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
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis
- Imbalanced Nutrition: Less Than Body Requirements
May be related to
- Hypermetabolic state (can be as much as 50%–60% higher than normal proportional to the severity of injury)
- Protein catabolism
- Anorexia, restricted oral intake
Possibly evidenced by
- Decrease in total body weight, loss of muscle mass/subcutaneous fat, and development of negative nitrogen balance
Desired Outcomes
- Demonstrate nutritional intake adequate to meet metabolic needs as evidenced by stable weight/muscle-mass measurements, positive nitrogen balance, and tissue regeneration.
| Nursing Interventions | Rationale |
|---|---|
| Nursing Assessment | |
| Auscultate bowel sounds. Note hypoactive or absent bowel sounds. | Ileus is often associated with postburn period but usually subsides within 36–48 hr, at which time oral feedings can be initiated. |
| Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. | Provides patient or SO sense of control; enhances participation in care and may improve intake. |
| Monitor muscle mass and subcutaneous fat as indicated. | Indirect calorimetry, if available, may be useful in more accurately estimating body reserves or losses and effectiveness of therapy. |
| Maintain strict calorie count. Weigh daily. Reassess percentage of open body surface area and wounds weekly. | Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As burn wound heals, percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made. |
| Monitor laboratory studies: serum albumin, prealbumin, Cr, transferrin, urine urea nitrogen. | Indicators of nutritional needs and adequacy of diet/therapy. |
| Therapeutic Interventions | |
| Provide small, frequent meals and snacks. | Helps prevent gastric distension or discomfort and may enhance intake. |
| Encourage patient to view diet as a treatment and to make food or beverage choices high in calories and protein. | Calories and proteins are needed to maintain weight, meet metabolic needs, and promote wound healing. |
| Encourage patient to sit up for meals and visit with others. | Sitting helps prevent aspiration and aids in proper digestion of food. Socialization promotes relaxation and may enhance intake. |
| Provide oral hygiene before meals. | Clean mouth and clean palate enhances taste and helps promote a good appetite. |
| Insert nasogastric tube, as indicated. | To decompress the stomach and avoid aspiration of stomach contents. |
| Perform fingerstick glucose, urine testing as indicated. | Monitors for development of hyperglycemia related to hormonal changes or demands or use of hyperalimentation to meet caloric needs. |
| Refer to dietitian or nutrition support team. | Useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes. |
| Provide diet high in calories or protein with trace elements and vitamin supplements. | Calories (3000–5000 per day), proteins, and vitamins are needed to meet increased metabolic needs, maintain weight, and encourage tissue regeneration. Note: Oral route is preferable once GI function returns. |
| Insert and maintain small feeding tube for enteral feedings and supplements if needed. | Provides continuous supplemental feedings when patient is unable to consume total daily calorie requirements orally. Note: Continuous tube feeding during the night increases calorie intake without decreasing appetite and oral intake during the day. |
| Administer parenteral nutrition solutions containing vitamins and minerals, as indicated. | Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings. |
| Administer insulin as indicated. | Elevated serum glucose levels may develop because of stress response to injury, high caloric intake, pancreatic fatigue. |
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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