When tissues are burned; fluid leaks into the tissues from the blood vessels which cause swelling and pain. However, some burns may be severe which affects deeper body structures, such as fat, muscle or bone.
There are five classifications of burns:
- Superficial partial thickness burn – injury in the skin tissues involving only the epidermis; the wound may appear bright pink to red with minimal edema and without blisters. The affected skin is dry and warm to touch.
- Moderate partial thickness burn – it involves the epidermis and the dermis by which the wound appears to be red to pink with moderate edema and with moist and weeping blisters. When the burn is
- Deep partial thickness burn – it involves the deep dermis by which the wound looks pink to pale ivory with moderate edema and blisters; the wound is dryer than moderate partial thickness burn.
- Full thickness (3rd degree) burn – it involves all the layers of the skin, also including the subcutaneous fat, muscle, nerves and blood supply in some cases. The wound appears from cherry red to brown or black with no blistering formation. It is dry and leathery in texture.
- Full thickness (4th degree) burn – it involves all the layers of the skin including the muscles, organ tissues and bone. Charring occurs in this case.
The Merck Manual of Medical Information 2nd Home Edition. (2003). Merck & Co., Inc.
Nursing Diagnosis: Risk for Fluid Volume Deficit
Possible Etiologies: (Related to)
- Loss of fluid through abnormal routes, i.e. burn wounds
- Increased requirement need for fluid
- Hypermetabolic state
- Insufficient intake
- Hemorrhagic losses
Defining Characteristics: (Evidenced by)
*NOT APPLICABLE since the problem has not occurred yet and nursing intervention focus on prevention.
Short term goal:
Client will be able to demonstrate an improved fluid balance as evidenced by client’s adequate urinary output, stable vital signs and moist mucous membranes after one week of nursing care.
Long term goal:
Client will be able to understand condition and identify risk factors potential for further fluid volume deficit.
Client will be able to maintain normal fluid volume balance as evidenced by urine output more or equal to 30 cc per hour (reflecting normal fluid intake), stable vital signs and good skin turgor and moist mucous membranes after one week of nursing care.
Client will be able to understand condition and identify risk factors contributing to imbalance in fluid volume.
|Assess and monitor vital signs and note for the capillary refill and strength of pulses.||- It provides as baseline data for fluid replacement therapy.|
|Monitor urinary output of client.||- Fluid replacement should be adjusted to ensure average urinary output of 30 – 50 cc/ hour.|
|Assess for the estimate of wound drainage and insensible loss.||-Increased capillary permeability, protein shifts and inflammatory process greatly affect the circulatory volume and urine output.|
|Strictly document the amount and type fluid used during replacement therapy.||-Ensures accuracy and effectiveness of fluid replacement therapy.|
|Weigh client daily.||-A 15% – 20% weight gain within 72 hours can be expected, which will return to preborn weight after 10 days in approximation.|
|Investigate changes in mentation.||-Decrease in LOC may indicate inadequate cerebral perfusion.|
|Observe for presence of gastric distention, hematemesis, and tarry stools.||-Stress ulcer occurs in up to half of all severely burned clients, which happens usually in the first week.|
|Insert and maintain an indwelling catheter as indicated.||-This allows close observation of renal functions and prevents urinary retention.|
|Insert and maintain large bore IV cannula.||- To accommodate large and rapid infusion of fluids.|
|Administer intravenous fluids as indicated or as needed.||- It helps prevent fluid deficit and any loss should be replacement effectively.|
|Monitor laboratory results like hemoglobin, hematocrit, and electrolyte levels.||- It could aid in determining blood loss or RBC destruction as well as the need for electrolyte replacements.|
|Administer medications like diuretics, potassium, and antacids.||- Diuretics are given to enhance urinary output; potassium is administered for replacement of large fluid losses; and antacids, to reduce gastric acidity.|
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