Page 315 - Critical Care Nursing Demystified

300 CRITICAL CARE NURSING DeMYSTIFIED

BUN and creatinine determine if renal failure is occurring.
Glucose temporarily elevated due to stress response.

WBCs can show if infection is developing.

Hallmark Signs and Symptoms
Nasal singeing and cherry red mucous membranes can indicate carbon mon-
oxide inhalation injury.
Skin can be assessed using the depth of skin involvement at the burn surface
area. Burn depths are known as superficial (first degree), partial-thickness
(second degree), full-thickness (third degree), and fourth-degree burns
(see Table 6–10).

TABLE 6–10 Depth of Burns

Classification of Layer of Skin
Burn and Examples Involved Description/Healing
Superficial burns: Epidermis or Pink to red in color and will be slightly
Scald outer layer of edematous
skin Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Slight Sunburn Heal within 3 to 6 days
Painful, rarely require hospitalization
Partial-thickness Epidermis and Bright red; edematous with blister
burns: the dermal layer formation occurring within minutes of
Severe scald of skin exposure
Immersion Hair follicles and sebaceous and sweat
thermal burn glands remain intact
Healing occurs within 3 weeks without
scarring
Full-thickness Encompasses all Ranges from pale to bright red
burn: layers of the skin Capillary refill is compromised; blood
Severe chemical vessels may appear black and
exposure thrombosed
Little or no pain due to loss of pain
receptors
Hair growth will be absent due to loss
of hair follicles
Require skin grafting for full recovery
Fourth-degree Extends into the Black or charred, necrotic tissue
burn: subcutaneous Removal of necrotic tissue is required
Severe electrical tissues, muscle, High mortality rate
burn and bone