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

Skin involvement:

It is a full thickness burns involving all 3 layers of skin till dermis.

Clinical Manifestations:

• Blister
• Skin peel
• Red skin
• Swelling
• Signs of shock
• Pain ( but here pt can't sense pain as the burns have affected the nerves

Wound appearance:

It will be white, brown or leathery and stiff

Pathophysiology:

Burns>>loss of protein in skin>>cell and tissue damage>>potassium is lost>> water and sodium retention>>inflammatory response>>loss of blood volume>>poor blood supply to kidney and gastrointestinal system>>stomach ulcer and kidney failure

Complication:

• Infection
• Shock
• Hypothermia
• Hypovolemia
• Blood loss

Nursing diagnosis:

High risk for infection related to skin breakdown

* Follow strict asepsis while during procedure and handling the patient

Breakdown in skin is a leading cause of getting bacterial infection .

Impaired body temperature related to alteration in thermoregulation secondary to burns