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.

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

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  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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Fear/Anxiety

Nursing Diagnosis

May be related to

  • Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Possibly evidenced by

  • Expressed concern regarding changes in life, fear of unspecified consequences
  • Apprehension; increased tension
  • Feelings of helplessness, uncertainty, decreased self-assurance
  • Sympathetic stimulation, extraneous movements, restlessness, insomnia

Desired Outcomes

  • Verbalize awareness of feelings and healthy ways to deal with them.
  • Report anxiety/fear reduced to manageable level.
  • Demonstrate problem-solving skills, effective use of resources.
Nursing InterventionsRationale
Nursing Assessment
Assess mental status, including mood and affect, comprehension of events, and content of thoughts.Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
Therapeutic Interventions
Give frequent explanations and information about care procedures. Repeat information as needed.Knowing what to expect usually reduces fear and anxiety, clarifies misconceptions, and promotes cooperation. Because of the shock of the initial trauma, many people do not recall information provided during that time.
Demonstrate willingness to listen and talk to patient when free of painful procedures.Helps patient and SO know that support is available and that healthcare provider is interested in the person, not just care of the burn.
Involve patient and SO in decision making process whenever possible. Provide time for questioning and repetition of proposed treatments.Promotes sense of control and cooperation, decreasing feelings of helplessness or hopelessness.
Investigate changes in mentation and presence of hypervigilance, hallucinations, sleep disturbances, nightmares, agitation, apathy, disorientation, and labile affect, all of which may vary from moment to moment.Indicators of extreme anxiety and delirium state in which patient is literally fighting for life. Although cause can be psychologically based, pathological life-threatening causes must be ruled out.
Provide constant and consistent orientation.Helps patient stay in touch with surroundings and reality.
Encourage patient to talk about the burn circumstances when ready.Patient may need to tell the story of what happened over and over to make some sense out of a terrifying situation. Adjustment to the impact of the trauma, grief over losses and disfigurement can easily lead to clinical depression, psychosis, and posttraumatic stress disorder (PTSD).
Explain to patient what happened. Provide opportunity for questions and give honest answers.Compassionate statements reflecting the reality of the situation can help patient and SO acknowledge that reality and begin to deal with what has happened.
Identify previous methods of coping and handling of stressful situations.Past successful behavior can be used to assist in dealing with the present situation.
Create a restful environment, use guided imagery and relaxation exercises.Patients experience severe anxiety associated with burn trauma and treatment. These interventions are soothing and helpful for positive outcomes.
Assist the family to express their feelings of grief and guilt.The family may initially be most concerned about patient’s dying and/or feel guilty, believing that in some way they could have prevented the incident.
Be empathic and nonjudgmental in dealing with patient and family.Family relationships are disrupted; financial, lifestyle or role changes make this a difficult time for those involved with patient, and they may react in many different ways.
Encourage family/SO to visit and discuss family happenings. Remind patient of past and future events.Maintains contact with a familiar reality, creating a sense of attachment and continuity of life.
Involve entire burn team in care from admission to discharge, including social worker and psychiatric resources.Provides a wider support system and promotes continuity of care and coordination of activities.
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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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