Last updated on July 21st, 2023 at 09:01 pm
Burns Nursing Care Plans Diagnosis and Interventions
Burns NCLEX Review and Nursing Care Plans
Burns occur as a result of skin damage secondary to exposure to heat, chemicals, sunlight, electricity, or radiation.
Most burns happen accidentally.
Burns come in a variety of degrees. The depth of burn and the amount of skin affected are the two determinants of the extent or degree of burn.
Burns can be excruciatingly unpleasant and can be susceptible to infection if left untreated.
Classification of Burns
Burns are classified as first, second, third, or fourth-degree based on how deeply and badly they penetrate the skin’s surface. When a burn occurs, it may be tough to classify it right away. It may take a day or two for them to realize the full magnitude of the problem.
- First-degree burns or superficial burns. In first-degree burns, the outermost layer of the skin (epidermis) is affected. The burn is red, unpleasant, dry, and blister-free. A good example is a little sunburn. Long-term tissue damage is uncommon and usually manifests itself as a change in skin color.
- Second-degree burns or partial-thickness burns. Second-degree burns affect the epidermis and a portion of the dermis, the skin’s lower layer. The burned area is characterized by the presence of erythematous blisters which are swollen and painful.
- Third-degree burns or whole or full thickness burns. Third-degree burns are also regarded as whole or full thickness burns as they destroy both the epidermis and the underlying dermis. They may penetrate the skin’s deepest layer, the subcutaneous tissue. The skin of the affected area may appear whitish, blackened, or charred.
- Fourth-degree burns. Fourth-degree burns penetrate both the top and bottom layers of the skin, as well as deeper tissue, including muscle and bone. The nerve endings have been damaged, therefore there is no feeling in the area.
Types of Burns
An energy transfer to the body usually causes a burn injury. Thermal, radiation, chemical, or electrical contact can result in a variety of burns.
- Thermal burns. External heat sources induce thermal burns, which elevate the temperature of the skin and tissues, causing tissue cell death or charring. Thermal burns are caused by hot metals, scalding liquids, steam, and flames coming into contact with the skin.
- Radiation burns. These are burns are caused by extended exposure to the sun’s UV rays or other sources of radiation, such as x-rays.
- Chemical burns. Burns caused by powerful acids, alkalies, detergents, or solvents contacting the skin or eyes.
- Electrical burns: These are caused by alternating current (AC) or direct current (DC) electrical current (DC)
Signs and Symptoms of Burns
The symptoms are frequently worst in the hours or days following a burn and vary according to the extent of the burn. Symptoms of burns usually include
- White or charred (black) skin
- Peeling skin
Causes of Burns
A burn can result from a variety of factors. Burns are most caused by thermal sources such as fire, hot liquids, steam, and contact with hot surfaces. Other factors to consider include:
- Chemicals, such as cement, acids or drain cleaners.
- Sun (ultraviolet or UV light)
Risk Factors to Burns
- Biological sex. According to the most recent data, females have slightly greater rates of burn fatality than males. This is in contrast to the conventional damage pattern, in which males are more likely than females to be injured by various injury mechanisms.
Open fire cooking or fundamentally dangerous cookstoves, which might ignite loose garments, are connected with a higher risk for females. Open flames for heating and lighting are also dangerous, as are self-directed or interpersonal aggression (although understudied)
- Age. Children, like adult women, are especially vulnerable to burns. Burns are the seventh most common non-fatal injury in children. While adult supervision is a big concern, child maltreatment is responsible for a significant number of burn injuries in children.
- Regional influences. Burn deaths are more than twice as common in children under the age of five in the WHO African Region than they are overall. Boys under the age of five who live in low- and middle-income countries in the WHO Eastern Mediterranean Region are nearly twice as likely as boys in the WHO European Region to die from burns. Burn injuries needing medical attention are about 20 times more common in the WHO Western Pacific Region than in the WHO Americas Region.
- Socioeconomic factors. People in low- and middle-income countries are more likely to suffer from burns than those in high-income countries. However, burn risk is linked to socioeconomic position in all countries.
