11 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

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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.

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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
  12. Other possible nursing care plans
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Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk factors may include

  • Loss of fluid through abnormal routes, e.g., burn wounds
  • Increased need: hypermetabolic state, insufficient intake
  • Hemorrhagic losses

Desired Outcomes

  • Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes.
Nursing InterventionsRationale
Nursing Assessment
Monitor vital signs, central venous pressure (CVP). Note capillary refill and strength of peripheral pulses.Serves as a guide to fluid replacement needs and assesses cardiovascular response. Note: Invasive monitoring is indicated for patients with major burns, smoke inhalation, or preexisting cardiac disease, although there is an associated increased risk of infection, necessitating careful monitoring and care of insertion site.
Monitor urinary output and specific gravity. Observe urine color and Hematest as indicated.Generally, fluid replacement should be titrated to ensure average urinary output of 30–50 mL/hr (in the adult). Urine can appear red to black (with massive muscle destruction) because of presence of blood and release of myoglobin. If gross myoglobinuria is present, minimum urinary output should be 75–100 mL/hr to reduce risk of tubular damage and renal failure.
Estimate wound drainage and insensible losses.Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24–72 hr after burn injury.
Weigh daily.Fluid replacement formulas partly depend on admission weight and subsequent changes. A 15%–20% weight gain can be anticipated in the first 72 hr during fluid replacement, with return to pre-burn weight approximately 10 days after burn.
Evaluate changes in mentation.Deterioration in the level of consciousness may indicate inadequate circulating volume and reduced cerebral perfusion.
Measure circumference of burned extremities as indicated.May be helpful in estimating extent of edema and fluid shifts affecting circulating volume and urinary output.
Observe for gastric distension, hematemesis, tarry stools. Hematest nasogastric (NG) drainage and stools periodically.Stress (Curling’s) ulcer occurs in up to half of all severely burned patients and can occur as early as the first week. Patients with burns more than 20% TBSA are at risk for mucosal bleeding in the gastrointestinal (GI) tract during the acute phase because of decreased splanchnic blood flow and reflex paralytic ileus.
Monitor laboratory studies: Hb/Hct, electrolytes, random urine sodium.Identifies blood loss or RBC destruction and fluid and electrolyte replacement needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. Note: During first 24 hr after burn, hemoconcentration is common because of fluid shifts into the interstitial space.
Therapeutic Interventions
Maintain cumulative record of amount and types of fluid intake.Massive or rapid replacement with different types of fluids and fluctuations in rate of administration require close tabulation to prevent constituent imbalances or fluid overload.
Insert and maintain indwelling urinary catheter.Allows for close observation of renal function and prevents urinary retention. Retention of urine with its by-products of tissue-cell destruction can lead to renal dysfunction and infection.
Insert and maintain large-bore IV catheter(s).Accommodates rapid infusion of fluids.
Administer calculated IV replacement of fluids, electrolytes, plasma, albumin.Fluid resuscitation replaces lost fluids and electrolytes and helps prevent complications (shock, acute tubular necrosis). Replacement formulas vary but are based on extent of injury, amount of urinary output, and weight. Note: Once initial fluid resuscitation has been accomplished, a steady rate of fluid administration is preferred to boluses, which may increase interstitial fluid shifts and cardiopulmonary congestion.
Administer medications as indicated:
May be indicated to enhance urinary output and clear tubules of debris and prevent necrosis if acute renal failure (ARF) is present.
  • Potassium
Although hyperkalemia often occurs during first 24–48 hr (tissue destruction), subsequent replacement may be necessary because of large urinary losses.
  • Antacids: calcium carbonate (Titralac), magaldrate (Riopan)
Antacids may reduce gastric acidity;
  • histamine inhibitors: cimetidine (Tagamet) and ranitidine (Zantac).
histamine inhibitors decrease production of hydrochloric acid to reduce risk of gastric irritation and bleeding.
Add electrolytes to water used for wound debridement, as indicated.Washing solution that approximates tissue fluids may minimize osmotic fluid shifts.
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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other nursing care plans affecting the integumentary system:

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.
Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics. Finding help online is nearly impossible. His situation drove his passion for helping student nurses by creating content and lectures that are easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively.
  • Thanks Staff Matt for the NCP’S, they’ve been very helpful in my studies! Keep up the hardwork!
    -God bless

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

  • Thanks and appreciation to the staff of this website. You have brought the world close to us that we can read at anytime we want to. May God Almighty work for your good wishes!
    🙏🙏 THANKS

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