11 Burn Injury Nursing Care Plans

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Burn Injury Nursing Care Plans
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In this guide are nursing diagnosis for burns nursing care plans. Included are nursing interventions and nursing assessment for burns. Learn about the goals, related factors of each nursing diagnosis and rationale for each nursing interventions for burns.

A burn injury is damage to your body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns. A major burn is a catastrophic injury, requiring painful treatment and long period of rehabilitation. It’s commonly fatal or permanently disfiguring and incapacitating (both emotionally and physically).

Classification of Burns

Burns are classified according to depth and extent of injury. Classifications of the depth of burns include: first-degree (partial thickness), second-degree (superficial or deep partial thickness), and third-degree (full-thickness).

A first-degree burn indicates destruction of the epidermis resulting in localized pain and redness. Healing is complete and occurs within 5 to 10 days. A superficial second-degree burn indicates destruction of the epidermis and the upper third of the dermis; it is characterized by pain and blister formation. Healing is complete but requires extended time to occur. A deep second-degree burn indicates destruction of the epidermis and dermis, leaving only the epidermal skin appendages within the hair follicles. The skin may be waxy white in appearance and require grafting or prolonged periods of recovery. A third-degree burn indicated destruction of the entire epidermis and dermis and typically involves fat and muscle; the skin may be white, charred, or leathery in appearance. This burn requires skin grafting and prolonged periods of recovery.

Phases of Burn Injury

Paying attention and caring for a patient with burns serve as an extraordinary demand to even the most experienced nursing staff because few injuries pose a greater threat to the patient’s physical and emotional wellbeing. There are three phases of burn injury, each requiring various levels of patient care. The three three phases are emergent phase, intermediate phase, and rehabilitative phase.

The emergent phase starts with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of patient care involves maintaining an adequate airway and treating the patient for burn shock.

The intermediate phase of burn care starts about 48–72 hours after the burn injury. Alterations in capillary permeability and a return of osmotic pressure bring about diuresis or increased urinary output. If renal and cardiac functions do not return to normal, the added fluid volume, which prevented hypovolemic shock, can now produce manifestations of congestive heart failure. Assessment of central venous pressure gives information regarding the patient’s fluid status.

The final stage in caring for a patient with burn injury is the rehabilitative stage. This stage starts with closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.

Nursing Care Plans

Nursing care involves immediate and aggressive burn treatment. Supportive measures and strict sterile technique should be implemented to minimize infection.

Here are 11 nursing care plans (NCP) and nursing diagnosis for patients with a burn injury (burns): 

  1. Impaired Physical Mobility
  2. Deficient Knowledge
  3. Disturbed Body Image
  4. Fear/Anxiety
  5. Impaired Skin Integrity
  6. Imbalanced Nutrition: Less Than Body Requirements
  7. Risk for Ineffective Tissue Perfusion
  8. Acute Pain
  9. Risk for Infection
  10. Risk for Deficient Fluid Volume
  11. Risk for Ineffective Airway Clearance
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Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

May be related to

  • Neuromuscular impairment, pain/discomfort, decreased strength and endurance
  • Restrictive therapies, limb immobilization; contractures

Possibly evidenced by

  • Reluctance to move/inability to purposefully move
  • Limited ROM, decreased muscle strength control and/or mass

Desired Outcomes

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  • Maintain position of function as evidenced by absence of contractures.
  • Maintain or increase strength and function of affected and/or compensatory body part.
  • Verbalize and demonstrate willingness to participate in activities.
  • Demonstrate techniques/behaviors that enable resumption of activities.
Nursing InterventionsRationale
Nursing Assessment
Note circulation, motion, and sensation of digits frequently.Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
Initiate the rehabilitative phase on admission.It is easier to enlist participation when patient is aware of the possibilities that exist for recovery.
Therapeutic Interventions
Maintain proper body alignment with supports or splints, especially for burns over joints.Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
Perform ROM exercises consistently, initially passive, then active.Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
Medicate for pain before activity or exercise.Reduces muscle and tissue stiffness and tension, enabling patient to be more active and facilitating participation.
Schedule treatments and care activities to provide periods of uninterrupted rest.Increases patient’s strength and tolerance for activity.
Encourage family/SO support and assistance with ROM exercises.Enables family/SO to be active in patient care and provides more consistent therapy.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able.Promotes independence, enhances self-esteem, and facilitates recovery process.
Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.Combining activities produces improved results by enhancing effects of each.
Encourage patient participation in all activities as individually able.Promotes independence, enhances self-esteem, and facilitates recovery process.
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Other Possible Nursing Care Plans

  • Post-trauma syndrome related to life-threatening event, possibly evidenced by reexperiencing the event, repetitive dreams/nightmares, emotional numbness, and sleep disturbance.
  • Ineffective protection related to extremes of age, inadequate nutrition, anemia, impaired immune system, possibly evidenced by impaired healing, deficient immunity, fatigue, anorexia.
  • Deficient diversional activity related to long-term hospitalization, frequent or lengthy treatments, and physical limitations, possibly evidenced by expressions of boredom, restlessness, withdrawal and requests for something to do.
  • Risk for delayed development—risk factors may include effects of physical disability, separation from SO, and environmental deficiencies.

References and Sources

The following are the references and recommended sources for [focus keyword] including interesting resources to further your reading about the topic:

  • Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby. [Link]
  • Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier. [Link]
  • Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins. [Link]
  • Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis. [Link]
  • Fisher, M. E., Moxham, P. A., & Bradshaw, B. W. (1989). U.S. Patent No. 4,813,422. Washington, DC: U.S. Patent and Trademark Office. [Link]
  • Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
  • Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2017). Medical-surgical nursing: Assessment and management of clinical problems.

See Also

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Integumentary Care Plans

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3 COMMENTS

  1. Thanks Staff Matt for the NCP’S, they’ve been very helpful in my studies! Keep up the hardwork!
    -God bless

  2. Comment: thank you so much for the care plan. but can we say the diagnose and the care plan are according to priority?

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