Complications of Burns
Third-degree burns that are deep and cover a big area of skin are extremely dangerous and can be fatal. Burns of the first and second degrees can become infected, resulting in discoloration and scarring. Scarring is not present in first-degree burns.
Third-degree burns can lead to the following complications:
- An electrical burn causes arrhythmia, or cardiac rhythm problems
- Scars and contractures
- Failure of organs
- Hypotension that can lead to shock
- Severe infection that can result in amputation or sepsis
Diagnosis of Burns
To determine the total body surface area (TBSA) that is affected by burns, many approaches are utilized. The most common include:
- Rule of Nines. The rule of nines is a typical approach for estimating the extent of burns in adults by dividing the body into multiples of nine, with the sum of these portions equaling the total body surface area affected.
- Lund and Browder Method. This approach calculates the proportion of the surface area of various anatomic regions, particularly the head and legs, based on the patient’s age.
- Palmer Method. The size of the patient’s palm, excluding the surface area of the digits, is roughly 1% of the TBSA, whereas the size of the patient’s palm without the fingers is equivalent to 0.5 percent TBSA and is used as a universal measurement for all age groups.
Treatment for Burns
Burn treatment is a sensitive undertaking for any nurse to undertake and understanding the right sequencing of interventions is crucial.
- Transport. The hospital and physician are notified that the patient is on the way so that immediate life-saving measures can be taken.
- Priorities. The airway, breathing, and circulation are the first priority in the emergency room.
- Airway. The patient is given 100% humidified oxygen and encouraged to cough so that secretions can be eliminated through coughing.
- Chemical Burns. Chemical burns should be cleansed, and all clothing and jewelry should be removed.
- Intravenous access is available. In the non-burned area, a large bore (16 or 18 gauge) IV catheter is placed.
- Gastrointestinal access. Because some patients with extensive burns become nauseated, a nasogastric tube is placed and coupled to low intermittent suction if the burn exceeds 20% to 25% TBSA.
- Clean linens. To cover the burn wound from contamination, regulate body temperature, and lessen the discomfort caused by air currents passing over exposed nerve endings, clean sheets are placed over and under the patient.
- Fluid replacement therapy. The resuscitation formula guides the total volume and pace of IV fluid replacement, which is determined by the patient’s response.
Burns NCLEX Questions
Nursing Diagnosis for Burns
Nursing Care Plan for Burns 1
Nursing Diagnosis: Disturbed Body Image related to a traumatic event, disfigurement, and pain secondary to burns as evidenced by fear of rejection/reaction by others, negative sentiments about body/self, preoccupation with change/loss, focus on prior look and abilities, and changes in physical capacity and social interaction.
- The patient will change his/her self-concept without losing his/her self-esteem.
- The patient will verbalize self-acceptance in the situation.
- The patient will discuss the situation their family/significant other (SO).
- The patient will make future goals and strategies that are feasible.
|Nursing Interventions for Burns
|Examine the patient’s and SO’s reactions to the loss or change, including future expectations and the impact of cultural or religious beliefs.
|A traumatic event causes abrupt, unplanned changes, causing grief over actual or perceived losses. This demands assistance in order to reach a satisfactory conclusion.
|Accept and acknowledge frustration, reliance, rage, grief, and hostility as feelings. Take note of the withdrawn manner and denial.
|Accepting these feelings as a normal reaction to what has happened can help with resolution. Pushing a patient before they are ready to deal with an issue is neither helpful nor possible. Because the patient is not ready to deal with personal concerns, denial may be prolonged and serve as an adaptive mechanism.
|Place restrictions on maladaptive behavior. While providing care, maintain a nonjudgmental attitude and assist the patient in identifying positive behaviors that will aid in recovery.
|The patient and SO likely to approach this issue in the same manner they have approached previous problems. Staff may find it challenging and upsetting to deal with disruptive and unhelpful conduct, but they should keep in mind that the behavior is usually directed at the situation rather than the caregiver.
|Be realistic and optimistic during treatments, health education, and goal-setting within constraints.
|Improves patient and nurse trust and rapport.
