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Nursing Diagnosis: Nutrition: imbalanced, less than body requirements
May be related to
- Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
- Protein catabolism
- Anorexia, restricted oral intake
Possibly evidenced by
- Decrease in total body weight, loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance
Desired Outcomes
- Demonstrate nutritional intake adequate to meet metabolic needs as evidenced by stable weight/muscle-mass measurements, positive nitrogen balance, and tissue regeneration.
11 Burn Injury Nursing Care Plan (NCP)
- Impaired Physical Mobility — Burns Nursing Care Plan (NCP)
- Knowledge Deficit — Burns Nursing Care Plan (NCP)
- Disturbed Body Image — Burns Nursing Care Plan (NCP)
- Fear/Anxiety — Burns Nursing Care Plan (NCP)
- Impaired Skin Integrity — Burns Nursing Care Plan (NCP)
- Imbalanced Nutrition — Burns Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Burns Nursing Care Plan (NCP)
- Acute Pain — Burns Nursing Care Plan (NCP)
- Risk for Infection — Burns Nursing Care Plan (NCP)
- Risk for Deficient Fluid Volume — Burns Nursing Care Plan (NCP)
- Risk for Ineffective Airway Clearance — Burns Nursing Care Plan (NCP)
Imbalanced Nutrition — Burn Injury Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Auscultate bowel sounds, noting hypoactive/absent sounds. | Ileus is often associated with postburn period but usually subsides within 36–48 hr, at which time oral feedings can be initiated. |
| Maintain strict calorie count. Weigh daily. Reassess percentage of open body surface area/wounds weekly. | Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As burn wound heals, percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made. |
| Monitor muscle mass/subcutaneous fat as indicated. | Indirect calorimetry, if available, may be useful in more accurately estimating body reserves/losses and effectiveness of therapy. |
| Provide small, frequent meals and snacks. | Helps prevent gastric distension/discomfort and may enhance intake. |
| Encourage patient to view diet as a treatment and to make food/beverage choices high in calories/protein. | Calories and proteins are needed to maintain weight, meet metabolic needs, and promote wound healing. |
| Ascertain food likes/dislikes. Encourage SO to bring food from home, as appropriate. | Provides patient/SO sense of control; enhances participation in care and may improve intake. |
| Encourage patient to sit up for meals and visit with others. | Sitting helps prevent aspiration and aids in proper digestion of food. Socialization promotes relaxation and may enhance intake. |
| Provide oral hygiene before meals. | Clean mouth/clear palate enhances taste and helps promote a good appetite. |
| Perform fingerstick glucose, urine testing as indicated. | Monitors for development of hyperglycemia related to hormonal changes/demands or use of hyperalimentation to meet caloric needs. |
| Refer to dietitian/nutritional support team. | Useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes. |
| Provide diet high in calories/protein with trace elements and vitamin supplements. | Calories (3000–5000/day), proteins, and vitamins are needed to meet increased metabolic needs, maintain weight, and encourage tissue regeneration. Note: Oral route is preferable once GI function returns. |
| Insert/maintain small feeding tube for enteral feedings and supplements if needed. | Provides continuous/supplemental feedings when patient is unable to consume total daily calorie requirements orally. Note: Continuous tube feeding during the night increases calorie intake without decreasing appetite and oral intake during the day. |
| Administer parenteral nutritional solutions containing vitamins and minerals, as indicated. | Total parenteral nutrition (TPN) maintains nutritional intake/meets metabolic needs in presence of severe complications or sustained esophageal/gastric injuries that do not permit enteral feedings. |
| Monitor laboratory studies, e.g., serum albumin/ prealbumin, Cr, transferrin; urine urea nitrogen. | Indicators of nutritional needs and adequacy of diet/therapy. |
| Administer insulin as indicated. | Elevated serum glucose levels may develop because of stress response to injury, high caloric intake, pancreatic fatigue. |
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