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
Deficient Knowledge
Nursing Diagnosis
May be related to
- Lack of exposure/recall
- Information misinterpretation; unfamiliarity with resources
Possibly evidenced by
- Questions/request for information, statement of misconception
- Inaccurate follow-through of instructions, development of preventable complications
Desired Outcomes
- Verbalize understanding of condition, prognosis, and potential complications.
- Verbalize understanding of therapeutic needs.
- Correctly perform necessary procedures and explain reasons for actions.
- Initiate necessary lifestyle changes and participate in treatment regimen.
| Nursing Interventions | Rationale |
|---|---|
| Nursing Assessment | |
| Review condition, prognosis, and future expectations. | Provides knowledge base from which patient can make informed choices. |
| Discuss patient’s expectations of returning home, to work, and to normal activities. | Patient frequently has a difficult and prolonged adjustment after discharge. Problems often occur (sleep disturbances, nightmares, reliving the accident, difficulty with resumption of social interactions, intimacy and sexual activity, emotional lability) that interfere with successful adjustment to resuming normal life. |
| Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies. | Promotes competent self-care after discharge, enhancing independence. |
| Discuss skin care. Teach proper use of moisturizers, sunscreens, and anti-itching medications. | Itching, blistering, and sensitivity of healing wounds or graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue. |
| Review medications, including purpose, dosage, route, and expected and/or reportable side effects. | Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate. |
| Therapeutic Interventions | |
| Explain scarring process and necessity for and proper use of pressure garments when used. | Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars. |
| Encourage continuation of prescribed exercise program and scheduled rest periods. | Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process. |
| Identify specific limitations of activity as individually appropriate. | Imposed restrictions depend on severity and location of injury and stage of healing. |
| Emphasize importance of sustained intake of high-protein and high-calorie meals and snacks. | Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing. |
| Advise patient and/or SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion with appropriate professional counselors. | Provides perspective to some of the problems patient and/or SO may encounter, and aids awareness that assistance is available when necessary. |
| Identify signs and symptoms requiring medical evaluation: inflammation, increase or changes in wound drainage, fever/chills; changes in pain characteristics or loss of mobility and/or function. | Early detection of developing complications (infection, delayed healing) may prevent progression to more serious or life-threatening situations. |
| Stress importance of follow-up care and rehabilitation. | Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery. |
| Provide phone number for contact person. | Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications. |
| Ensure patient’s immunizations are current, especially tetanus. | To prevent further injury. |
| Identify community resources: skin or wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Amblicab, homemaker service. | Facilitates transition to home, provides assistance with meeting individual needs, and supports independence. |
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?
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