A 5-year-old girl was admitted to the emergency room after a house fire. She had

Question

A 5-year-old girl was admitted to the emergency room after a house fire. She had burns over her trunk, extremities, and back. The physician notes that 60% are the burns are second-degree full-thickness burns. On admission assessment, the nurse finds the patient's BP was 90/60, P 110, and R 20. Why is it so important in this patient for the nurse to monitor fluid balance? The patient complains of shortness of breath, and the nurse notes an increased respiratory rate. Why is it important for the nurse to monitor carefully respiratory function? Why is infection an important risk in this patient? (Learning Objective 11, 12, 13, 14, 15)

Explanation / Answer

Full thickness burns cause damage to epidermis, dermis, and sub-cutaneous layers of skin and tissue.

1. As skin is responsible for providing protection against fluid and electrolyte loss and burn injury affects this function and a systemic dehydration can be a result of the loss of skin integrity which can trigger a fluid loss.

2. Thermal injury can result in inhalation of smoke, carbon monoxide poisoning, and problems secondary to airway obstruction. Airway obstruction from oral or facial edema, or bronchospasm and alveolar damage from inhalation of toxic vapors or particles are commonly seen in such cases. Thus, it is important to monitor carefully respiratory function.

3. All the burn woulds are characterized by the presence of bacteria, so a nurse must perform detailed surveillance of burn wounds to notice any change in color, increased exudate, and pain.

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