burns nursing care plan

Burns, or burn injuries, are a result of tissue damage due to heat transfer from one site to another. In most cases, this heat is much more than the skin can withstand, leading to disruption in the skin’s integrity and other problems such as fluid loss, increased risk for infection, ineffective thermoregulation, and issues with aesthetic appearance and body image of the patient.

Among patients who are at highest risk for development of complications related to burn injuries are those who are very young and the very old. This is due to the percentage of body fluids among these patients, their abilities to heal from tissue injuries and the existence of other comorbid conditions such as coronary artery diseases, diabetes mellitus, cancer and others. Also, because the severity of the burn injuries worsen the longer it persists, there is a need for the nurse to properly assess and diagnose patients’ needs that require immediate attention while ensuring that problems at highest risk to develop are prevented if not eliminated.

Burns are classified according to their thickness and degree of injury. These are made to denote to the extent of tissue injury and destruction, as well as to help in planning interventions to minimize the complications that the injury can bring about to the patient. Classification according to thickness include:

  • Superficial partial thickness burns- in this type of injury, only the epidermis is damaged, but some portions of the dermis may also be injured.
  • Deep partial thickness burns- this type is characterized by the full injury of the epidermis, and involvement of the upper layer and deeper portions of the dermis.
  • Full thickness burns as the name implies, full thickness burns involve the destruction of both the dermal and epidermal layers as well as involvement of the surrounding tissues, muscles and even bones.

Burns may also be classified according to degree of tissue involvement (see Fig.1 for representation). These are:

  • First Degree Burns- this classification is made when the burn injury only affects the outer layer of the skin and is characterized by the presence of red, painful and dry skin surrounding the injury. This is the most painful of all types of injury because of the exposure of naked nerve endings.
  • Second Degree Burns- this involves damage to the entire epidermis and some portions of the dermis that is characterized by the presence of red, painful and oftentimes blistered areas. In some cases, edema and swelling are also part of the assessment findings.
  • Third Degree Burns- also called as full thickness burns, this involves the destruction of both the dermis and the epidermis and sometimes goes into the innermost layers of the skin. The burnt site usually looks whitish, charred or even blackened.
  • Fourth Degree Burns- this type of burn injury goes through all layers of the skin, muscles and bone. In this type of injury, there is eschar formation and the patient normally does not feel anything at the site of injury.
burn classification of injuries
Figure 1. Classifications of Burn Injuries According to Thickness (Image Copyright: Schwartz’s Principle of Surgery, 10th ed.)

While the problem with burns is mostly integumentary, there are also other nursing problems that can be seen among patients.

Burns Nursing Care Plan

There are a number of nursing diagnoses (both risk and actual problems) for burns that the nurse can identify based on assessment findings such as:

  • Ineffective airway clearance
  • Impaired gas exchange
  • Impaired/Alteration in skin integrity
  • Risk for/Fluid volume deficit
  • Risk for Infection
  • Pain
  • Anxiety
  • Body Image Disturbance

Assessment of the patient will need to be structured to ensure that the patient will not be stressed unnecessarily, and that the nurse will be able to fully identify the signs and symptoms indicative of the health problem. Moreover, the assessment for potential or at risk health problems should be made thoroughly and any intervention to prevent is must be aligned to the overall care plan for the patient. Below are examples of care plans for 2 actual and 2 potential/risk problems for patients suffering from burns.

Ineffective Airway Clearance

Ineffective airway clearance related to increased/increasing congestion in the airway passages secondary to smoke inhalation as evidenced by presence of inspiratory and expiratory wheezing, sooty sputum production, persistent cough and use of accessory muscles when breathing.

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Demonstrate improved airway patency as evidenced by clear breath sounds
  • Have decreased coughing episodes
  • ABGs and other laboratory values within normal limits
Nursing Action Rationale
Assess vital signs, focusing on respiratory rate and rhythm, depth of respirations and symmetrical chest expansions Vital signs assessment can help provide the nurse information on the extent of airway impairment that the injury causes to the patient. This also helps set the baseline for evaluation of care.
Observe the patient for other signs of inhalation injury such as damage to the circumoral mucosa, burns along the nostrils, face or neck. These surrounding structures are also important in air exchange and may cause disruptions in airway clearance when injured or damaged.
Position the patient in semi-Fowler’s or high Fowler’s position. Positioning the patient this way helps in promoting optimal lung expansion and removal of secretions. It also allows the patient to be positioned comfortably.
Provide the patient oxygen therapy when needed. Humidified oxygen therapy helps meet the needs of the patient for tissue perfusion and reduces the risk for hypoxia.
If the patient is on oxygen therapy, monitor the ABGs as needed. ABGs are a good indicator of the oxygenation status of the patient along with the pulse oximetry readings. Changes in these readings should be documented and reported to the physician when needed.
Instruct patient and significant others on how to turn patient properly on bed, coughing and deep breathing exercises and use of incentive spirometer. These all help in establishing patent airway, maintaining optimum lung capacity and promote independence for self care.

Alteration/Impairment in Skin Integrity

Impaired skin integrity related to damage to the skin and surrounding tissues sec0ndary to burn injury as evidenced by (indicate the signs seen on patient depending on the thickness/degree of the burn injury).

