Signs and Symptoms
A major burn injury causes loss of this primary protective function of the skin, leading to increased infection risk and fluid loss.
What is the skin’s protective barrier function?
This is the most common cause of burn injuries and often results from direct exposure to open heat sources such as house fires or explosions.
What is flame burns?
This is the primary method used to diagnose burns and determine severity before any laboratory or imaging studies are ordered.
What is a physical assessment?
This is ALWAYS the first priority in the emergent stage of burn care before any wound treatment or pain management.
What is airway, breathing, and circulation (ABCs)?
This information is essential to determine burn severity and guide fluid resuscitation, including depth, extent, agent, and duration of contact.
What is data collected on burn type, depth, extent (TBSA), cause, and duration of exposure?
In the first 48 hours after a major burn, increased capillary permeability leads to fluid moving into tissues, causing this life-threatening condition if untreated.
What is hypovolemic shock?
This type of burn occurs when hot liquids or steam cause tissue injury and is especially common in children and older adults during cooking or bathing accidents.
What are scald burns?
In a burn patient with soot in sputum and facial burns, these specialized tests are ordered to evaluate oxygenation and confirm suspected inhalation injury.
What are arterial blood gases (ABGs), carboxyhemoglobin levels, and bronchoscopy?
This is the primary reason large-volume IV fluids are given immediately after a major burn injury.
What is prevention of hypovolemic shock due to massive fluid shifts and capillary leakage?
These findings suggest a high suspicion for inhalation injury in a burn patient and require immediate airway-focused intervention.
What are burns in an enclosed space, facial/neck burns, soot in sputum, and voice changes or coughing carbon particles?
In full-thickness burns, this clinical finding is absent because nerve endings are destroyed in the deepest layer of tissue injury.
What is pain (absence of pain in the burn center)?
In a patient with a major burn and suspected inhalation injury, this system must be assessed and stabilized first according to ABC priorities.
What is the airway?
These laboratory tests are commonly monitored in burn patients to evaluate hydration status, infection risk, nutrition, and metabolic response.
What are CBC, electrolytes, BUN, glucose, and serum protein/albumin?
This is done daily to remove dead tissue, reduce infection risk, and prepare the wound bed for grafting.
What is wound cleansing and debridement (mechanical, chemical, or surgical removal of eschar)?
This nursing diagnosis takes priority in the acute phase due to airway edema, CO exposure, and impaired oxygenation.
What is Impaired Gas Exchange related to airway edema and carbon monoxide poisoning?
Patients with major burns are at high risk for this temperature-related complication because the skin can no longer regulate heat or sweat effectively.
What is hypothermia?
This life-threatening complication of burns occurs when smoke or toxic gases are inhaled in an enclosed space and is a major cause of burn-related death.
What is inhalation injury?
In a burn patient with soot in sputum and facial burns, the nurse’s immediate priority concern is this life-threatening complication.
What is inhalation injury and airway compromise?
This procedure is performed when eschar acts like a tourniquet and pulses are lost in a burned extremity.
What is an escharotomy?
This clinical parameter is the most important indicator that fluid replacement therapy is effective in burn management.
What is urine output of 30–50 mL/hr in adults?
After a severe burn injury, elevated catecholamines and glucagon trigger this state characterized by increased energy use, muscle breakdown, and poor wound healing.
What is hypermetabolism (catabolic state)?
This complication occurs when burned tissue forms a rigid eschar that restricts circulation and compresses underlying nerves and vessels, risking distal ischemia.
What is neurovascular compromise (compartment syndrome from eschar)?
A severe burn patient with fractures, airway symptoms, and extensive injuries requires care from multiple disciplines including this type of provider team.
What is a multidisciplinary health-care team (ED, burn unit, respiratory therapy, surgery, radiology, rehabilitation, and nursing)?
This begins 24–48 hours after injury and is critical to prevent long-term disability and contractures.
What is early mobilization with splinting and range-of-motion exercises to prevent contractures and maintain function?
This nursing intervention is critical because the burn wound provides an open environment for bacterial growth and sepsis risk is high.
What is strict sterile technique and protective infection control precautions during all wound care?