This guide contains nursing diagnoses for burns nursing care plans, including nursing assessments and interventions. Discover the goals, related factors, and rationale for each nursing intervention, and learn how to create effective nursing care plans for burns.
What is Burn Injury?
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 a 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 the depth and extent of the 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 the 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 well-being. There are three phases of burn injury, each requiring various levels of patient care. The three phases are the 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 a burn injury is the rehabilitative stage. This stage starts with the 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
The nursing care planning goals for a patient with a burn injury include pain management, infection prevention, wound care, nutritional support, psychological support, and promoting mobility and rehabilitation. The overall goal is to provide comprehensive care that addresses the patient’s physical, emotional, and psychological needs to promote healing, prevent complications, and promote recovery.
Here are eleven (11) nursing care plans (NCP) and nursing diagnosis for patients with burn injuries (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
Impaired Physical Mobility
Patients with burn injuries may experience impaired physical mobility due to a variety of factors including neuromuscular impairment, pain/discomfort, and decreased strength and endurance. In addition, restrictive therapies, limb immobilization, and contractures can further contribute to impaired physical mobility by limiting the range of motion and causing muscle atrophy. All of these factors can make it difficult for patients to perform daily activities and participate in rehabilitation programs, which can delay recovery and increase the risk of long-term complications.
Nursing Diagnosis
- Impaired Physical Mobility
May be related to
- Neuromuscular impairment, pain/discomfort, decreased strength and endurance
- Restrictive therapies, limb immobilization; contractures
Possibly evidenced by
- Reluctance to move/inability to purposefully move
- Limited ROM, decreased muscle strength control, and/or mass
Desired Outcomes
- The client will maintain a position of function as evidenced by the absence of contractures.
- The client will maintain or increase the strength and function of the affected and/or compensatory body part.
- The client will verbalize and demonstrate a willingness to participate in activities.
- The client will demonstrate techniques/behaviors that enable the resumption of activities.
Nursing Assessment and Rationales
1. Note circulation, motion, and sensation of digits frequently.
It is crucial to note the circulation, motion, and sensation of digits frequently in patients with burns. Edema, a common occurrence in burn injuries, can compromise circulation to the extremities and potentially lead to tissue necrosis and contractures. Assessing the circulation, motion, and sensation of digits regularly can help detect early signs of compromised circulation and prevent long-term complications such as the loss of digits or limbs. It is essential to include assessment of the digits in the nursing care plan for burn patients to ensure prompt and appropriate interventions are in place.
Nursing Interventions and Rationales
1. Maintain proper body alignment with supports or splints, especially for burns over joints.
Proper alignment with supports or splints is critical for burn patients, particularly over joints. This promotes functional positioning of the extremities and helps prevent contractures, which can cause permanent damage and impair daily activities. Regular monitoring and adjustment of interventions are essential for optimal outcomes.
2. Perform ROM exercises consistently, initially passive, then active.
Prevents progressively tightening scar tissue and contractures; enhances the maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
3. Encourage patient participation in all activities as individually able.
Promotes independence, enhances self-esteem, and facilitates the recovery process.
4. Encourage family/SO support and assistance with ROM exercises.
Enables family/SO to be active in patient care and provides more consistent therapy.
5. Medicate for pain before activity or exercise.
Reduces muscle and tissue stiffness and tension, enabling the patient to be more active and facilitating participation.
6. Schedule treatments and care activities to provide periods of uninterrupted rest.
Increases patient’s strength and tolerance for activity.
7. Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
Combining activities produces improved results by enhancing the effects of each.
8. Initiate the rehabilitative phase on admission.
It is easier to enlist participation when the patient is aware of the possibilities that exist for recovery.
9. Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
Combining activities produces improved results by enhancing the effects of each.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
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:
- Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier. [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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