Faulkner State Community College; Division of Nursing

NUR 201
Clinical Paperwork Data Sheet

Student Name___________________________________ Clinical Week_______________________________

Date _____________ Client Initials__________ Age _______________ Admission Date ______________

Instructor_______________________________________ Clinical Area ________________________________

Medical Diagnosis and Pathophysiology: (Be sure to list signs and symptoms). Please indicate your
source of information.

The patient was using gasoline to fuel a trash fire and fire flashed up. This most common type of burn is a
thermal burn, which is caused by steam, scalds, contact with heat, and fire injuries. The patient has 40%
TBSA burns. The patient has partial-thickness burns on the head, neck, anterior trunk, R thigh, L thigh, R
leg, and L leg. Patient has partial-thickness & full-thickness burns on L upper arm, R upper arm, L lower
arm, R hand, and L hand. This patient has partial-thickness and full-thickness burns. Partial-thickness
burns involve the upper third of the dermis. A light to bright red or mottled appearance characterizes
superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are
extremely painful and sensitive to air currents. A full-thickness burn involves destruction of all the layers of
the skin down to and including the subcutaneous tissue and occasionally bone. A full thickness burn may
appear pale, white, charred, red, brown, and leathery. The surface of the burn may be dry, and if the skin
is broken, fat may be exposed. Full-thickness burns are usually painless and insensitive to palpation due to
nerve ending destruction. Extensive full-thickness wounds leave the patient extremely susceptible to
infections, fluid and electrolyte imbalances, alterations in thermoregulation, and metabolic disturbances.

The skin is the largest organ of the human body providing functions crucial to human survival. A burn is
an injury resulting in tissue loss and/or damage. Injury to tissue can be caused by exposure to thermal,
electrical, chemical, and/or radiation sources. Recognition of the magnitude of burn injury, which is based
on the depth and size of the burn and previous health of the patient, is crucial in the overall plan of care.
In the hospital setting, the Lund and Browder method is the most accurate and accepted method for
determining the percentage of burn. Surface area measurements are assigned to each body part in terms of
the age of the patient. Currently, burns are classified as superficial, partial-thickness, or full-thickness.

Burn injuries greater than 35% TBSA can result in burn shock. Shock is defined as inadequate cellular
perfusion, and significant burn injury results in hypovolemic shock and tissue trauma. In hypovolemic
shock, the burning agent produces a dilation of the capillaries and small vessels, thus increasing the
capillary. At the cellular level the burning agent produces a dilation of the capillaries and small vessels,
thus increasing the capillary permeability. Plasma seeps out into the surrounding tissue, producing
blisters and edema. The type, duration, and intensity of the burn all effect the amount and extent of fluid
loss. This progressive fluid loss in extensive burns results in significant intravascular fluid volume deficit.
The edema occurs locally in the burn wound and systemically in unburned tissues. Edema formation is
unique to thermal injury.

Thelans Critical Care Nursing, 5 th Edition; Linda D. Urden, Kathleen M. Stacy, Mary E. Lough
Medical-Surgical Nursing, 5 th Edition; Ignatavicius, Workman

List and prioritize any secondary diagnosis that has been identified for your client (Based on your patient's
problems).

1. MRSA 5.
2. Pneumonia 6.
3. 7.
4. 8.