Nursing Assessment During the Resuscitation/Emergent Phase of Superficial Partial-Thickness Burns

Introduction

The resuscitation/emergent phase of a burn injury is the first 24-48 hours after the injury occurs. During this time, the body is in shock and there is a risk of fluid loss and electrolyte imbalances. The primary goal of resuscitation is to restore fluid and electrolyte balance and prevent complications.

Nursing Assessment During the Resuscitation/Emergent Phase of Superficial Partial-Thickness Burns

The nurse will assess the client for the following during the resuscitation/emergent phase of superficial partial-thickness burns:

• Vital signs: The nurse will monitor the client’s vital signs closely for signs of shock, such as hypotension, tachycardia, and tachypnea.
• Airway: The nurse will assess the client’s airway to ensure that it is patent and that the client is able to breathe adequately.
• Breathing: The nurse will assess the client’s respiratory rate and depth. The nurse will also look for any signs of respiratory distress, such as shortness of breath, wheezing, or cyanosis.
• Circulation: The nurse will assess the client’s circulation to ensure that they have adequate blood flow. The nurse will check the client’s capillary refill time, pulse, and blood pressure.
• Disability: The nurse will assess the client’s level of consciousness and responsiveness. The nurse will also assess the client’s neurological status, including their pupils, motor strength, and sensory function.
• Exposure: The nurse will completely expose the client’s body to assess the severity of their burns. The nurse will also look for any other injuries that may not be immediately apparent.

Specific Findings in Superficial Partial-Thickness Burns

In addition to the above, the nurse may expect to note the following findings during the resuscitation/emergent phase of superficial partial-thickness burns:

• Pain: Superficial partial-thickness burns are typically painful. The nurse will assess the client’s pain level and provide pain medication as needed.
• Edema: Superficial partial-thickness burns can cause edema (swelling) in the affected area. The nurse will monitor the client’s edema and provide elevation of the affected extremity as needed.
• Blisters: Superficial partial-thickness burns often form blisters. The nurse will inspect the blisters for any signs of infection, such as redness, swelling, or drainage.
• Fluid loss: Superficial partial-thickness burns can cause fluid loss through the burned skin. The nurse will monitor the client’s fluid status and provide fluid resuscitation as needed.

Conclusion

The nurse will carefully assess the client during the resuscitation/emergent phase of superficial partial-thickness burns. The nurse will monitor the client’s vital signs, airway, breathing, circulation, disability, and exposure. The nurse will also assess the client for pain, edema, blisters, and fluid loss.

Additional Information

The nurse should also educate the client on the signs and symptoms of complications from superficial partial-thickness burns, such as infection and compartment syndrome. The nurse should instruct the client to report any of the following symptoms to the nurse immediately:

• Increased pain
• Increased swelling
• Redness or warmth at the wound site
• Drainage from the wound site
• Fever
• Fast heart rate
• Difficulty breathing