Desired Outcomes

After nursing interventions, the patient is expected to:

  • Manifest increased capacity for wound healing
  • Cooperate with plan of care for burn wounds
  • Have reduced risk to develop infections secondary to wounds
Nursing Action Rationale
Assess status of the burned area, noting for the degree of tissue involvement and extent of the damage. Knowing exactly the wound coverage helps in planning for care of the patient.
Determine the type of irritating agent that caused the wound. There are specific care requirements for some type of wounds depending on the nature of injury (i.e., thermal vs. chemical). Knowing these would help the nurse in planning appropriate care for the patient.
Provide the patient support during initial phases of wound care. In some cases, the initial phases of wound care for burns may be painful and distressing to the patient, especially when these involve debridement. Providing the patient support eases stress and anxiety and helps the patient to cooperate in his care plan.
Involve the patient and his significant others in performing wound care and dressing changes. This action helps to promote independent self care for the patient and collaboration between the patient, his significant others and the members of the health team.
Administer medications as prescribed. These substances are prescribed to the patient to help promote tissue growth, wound healing and in some cases, prevent formation of keloids.
Stress the importance of asepsis, especially when handling wound. This helps prevent infections at the wound site.
Make referral to physical/occupational therapy when needed. In cases where wound affects functionality of a certain part of the body, the patient may need to be referred to a PT/OT to help promote optimal functioning.
Consider referring to cosmetic/aesthetic surgery and/or other support groups when needed. Severe damage to the skin may need to be aesthetically reconstructed and the patient may need counseling or therapy to help deal with the potential for body image problems later on.

Risk for Fluid Volume Deficit

Risk for  fluid volume deficit related to loss of fluids through abnormal routes secondary to burn injury

Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already make the nursing problem an actual diagnosis.

Desired Outcomes

After nursing interventions, the patient is expected to (choose the factor that is related to the factor that poses as a risk):

  • Establish normal fluid volume
  • Minimize unnecessary fluid losses
  • Increase intake of oral fluids (if allowed, and/or tolerated)
Nursing Action Rationale
Monitor vital signs while paying close attention to monitoring the hourly urine output, central venous pressures, cardiac output and pulmonary artery pressures. These are indicative of the hemodynamic status of the patient and would alert the nurse if the patient suffers from dehydration or over hydration.
If needed, calculate fluid volume replacement needs by the patient and infuse accordingly. During the initial stages after a burn injury, there is a need to ensure that fluid volume need replacement is established. In some cases, Parkland Formula is used to calculate the fluid needs for the first 24 hours:

 

BSA (% burned) x 4 x Body Weight (in kg)

 

The resulting volume will then be divided by 2, with the first 50% of the volume infused over an 8 hour period, while the remaining 50% infused in a 16-hour timeframe.

Ensure patency of IV lines and encourage the patient to take fluids orally (if not contraindicated) and document. This helps ensure adequate fluid volumes are restored and maintained and the risk for fluid volume deficit is minimized.
Monitor serum electrolyte levels regularly. To help determine developing electrolyte imbalances and to correct them early on.
Position patient comfortably on bed and maintain room temperature at comfortable level. This helps relax the patient while ensuring that room temperature does not promote drying of the skin or excessive sweating
Notify physician immediately when the patient assessment reveals reduced urine output, reduction in blood pressure or lowering of other indicators of hemodynamic status. Early identification of these symptoms can help the health care team address any hemodynamic imbalances on the patient and restore normal fluid volume.

Risk for Infection

Risk for infection related to decreased primary defenses secondary to burn injury

Note: “evidenced by” is not usually applicable for a risk diagnosis since the presence of signs and symptoms already make the nursing problem an actual diagnosis.

Desired Outcomes

After the nursing interventions, the patient is expected to:

  • Have reduced risk for developing wound infections
  • Verbalize knowledge on maintaining aseptic technique in handling wounds
  • Manifest enhanced capacity to promote wound healing
Nursing Action Rationale
Institute the use of aseptic technique in handling wound. This helps ensure that infective agents and microorganisms are limited from coming in contact with the wound site and the risk of infection is reduced.
Adhere to the wound changing and dressing schedule, noting carefully the times when dressings need to be changed. This helps promote adequate wound healing and avoid infection by ensuring that the dressings remain free of moisture so it does not harbor microorganisms.
Remind the patient to avoid touching the wound, only touching it during wound dressings. The hand is one of the worst contaminants of wounds and frequent touching increases the risk of infections. Only touching it during wound dressings would reduce the risk for infection dramatically.
Prevent the skin surfaces from rubbing together and ensure that the surrounding skin is kept clean and dry, Excessive moisture or dryness of the skin can cause further breaks in skin integrity and rubbing skin surfaces together may cause micro lacerations which can eventually become portal of entry for other microorganisms.
Increase intake of foods rich in protein and vitamin C. Protein is essential for tissue growth and repair while vitamin C can help restore vessel integrity and increase immune system response.

References

  1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis.
  2. Carpenito, L. (2016). Handbook of Nursing Diagnosis (15th ed.).
  3. Herdman, T., & Kamitsuru, S. (2018). NANDA International, Inc. nursing diagnoses (11th ed.).
  4. Brunicardi, F., & Anderson, D. (2015). Schwartz’s principles of surgery. (includes DVD). New York: McGraw-Hill.

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