scarring
- EXAMPLE: Flame or burn scalds
Burn Assessment: Objective Data/PHYSICAL FINDINGS
DEEP PARTIAL THICKNESS
SKIN CHARACTERISTICS (5)
SENSATION/HEALING (4)
EXAMPLE (3)
ASSESS DEPTH OF INJURY
(3/5) AREAS OF INVOLVED
- DEEP PARTIAL THICKNESS: damage to entire epidermis and deep into the dermis
- SKIN CHARACTERISTICS (5)
Red to white, with moderate edema, free of blisters, and soft and dry eschar
- SENSATION/HEALING (4)
Painful and sensitive to touch Heals within 3 to 6 weeks Scarring likely, Possible grafting involved
- EXAMPLE:
Flame and burn scalds, Grease, tar, or chemical burns, Exposure to hot objects for prolonged time
Burn Assessment: Objective Data/PHYSICAL FINDINGS
FULL THICKNESS
SKIN CHARACTERISTICS (4)
SENSATION/HEALING (4)
EXAMPLE (5)
ASSESS DEPTH OF INJURY
(4/5) AREAS OF INVOLVED
- FULL THICKNESS:
damage to the entire epidermis and dermis, and may extend into the subcutaneous tissue. Nerve damage also occurs
- SKIN CHARACTERISTICS (4)
Red to tan, black, brown, or white, Free from blisters, severe edema, and hard and inelastic eschar
- SENSATION/HEALING (4)
Pain may or may not be present, As burn heals, painful sensations return and severity of pain increases, Heals within weeks to months, ScarringGrafting required
- EXAMPLE:
Burn scalds, Grease, tar, chemical, or electrical burns Exposure to hot objects for prolonged time
Burn Assessment: Objective Data/PHYSICAL FINDINGS
DEEP FULL THICKNESS
SKIN CHARACTERISTICS (2)
SENSATION/HEALING (4)
EXAMPLE (1)
ASSESS DEPTH OF INJURY
(5/5) AREAS OF INVOLVED
- Deep full thickness – damage to all layers of skin and extends to muscle, tendons and bones
- SKIN CHARACTERISTICS (2) Black, no edema
- SENSATION/HEALING (4) Heals within weeks to months, Scarring, Grafting required
- EXAMPLE: Chemical Burns
Burn Assessment: Objective Data/LEVELS OF CARE (3)
- Inhalation Damage
- Carbon Monoxide Inhilation
- Hypovolemia and shock
Burn Assessment: Objective Data/LEVELS OF CARE (1/3)
- Inhalation Damage Findings (6)
- Clinical Manifestations (4)
- Inhalation damage findings may include singed nasal hair, eye brows, and eyelashes; a sooty appearance to sputum; hoarseness; and wheezing.
- Clinical manifestations may not be evident for 24 to 48 hr and are seen as wheezing, hoarseness, and increased respiratory secretions.
Burn Assessment: Objective Data/LEVELS OF CARE (2/3)
- Carbon monoxide inhalation findings (3)
- (suspected if the injury took place in an enclosed area) findings include erythema (pink or cherry red color of skin) and upper airway edema, followed by sloughing of the respiratory tract mucosa.
Burn Assessment: Objective Data/LEVELS OF CARE (3/3)
Hypovolemia and shock
Hypovolemia and shock may result when injury to at least __?__TBSA occurs. Fluidshifts from the __?__ and __?__space to the interstitial space. Additional findings include __?__, __?__ and decreased __?__.
Hypovolemia and shock may result when injury to at least 20% to 30% TBSA occurs. Fluidshifts from the intercellular and intravascular space to the interstitial space. Additional findings include hypotension, tachycardia, and decreased cardiac output.
