Question

Mr. Cinder is a 55-year old man admitted to the burn unit 48 hours ago with a diagnosis of third degree burns. He was burning leaves in his yard when his clothes caught fire. The RN is going to care for Mr. Cinder, what will he/she expect to find related to: Skin involvement, clinical manifestations, and wound appearance. What are the pathophysiological changes associated with severe burns? When Mr. Cinder enters the rehabilitative phase of his recovery what are three possible complications? For one of the complications what nursing diagnosis would you identify as a priority and why?

Answer 1

Third degree burns are the most severe type of burns. They cause damage to every layer of the skin. This type of burns is so severe that there will not be pain because of nerve damage.  
Clinical manifestations of third degree burns:
• Waxy and white colour
• Char
• Dark brown colour
• Raised and leathery texture
• Blisters that do not develop
Pathophysiology:
Pathophysiology of a burn wound involves the inflammatory response. This leads to edema formation due to increased microvascular permeability, vasodilation and increased extravascular osmotic activity.
Complications:
• Infection
• Blood loss
• Shock
Other complications:
• Scarring
• Contracture
• Tetanus
• Hypovolemia
• Hypothermia
The priority nursing diagnosis is risk for infection because of destruction of skin barrier and trauma to the tissues. There is a chance for suppression of the immunity. During the rehabilitative phase the patient may undergo many procedures like debridement which can cause infection.