- Sympathetic stimulation during the emergent phase causes reduced GI motility and
paralytic ileus
- Auscultate the abdomen to assess bowel sounds which may be reduced
- Monitor for n/v and abdominal distention
- Clients with burns of 25% TBSA or who are intubated generally require a NG tube
inserted to prevent aspiration and removal of gastric secretions
Skin Assessment
- Assess the skin to determine the size and depth of burn injury
- The size of the injury is first estimated in comparison to the total body surface area
(TBSA). For example, a burn that involves 40% of the TBSA is a 40% burn
- Use the rule of nines for clients whose weights are in normal proportion to their
heights
Classification of Extent of Burn Injury
- Minor Burn Injury
- Second-degree burn of <15% total body surface area (TBSA) in adults or <10%
TBSA in children
- Third-degree burn of <2% TBSA not involving special care areas (eyes, ears, face,
hands, feet, perineum, joints)
- Excludes all patients with electrical injury, inhalation injury, or concurrent trauma and
all poor-risk patients (eg, extremes of age, intercurrent disease)
- Moderate, Uncomplicated Burn Injury
- Second-degree burns of 15–25% TBSA in adults or 10–20% in children
- Third-degree burns of <10% TBSA not involving special care areas
- Excludes electrical injury, inhalation injury, or concurrent trauma and all poor-risk
patients (eg, extremes of age, intercurrent disease)
- Major Burn Injury
- Second-degree burns >25% TBSA in adults or >20% in children
- All third-degree burns >10% TBSA
- All burns involving eyes, ears, face, hands, feet, perineum, joints
- All inhalation injury, electrical injury, or concurrent trauma, and all poor-risk patients