Name:
Group 1
Type of Burn: Second degree burn
Clinical Manifestations (Symptoms): Pain, hyperesthesia, and sensitivity to air
Nursing Assessment: Assess using “Rule of 9’s”. It’s blistered with a molted red base, disrupted
epidermis, edema, with weeping surface.
Labs/Diagnostic Tests: There is nothing to test unless it appears to be infected, then a culture may be
done for determining correct type of anti-biotics. These are usually painful with a blister formation
and healing is dependent upon depth of dermal injury – usually 2 -3 weeks. Hair follicles remain
intact.
Nursing Interventions: Patient education. Let them know that recovery usually lasts 2-3 weeks. Some
scarring or depigmentation is possible. Grafting may be necessary and depending on percentage of
body affected they may be referred to a burn center.
Cool the Burn, remove rings or other tight items, don’t break the blisters, apply lotion, bandage the
burns, take pain reliever, and consider a tetanus shot if it’s been more than 5 years.
Name:
Group 2
Type of Burn: First degree
Clinical Manifestations (Symptoms): Tingling, pain that is soothed by cooling, hyperesthesia, peeling,
and itching.
Nursing Assessment: Area is reddened and blanches with pressure. Dry, no edema. Possible blisters
and pain is mild to moderate. Heals in 3-6 days. Rule of nines still applies for documentation.
Labs/Diagnostic Tests: These burns are considered “erythematous”, but the epidermis is intact. If
rubbed, the burned tissue does not separate from the underlying dermis, also known as Nikolski’s
Sign.
Nursing Interventions: Patient should be educated on recovery time-frame which is usually only a few
days. Oral pain medications and cool compresses will help soothe. Stay out of direct sunlight and
increase water intake.
Name:
Group 3
Type of Burn: Fourth degree burn
Clinical Manifestations (Symptoms): This involves tendon, muscle, nerves, and bone. It is considered
full thickness and underlying structures are visible. There is a high risk for infection and often requires
surgical amputation.
Nursing Assessment: Airway patency and cervical protection are priority. If patient has been exposed
to this amount of heat, it is likely they inhaled extremely hot air as well. Rule of nines still applies to
amount of tissue involved. Breathing, cardiac status and peripheral circulation needs to be assessed
and monitored. Stabilize any disability or gross deformity. Remove clothing to assess the full extent of
burns or concurrent injuries.
Labs/Diagnostic Tests: CBC, BUN, glucose, creatinine, and electrolytes will be evaluated within 24
hours of admission. If patient was in an enclosed space an ABG and carboxyhemoglobin will be
performed as well. Chest x-ray forfluid accumulation and/or ET position and EKG is typical. Other test
that may be performed are: serum lactate, cyanide, blood type and crossmatch, urine myoglobin,
serum creatine kinase. Tetanus is usually updated.
Nursing Interventions: Patient will need burn unit. Immediate and aggressive treatment using strict
sterile technique is necessary. Clothing removal is necessary, then cover patient with clean, dry
sheets. Oxygen sat needs to be managed and kept at 94% or higher. Intubation is likely along with
mechanical ventilation. Would care and fluid replacement will be necessary and a foley is commonly
inserted to evaluate I&O levels. Analgesic as needed and IV access will be necessary. Prior to dressing
changes ensure pain medication is given as ordered. Weight patient daily and auscultate heart and
lungs. Reposition every 2 hours and provide NG tube feedings if needed.
Name:
Group 4
Type of Burn: Third degree burn
Clinical Manifestations (Symptoms): This burn involves all layers of epidermis and dermis and may
destroy subcutaneous structures. It usually appears either white or charred. They are insensate
because of the amount of destruction of nerve endings and are usually best treated with skin grafting
to limit scarring.
Nursing Assessment: Rule of nines for documentation % affected. Waxy, white, leathery, or charred
skin that does not blanch and is nonpliable to palpation will be present. Stridor, wheezing, crackle, or
rhonchi may also be present. Assess for hoarseness, soot marks on face, hypotension and blisters or
edema particularly of the oropharynx. Cause of burn may reveal other medical conditions.
Labs/Diagnostic Tests: Common test are ABG’s for smoke inhalation and decreased alveolar function
or hypoxia. CBC, H&H, BUN, and electrolytes are typical to determine fluid loss.
Nursing Interventions: Same as fourth degree - Patient will need burn unit. Immediate and aggressive
treatment using strict sterile technique is necessary. Clothing removal is necessary, then cover patient
with clean, dry sheets. Oxygen sat needs to be managed and kept at 94% or higher. Intubation is likely
along with mechanical ventilation. Would care and fluid replacement will be necessary and a foley is
commonly inserted to evaluate I&O levels. Analgesic as needed and IV access will be necessary. Prior
to dressing changes ensure pain medication is given as ordered. Weight patient daily and auscultate
heart and lungs. Reposition every 2 hours and provide NG tube feedings if needed.