Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide Signs and symptoms of partial-thickness burns: • Blisters • Edema Signs and symptoms of deep partial-thickness burns: • Red/white color • Blistering (rare) • • Signs and symptoms of full-thickness burns: • Leathery appearance • Eschar to bone and muscle • White/brown/yellow/cherry red/black tissue color • Sweat glands/hair follicles destroyed • Edema • Charred subcutaneous tissue Signs and symptoms of deep full-thickness burns: • Black color • Absence of blisters/pain/edema Nursing assessment for burns: • General head to toe assessment of body for injuries: smoke inhalation (upper body, lips, buccal mucosa, pharynx, singed nares, soot or oropharynx, black sputum, hoarseness, or increased respiratory sounds) • Vital signs and assess for signs of shock and pulse oximetry • Check for carbon monoxide exposure: cherry red skin, headaches, vision changes, irritable, nausea, ataxia, decreased judgement, and confusion • Ask if patient has had a recent tetanus toxoid immunization • Determine burn area percentage (BSA) of total body surface: o Rule of Nines : Head=9%, right/left arms=9% each, right/left legs=18% each, trunk=18%, back=18%, genital area=1%; the areas totaled up must equal 100%; the burn status is then determined by the percentage. o Minor burns: Full thickness burns less than 3% BSA, partial thickness burns less than 15% BSA, and less than 10% in children o Moderate burns: Involves 3-10% BSA with full thickness burns, 25% or more with partial thickness burns or 10-20% in children o Major burns: Over 10% BSA full thickness burns, over 25% BSA with partial thickness burns, and over 20% BSA in children; trauma and burns to feet, hands, face, genitals, perineum, respiratory, and electrical burns are also considered major • Pain Pain Edema (moderate)

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