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 (3 rd 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 (4 th degree) burn – it involves
all the layers of the skin including the muscles, organ tissues and bone. Charring occurs in this case.
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.