11 Burn Injury Nursing Care Plans

ADVERTISEMENTS

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

ADVERTISEMENTS

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.

ADVERTISEMENTS

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
ADVERTISEMENTS

Risk for Infection

Nursing Diagnosis

Risk factors may include

  • Inadequate primary defenses: destruction of skin barrier, traumatized tissues
  • Inadequate secondary defenses: decreased Hb, suppressed inflammatory response
  • Environmental exposure, invasive procedures

Desired Outcomes

  • Achieve timely wound healing free of purulent exudate and be afebrile.
Nursing InterventionsRationale
Nursing Assessment
Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.
Examine unburned areas (such as groin, neck creases, mucous membranes) and vaginal discharge routinely.Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.
Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.Water softens and aids in removal of dressings and eschar (slough layer of dead skin or tissue). Sources vary as to whether bath or shower is best. Bath has advantage of water providing support for exercising extremities but may promote cross-contamination of wounds. Showering enhances wound inspection and prevents contamination from floating debris.
Therapeutic Interventions
Implement appropriate isolation techniques as indicatedDependent on type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from simple wound and/or skin to complete or reverse to reduce risk of cross contamination and exposure to multiple bacterial flora.
Emphasize and model good handwashing technique for all individuals coming in contact with patient.Prevents cross contamination; reduces risk of acquired infection.
Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered bed linens or gowns.Prevents exposure to infectious organisms.
Monitor and/or limit visitors, if necessary. If isolation is used, explain procedure to visitors. Supervise visitor adherence to protocol as indicated.Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against patient’s need for family support and socialization.
Shave or clip all hair from around burned areas to include a 1-in border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.Opportunistic infections (yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.
Provide special care for eyes: use eye covers and tear formulas as appropriate.Prevents adherence to surface it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.
Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp).Identifies presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong sweet, musty smell at a graft site is indicative of Pseudomonas.
Remove dressings and cleanse burned areas in a hydrotherapy or whirlpool tub or in a shower stall with handheld shower head. Maintain temperature of water at 100°F (37.8°C). Wash areas with a mild cleansing agent or surgical soap.Early excision is known to reduce scarring and risk of infection, thereby facilitating healing.
Debride necrotic or loose tissue (including ruptured blisters) with scissors and forceps. Do not disturb intact blisters if they are smaller than 1–2 cm, do not interfere with joint function, and do not appear infected.Promotes healing. Prevents autocontamination. Small, intact blisters help protect skin and increase rate of re-epithelialization unless the burn injury is the result of chemicals (in which case fluid contained in blisters may continue to cause tissue destruction).
Photograph wound initially and at periodic intervals.Provides baseline and documentation of healing process.
Administer topical agents as indicated:The following agents help control bacterial growth and prevent drying of wound, which can cause further tissue destruction.
  • Silver sulfadiazine (Silvadene)
Broad-spectrum antimicrobial that is relatively painless but has intermediate, somewhat delayed eschar penetration. May cause rash or depression of WBCs.
  • Mafenide acetate (Sulfamylon)
Antibiotic of choice with confirmed invasive burn-wound infection. Useful against Gram-negative or Gram-positive organisms. Causes burning or pain on application and for 30 min thereafter. Can cause rash, metabolic acidosis, and decreased Paco2.
  • Silver nitrate
Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, but has poor eschar penetration, is painful, and may cause electrolyte imbalance. Dressings must be constantly saturated. Product stains skin/surfaces black.
  • Bacitracin
Effective against Gram-positive organisms and is generally used for superficial and facial burns.
  • Povidone-iodine (Betadine)
Broad-spectrum antimicrobial, but is painful on application, may cause metabolic acidosis or increased iodine absorption, and damage fragile tissues.
  • Hydrogels: Transorb, Burnfree
Useful for partial- and full-thickness burns; filling dead spaces, rehydrating dry wound beds, and promoting autolytic debridement. May be used when infection is present.Systemic antibiotics are given to control general infections identified by culture and sensitivity. Subeschar clysis has been found effective against pathogens in granulated tissues at the line of demarcation between viable or nonviable tissue, reducing risk of sepsis.
Administer other medications as appropriate: Subeschar clysis or systemic antibiotics; Tetanus toxoid or clostridial antitoxin, as appropriate.Tissue destruction and altered defense mechanisms increase risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
Place IV and/or invasive lines in non burned area.Decreased risk of infection at insertion site with possibility of progression to septicemia.
Obtain routine cultures and sensitivities of wounds and/or drainage.Allows early recognition and specific treatment of wound infection.
ADVERTISEMENTS

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

ADVERTISEMENTS

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

  • >