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Patient Name: James Watson
Diagnosis: Burn
Pathophysiology:
Burns are injuries of the skin, and they involve two main layers; the thin, outer epidermis as well as the thicker, deeper dermis. According to Schaefer and Szymanski (2019), there are different types of burns; the chemical burns are categorized into acid or alkali burns. Alkali burns tend to be more severe, leading to more penetration more in-depth into the skin by liquefying the skin. Acid burns penetrate less because they cause coagulation injury. Electrical burns, on the other hand, can be deceiving with short entry and exit wounds, however, there may be broad internal organ injury or associated traumatic injuries. Thermal burns are the most common type of burns.
Further, Schaefer and Szymanski (2019) opine that prolonged exposure to temperatures higher than 40 degrees leads to denaturation of proteins as well as the loss of plasma membrane integrity. Burn injuries impact the skin in three histological zones extending away from the center of the damage in two directions; out and down. These local pathophysiological alterations occurring around the burn are known as Jackson’s burn zones. At the central area of the burn, the point of ultimate damage is the zone of coagulation. This damage cannot be reversed because of necrosis of the tissue when proteins denature and are the main focus of the injury.
Risk Factors (Children develop in a predictable time frame, describe what types of burns they are at risk for during ages and developmental stages):
Children that are younger than 3 and adults older than 70 are at the highest risk for burn injury. Risk factors include inadequate adult supervision, psychomotor disorders like impaired judgment, and reduced mobility. Other risk factors include rural location, occupation, mobile home residence, lack of smoke detectors, fireworks, as well as misuse of cigarettes.
Types of burns children are at risk for during different ages and developmental stages
Burns, in very young children, mainly result from a mixture of curiosity as well as awkwardness. In children under the age of four years, the level of motor development does not often require the child’s intellectual development. Therefore injuries can occur more quickly.
Infants under the age of one year start to develop their mobility, and they reach out to touch objects. Subsequently, burns to the palms of the hands are common because of touching heaters, and hot water pipes. Because a child has a thinner skin on the palms and slower withdrawal reflexes, such contact burns tend to be deep, thus requiring prolonged and careful therapy during the healing stage.
Scald burns are the most common type of burns among children that are under the age of six years. Many scald burns happen when a child pulls down a container of hot fluid, such as a cup of coffee, onto the face, upper extremities, and trunk. These are mainly superficial second-degree burns.
As children grow older, the likelihood to be injured by mainstream household objects decreases because they are more interested in the outside world. For instance, boys that are older than six or eight years of age often become curious about fire, resulting in experimentation with matches, and fireworks (Peden et al., 2008). Younger siblings may also get injured while watching the experimentations.
Signs and Symptoms (Describe the type of burn, depth of burn, and size and extent of the burn. Also, how is the size of the burn calculated?)
Superficial burn (First-degree burn)
Appearance:
Mild to severe erythema; skin blanches with pressure; dry, no blisters; variable edema amount.
Sensation:
Painful, hyperesthetic, tingling, and pain is eased by cooling (Goodman & Fuller, 2011).
Partial-Thickness burn (Second-degree burns)
Large thick walled blisters covering the wide area (vesiculation)
Edema; mottled red base; broken epidermis; wet, shiny, weeping surface.
Sensation
Painful and sensitive to cold air.
Full-thickness burn (Third degree or fourth-degree burn)
Appearance
Variable: e.g. deep, red, white, black brown
Dry surface
Edema
Fat exposed
Tissue disrupted
Sensation
Little or no pain; insensate
Calculating the extent of the burn
There are many methods available used to estimate the percentage of the total body surface area burned.
Rule of nines: the head represents 9%, ever arm is 9%, the anterior chest, as well as abdomen, are 18%, the posterior chest, as well as the back, are 18%, while each leg is 18%, and the perineum is 1% (Schaefer & Szymanski, 2019). For children, the head is 18%, and the legs are 13.5% each.
Lund and Browder Chart: This is a more comprehensive technique, particularly for children, where each arm is 10%, anterior trunk and posterior trunk are each 13% and the percentage calculated for the head as well as legs vary about the patient’s age.
Palmar Surface: For minimal burns, the patient’s palm surface apart from the fingers, represent approximately 0.5% of their body surface area, and the hand surface represents about 1% of their body surface area (Schaefer & Szymanski, 2019).
Labs/Radiology:
Routine laboratory tests for burn patients include complete blood count, platelets, prothrombin time, activated partial thromboplastin time, thrombin time, blood urea nitrogen, electrolytes, creatinine, and blood glucose level. Continuous cardiac monitoring is essential for all patients with significant thermal burns (Karpel & Linz, 2019). If inhalation injury is suspected, arterial blood gas analysis, electrocardiogram, COHb level as well as chest radiography are relevant.
Diagnosis:
The significant components when assessing burned skin are the extent of the burns and estimated depth of burns: superficial, partial thickness or full thickness.
Recommended Treatments:
The PTA may be involved in wound care for mild burns comprising of cleansing: removal of any damaging agents, debridement of loose, nonviable tissue, and application of topical antimicrobial creams or ointment as well as sterile dressing. Blister management often involves debridement of the blister. Treatment of significant burns includes lifesaving interventions (ABCs) immediately after the injury, followed by restorative care like skin grafts, wound care as well as pain management. Therapeutic interventions include wound management: Irrigation, advanced wound dressing, and debridement (Goodman & Fuller, 2011). Positioning and immobilization after skin grafting to prevent unwanted movement and shearing of scar, grafts, and contracture prevention, as well as management, is also essential.
Patient Teaching:
Instructions for home care include observation for clinical manifestations of infection and active ROM exercise to maintain healthy joint function, decrease edema formation and manage possible scar formation. Encourage the client to request assistance whenever needed. Teach the patient measures to prevent pressure ulcers including adequate nutrition, mobility, and skin care.
Prevention:
Installation of smoke alarms
Residential sprinklers
Raising cooking areas off the ground
Increased knowledge about burns among young children
Community programs to ensure appropriate supervision of children
Educating parents about the use of safety equipment
Top Complications:
Decreased acute tubular necrosis and acute renal failure
Anoxic brain injury
Contractures and muscle wasting
Hypertrophic scars and keloid scars
Airway obstruction and respiratory failure as well as pneumonia
Feeding intolerance and mucosal ulceration
Bleeding
Potential Nursing Diagnoses (at least 2):
Disturbed body image related to altered physical appearance
Hypothermia-related to impaired skin integrity
Impaired physical mobility related to pain and contracture formation
Post-trauma syndrome related to a life-threatening event
Impaired skin integrity related to injury of the skin
What is your plan to care for the patient?
Assess and monitor respiratory function: breath sounds, rate, and rhythm of respiration, and hemoglobin. Initiate pulse oximetry.
Assess risk for inhalation injury
Monitor arterial blood gases and carboxyl hemoglobin
Monitor for clinical manifestations of carbon monoxide poisoning, upper airway obstruction, and chemical pneumonitis
Position client based on chest x-ray results to maximize oxygenation.
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