|Encourage the patient and SO to look at the wounds and aid with care as needed.
|Encourages acceptance of the realities of injury and physical change, as well as a new self-image.
|Provide hope within the boundaries of the unique situation; do not provide false assurance.
|Encourages a good attitude and provides opportunities to create objectives and make realistic plans for the future.
|Assist the patient in determining the extent of the real change in appearance and body function.
|Assists at the beginning of the process of looking forward to the future and how life will be different.
|Encourage positive reinforcement of progress and efforts toward achieving rehabilitative goals.
|Healthy coping behaviors can be aided by words of encouragement.
|Present photographs or videos of burn care and/or other patient outcomes, selecting what to show based on the specific situation. Encourage patients to express their feelings about what they’ve witnessed.
|Allows the patient and SO to set realistic goals. Additionally, it aids in the explanation of the importance and/or necessity of specific devices and procedures.
|Encourage engagement between family members and the rehabilitation staff.
|To improve patient and family communication and provide continuing assistance.
|Refer the patient who has been disfigured by burns to a reconstructive surgeon.
|Reconstructive surgery can help patients regain their confidence and self-esteem.
|Give the patient thorough instruction and detailed aftercare instructions. Emphasize the significance of keeping the dressing clean and dry.
|Reinforcing teaching can help the patient acquire self-care.
Nursing Care Plan for Burns 2
Nursing Diagnosis: Impaired Skin Integrity related to skin surface disruption with destruction of skin layers (partial/full-thickness burn) that necessitates grafting secondary to burns as evidenced by absence of viable tissue.
- The patient will demonstrate wound healing by secondary intention.
- The patient will demonstrate tissue regeneration.
- The patient will achieve timely healing of burned areas.
|Nursing Interventions for Burns
|Examine and note the size, color, and depth of the wound, as well as any necrotic tissue and the status of the surrounding skin.
|Provides baseline information on the requirement for skin grafting as well as possible insights about the area’s circulation.
|Provide proper burn treatment and infection control.
|Reduces the risk of infection and graft failure by preparing tissues for transplantation.
|If feasible, elevate the grafted area. When indicated, maintain the proper position and immobility of the region.
|Tissue movement under the graft can dislodge it, preventing proper healing.
|Maintain the following dressings over the freshly grafted area and/or donor site: mesh, petroleum, and non-adhesive.
|To avoid shearing of new epithelium and protect healing tissue, translucent, nonreactive surface material can be used between the graft and the outer dressing. After covering the donor site for 4–24 hours, bulky dressings are removed and fine mesh gauze is kept in place.
|Maintain and ensure that the patient’s skin is void of pressure.
|Improves circulation and prevents ischemia, necrosis, and graft failure.
|Examine the grafted and donor sites for color, as well as the presence or absence of healing
|Examines the efficacy of circulation and looks for any possible problems.
|After the dressings have been removed and healing has occurred, wash the sites with mild soap, rinse, and lubricate with cream several times daily.
|To preserve flexibility, newly grafted skin and healed donor areas require extra attention.
|Blebs under sheet grafts should be aspirated with a sterile needle or rolled with a sterile swab.
|Fluid-filled blebs make it difficult for grafts to adhere to the underlying tissue, increasing the risk of graft failure.
Nursing Care Plan for Burns 3
Nursing Diagnosis: Impaired Physical Mobility related to reduced strength and endurance, neuromuscular weakness, pain/discomfort, contractures, restrictive therapies, and limb immobility secondary to burns as evidenced by the inability to move purposefully/reluctance to move, limited range of motion, and decreased muscular strength and/or mass.
- The patient will maintain the position of function as demonstrated by the absence of contractures.
- The patient will maintain or improve the affected and/or compensatory body part’s strength and function.
- The patient will demonstrate and verbalize their eagerness to participate in events.
