Page 2431 - Saunders Comprehensive Review For NCLEX-RN

Priority Nursing Actions

Burn Injury: Care in the Emergency Department
1. Assess for airway patency.
2. Administer oxygen as prescribed.
3. Obtain vital signs.
4. Initiate an intravenous (IV) line and begin fluid replacement as prescribed.
5. Elevate the extremities if no fractures are obvious.
6. Keep the client warm and place the client on NPO (nothing by mouth) status.

Reference

Ignatavicius, Workman, Rebar (2018), p. 489.

1. Description: Cell destruction of the layers of the skin
caused by heat, friction, electricity, radiation, or
chemicals.
2. Small burns: The response of the body to injury is
localized to the injured area.
3. Large or extensive burns:
a. Major or extensive burns consist of 25%
or more of the total body surface area
for an adult and 10% or more of the
total body surface for a child.
b. The response of the body to the injury
is systemic.
c. The burn affects all major systems of the
body.
d. Electrical burns often have surface
injury that is small, but internal
injuries may be extensive.

4. Estimating the extent of injury (Fig. 69-14)

B. Burn depth

1. Superficial-thickness burn
a. Involves injury to the epidermis; the
blood supply to the dermis is still
intact.
b. Mild to severe erythema (pink to red) is
present, but no blisters.
c. Skin blanches with pressure.
d. Burn is painful, with tingling sensation,
and the pain is eased by cooling.
e. Discomfort lasts about 48 hours; healing
occurs in about 3 to 6 days.
f. No scarring occurs and skin grafts are
not required.

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