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):
- Impaired Physical Mobility
- Deficient Knowledge
- Disturbed Body Image
- Fear/Anxiety
- Impaired Skin Integrity
- Imbalanced Nutrition: Less Than Body Requirements
- Risk for Ineffective Tissue Perfusion
- Acute Pain
- Risk for Infection
- Risk for Deficient Fluid Volume
- Risk for Ineffective Airway Clearance
- Other possible nursing care plans
Risk for Ineffective Airway Clearance
Nursing Diagnosis
- Risk for Ineffective Airway Clearance
Risk factors may include
- Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion
- Trauma: direct upper-airway injury by flame, steam, hot air, and chemicals/gases
- Fluid shifts, pulmonary edema, decreased lung compliance
Desired Outcomes
- Demonstrate clear breath sounds, respiratory rate within normal range, be free of dyspnea/cyanosis.
| Nursing Interventions | Rationale |
|---|---|
| Nursing Assessment | |
| Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. | Exposure to materials burn can cause inhalation injury. |
| Draw blood samples for complete blood count, type and crossmatch and electrolyte glucose, blood urea nitrogen, creatinine, and ABG levels. | To have baseline data and may indicate choice of next steps of treatment. |
| Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking. | Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned (wood, plastic, wool, and so forth) suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications. |
| Assess gag and swallow reflexes; note drooling, inability to swallow, hoarseness, wheezy cough. | Suggestive of inhalation injury. |
| Monitor respiratory rate, rhythm, depth: note presence of pallor or cyanosis and carbonaceous or pink-tinged sputum. | Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress or pulmonary edema and need for medical intervention. |
| Auscultate lungs, noting stridor, wheezing or crackles, diminished breath sounds, brassy cough. | Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after burn. |
| Note presence of pallor or cherry-red color of unburned skin. | Suggests presence of hypoxemia or carbon monoxide. |
| Investigate changes in behavior or mentation: restlessness, agitation, altered LOC. | Although often related to pain, changes in consciousness may reflect developing or worsening hypoxia. |
| Monitor 24-hr fluid balance, noting variations/changes. | Fluid shifts or excess fluid replacement increases risk of pulmonary edema. Note: Inhalation injury increases fluid demands as much as 35% or more because of obligatory edema. |
| Monitor and graph serial ABGs or pulse oximetry. | Baseline is essential for further assessment of respiratory status and as a guide to treatment. Pao2 less than 50, Paco2 greater than 50, and decreasing pH reflect smoke inhalation and developing pneumonia or ARDS. |
| Review serial chest x-rays. | Changes reflecting atelectasis and/or pulmonary edema may not occur for 2–3 days after burn |
| Therapeutic Interventions | |
| Elevate head of bed. Avoid use of pillow under head, as indicated. | Promotes optimal lung expansion or respiratory function. When head or neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures. |
| Encourage coughing or deep breathing exercises and frequent position changes. | Promotes lung expansion, mobilization and drainage of secretions. |
| Suction (if necessary) with extreme care, maintaining sterile technique. | Helps maintain clear airway, but should be done cautiously because of mucosal edema and inflammation. Sterile technique reduces risk of infection. |
| Promote voice rest, but assess ability to speak and/or swallow oral secretions periodically. | Increasing hoarseness or decreased ability to swallow suggests increasing tracheal edema and may indicate need for prompt intubation. |
| Administer humidified oxygen via appropriate mode (face mask). | O2 corrects hypoxemia and acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum. |
| Provide and assist with chest physiotherapy and incentive spirometry. | Chest physiotherapy drains dependent areas of the lung, and incentive spirometry may be done to improve lung expansion, thereby promoting respiratory function and reducing atelectasis. |
| Prepare and assist with intubation or tracheostomy, as indicated | Intubation or mechanical support is required when airway edema or circumferential burn injury interferes with respiratory function or oxygenation. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans affecting the integumentary system:
- Burn Injury | 11 Care Plans
- Dermatitis | 4 Care Plans
- Herpes Zoster (Shingles) | 4 Care Plans
- Pressure Ulcer (Bedsores) | 3 Care Plans
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.
Thanks Staff Matt for the NCP’S, they’ve been very helpful in my studies! Keep up the hardwork!
-God bless
How u do the except outcome and goal of acute pain
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!
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