- The patient will demonstrate techniques/behaviors that allow daily activities to be resumed.
|Nursing Interventions for Burns
|Frequently note digit circulation, motion, and feeling.
|Edema can impair circulation to the extremities, increasing the risk of tissue necrosis and contractures.
|On admittance, begin the rehabilitation phase.
|When the patient is aware of the potential for recovery, it is easier to enlist their help.
|Use supports or splints to keep the patient’s body aligned, especially if they have burns over joints.
|Promotes functional extremity alignment and avoids contractures, which are more common over joints.
|Perform ROM exercises on a regular basis, first passively and later actively.
|This prevents the tightening of scar tissue and contractures as time progresses. This can also enhance muscle and joint function and decreases calcium sequestration from the bones.
|Before engaging in any activity or exercise, take pain medication.
|This allows the patient to be more active and participative by reducing muscle tension and tissue stiffness.
|Treatments and care tasks should be scheduled to provide for uninterrupted rest intervals.
|Increases the patient’s strength and exercise tolerance.
|Encourage family and SO involvement in ROM exercises.
|Allows family/SO to participate in patient care, resulting in more consistent therapy.
|Physical therapy, hydrotherapy, and nursing care should all be incorporated into ADLs.
|Combining activities improves outcomes by amplifying the effects of each.
|Encourage patients to participate in as many activities as they are capable of.
|Encourages independence, boosts self-esteem, and speeds up the rehabilitation process.
Nursing Care Plan for Burns 4
Nursing Diagnosis: Risk for Infection related to inadequate primary defenses (i.e., skin barrier breakdown, damaged tissues), insufficient secondary defenses (i.e., reduced Hb, lowered inflammatory response), invasive procedures, and exposure to the environment secondary to burns.
Desired Outcome: The patient will achieve timely wound healing as manifested by the absence of purulent exudate and fever.
|Nursing Interventions for Burns
|Examine wounds on a daily basis, taking note of any changes in look, odor, or discharge volume.
|Sepsis indicators, which frequently arise with full-thickness burns, require immediate investigation and treatment. Sensorium, bowel habits, and respiratory rate changes frequently precede fever and laboratory study changes.
|Unburned areas (such as the groin, neck creases, and mucous membranes) and vaginal discharge should be checked on a regular basis.
|Drainage from nearby burns may cause eyes to swell shut and/or become infected. Eye coverings may be required if the lids are burned, to avoid corneal injury.
|Fever, increased breathing rate and depth in combination with changes in sensorium, diarrhea, low platelet count, and hyperglycemia with glycosuria should all be monitored.
|Water softens, making it easier to remove dressings and eschar (slough layer of dead skin or tissue). Whether to take a bath or shower depends on the source. Bathing has the benefit of giving support for exercising extremities, but it may also cause wound cross-contamination. Showering improves wound examination and keeps floating debris from contaminating the wound.
|Implement the recommended isolation techniques.
|Isolation may range from simple wound and/or skin to complete or reverse to limit the danger of cross-contamination and exposure to multiple bacterial flora, depending on the type or size of wounds and the wound treatment (open versus closed).
|Instruct and demonstrate proper handwashing for all individuals who come into touch with the patient.
|To prevent cross-contamination and lowers the risk of illness.
|During direct wound care, use gowns, gloves, masks, and rigorous aseptic technique, and give sterile or newly laundered bed sheets or gowns.
|To protect against infectious germs.
|If necessary, keep track of and/or limit visitors. Explain the isolation technique to visitors if it is used. Ensure that visitors follow the protocol as directed.
|Cross-contamination from visitors is avoided. The patient’s need for family support and socializing should be balanced against the risk of infection.
|Including a 1-inch perimeter, shave or trim any hair from around burned areas (excluding eyebrows). Men should shave their beards and shampoo their heads every day.
|During systemic antibiotic therapy, opportunistic infections (yeast) are common due to immune system suppression and/or growth of normal body flora.
|Eyes require extra attention, so wear eye coverings and tear solutions as needed.
|Prevents adhesion to any surfaces it may come into contact with and promotes appropriate healing. It’s worth noting that ear cartilage has poor circulation and is susceptible to pressure necrosis.
|Avoid skin-to-skin contact on the surface (wrap each burned finger or toe separately; do not allow burned ear to touch scalp).
|Provides early diagnosis of burn-wound infection by detecting the presence of healing (granulation tissue). Infection can cause a partial-thickness burn to become a full-thickness damage. Pseudomonas is identified by a distinct sweet, musty odor at the graft site.
|In a hydrotherapy or whirlpool tub, or in a shower stall with a handheld shower head, remove dressings and cleanse burned areas. Maintain a temperature of 100°F (37.8°C) in the water. Use a gentle washing agent or surgical soap to clean the affected regions.
|Early excision is known to lessen scarring and infection risk, allowing for faster recovery.
|With scissors and forceps, remove necrotic or loose tissue (including ruptured blisters). If the blisters are smaller than 12 cm, do not interfere with joint function, and do not appear infectious, do not touch them.
|To promote recovery. Autocontamination is avoided. Unless the burn injury is caused by chemicals, small, intact blisters can preserve the skin and enhance the process of re-epithelialization (in which case fluid contained in blisters may continue to cause tissue destruction).
|Photograph the wound at first and thereafter at regular intervals.
|To establish a baseline and records the healing process.
|Topical agents should be used as directed.
|Topical agents aid in bacterial control and wound drying, which can lead to additional tissue loss.
|Other treatments should be given as needed: subeschar clysis or systemic antibiotics; tetanus toxoid or clostridial antitoxin, if needed.
|Tissue loss and weakened defense mechanisms raise the risk of tetanus or gas gangrene, particularly in serious burns produced by electricity.
|In the non-burned area, place IV and/or invasive lines.
|Reduced risk of infection at the insertion site, with the potential for septicemia.
|Obtain routine wound cultures and/or drainage sensitivity.
|To allow for the early detection and treatment of wound infections.
Nursing Care Plan for Burns 5
Nursing Diagnosis: Deficient Knowledge related to lack of awareness/recall, misinterpretation of information, and unfamiliarity with available resources secondary to burns evidenced by questions/requests for information, assertion of a misunderstanding, inaccurate follow-through of instructions, and development of avoidable complications.
- The patient will explain the disease, the prognosis, and any probable problems.
- The patient will communicate their comprehension of the therapeutic needs.
- The patient will perform necessary procedures correctly and explain reasons for their actions.
- The patient will make the essential lifestyle modifications and follow the treatment plan.
|Nursing Interventions for Burns
|Examine the patient’s condition, prognosis, and future prospects.
|Provides a knowledge base for patients to make well-informed decisions.
|Discuss the patient’s expectations for returning to his or her home, work, and normal activities.
|Following discharge, patients usually experience a tough and lengthy adjustment period. Sleep disturbances, nightmares, reliving the event, trouble resuming social interactions, intimacy and sexual activity, emotional lability are all common problems that obstruct successful return of regular life.
|Review and demonstrate proper burn, skin-graft, and wound care practices to the patient/SO. Determine the best outpatient care and supply options.
|After discharge, encourages effective self-care and independence.
|Talk about skin care. Teach how to apply moisturizers, sunscreens, and anti-itch drugs correctly.
|Itching, blistering, and sensitivity of healing wounds or graft sites can last a long time, and harm might occur due to the new tissue’s fragility.
|Examine drugs for their intended use, dose, mode of administration, and predicted and/or reportable side effects.
|Reiteration helps the patient to raise questions and confirm that their information is correct.
|Explain the scarring process, as well as the need for the proper application of pressure garments when they are required.
|Promotes healthy skin renewal while reducing hypertrophic scars and contractures and speeding up the healing process. Note: Long-term use of the pressure garment can lessen the need for reconstructive surgery to remove scars and release contractures.
|Encourage the patient to adhere to the planned workout routine and relaxation times.
|Maintains mobility, decreases problems, and prevents weariness, allowing for a quicker recovery.
|Individually appropriate activity constraints should be identified.
|Restrictions are imposed based on the degree and location of the injury, as well as the stage of recovery.
|Stress the necessity of eating high-protein, high-calorie meals and snacks on a regular basis.
|Optimal diet promotes tissue repair and overall happiness. Note: To meet calorie and protein requirements for recovery, patients frequently need to increase their caloric intake.
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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