Burns are traumatic injuries to the skin and underlying tissues caused by thermal, chemical, electrical, or radiation exposure. This nursing diagnosis focuses on identifying burn severity, preventing complications, managing pain, and promoting optimal wound healing.
Causes (Related to)
Burns can affect patients in various ways, with several factors contributing to their severity and healing process:
- Thermal exposure (flame, hot liquids, steam)
- Chemical exposure (acids, alkalis)
- Electrical burns
- Radiation exposure
- Friction burns
Contributing factors include:
- Duration of exposure
- Temperature/concentration of burning agent
- Pre-existing medical conditions
- Age (very young or elderly)
- Delayed treatment
Risk factors affecting outcomes:
- Diabetes
- Immunocompromised status
- Poor nutrition
- Chronic diseases
- Limited access to care
Signs and Symptoms (As evidenced by)
Burn injuries present with distinctive signs and symptoms that nurses must accurately assess for proper treatment.
Subjective: (Patient reports)
- Pain at the burn site
- Numbness or tingling
- Difficulty moving the affected area
- Anxiety and distress
- Difficulty breathing (in cases of inhalation burns)
- Changes in sensation
- Emotional disturbance
Objective: (Nurse assesses)
- Visible tissue damage
- Changes in skin color and texture
- Blistering
- Edema
- Altered peripheral pulses
- Circumferential burns
- Signs of infection
- Changes in the range of motion
Expected Outcomes
The following outcomes indicate successful management of burns:
- Pain will be effectively managed
- Wound healing will progress without complications
- The patient will maintain adequate fluid balance
- The patient will demonstrate proper wound care techniques
- The patient will maintain adequate nutrition
- The patient will show no signs of infection
- The patient will demonstrate improved functional ability
- The patient will show psychological adjustment to the injury
Nursing Assessment
Evaluate Burn Characteristics
- Determine burn depth
- Calculate total body surface area (TBSA)
- Assess burn location
- Document burn appearance
- Note circumferential burns
Monitor Vital Signs
- Check temperature
- Monitor blood pressure
- Assess heart rate
- Track respiratory rate
- Monitor oxygen saturation
Assess Fluid Status
- Monitor intake and output
- Check skin turgor
- Assess mucous membranes
- Track urine output
- Monitor electrolyte balance
Evaluate Pain
- Assess pain levels
- Document pain characteristics
- Monitor response to interventions
- Note breakthrough pain
- Evaluate anxiety levels
Check for Complications
- Monitor for infection signs
- Assess circulation
- Check for compartment syndrome
- Evaluate respiratory status
- Monitor nutritional status
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to tissue damage and inflammatory response as evidenced by verbal reports of pain, guarding behavior, and altered vital signs.
Related Factors:
- Tissue damage
- Inflammatory response
- Wound care procedures
- Anxiety
- Movement
Nursing Interventions and Rationales:
- Administer prescribed pain medications
Rationale: Provides comfort and facilitates participation in care - Position the affected area appropriately
Rationale: Minimizes pressure and promotes comfort - Assess pain regularly using the appropriate scale
Rationale: Ensures effective pain management
Desired Outcomes:
- The patient will report decreased pain levels
- Patient will demonstrate improved participation in care
- The patient will maintain an optimal comfort level
Nursing Care Plan 2: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to compromised skin integrity and invasive procedures as evidenced by the presence of burn wounds.
Related Factors:
- Disrupted skin barrier
- Invasive procedures
- Decreased immune response
- Environmental exposure
- Nutritional deficits
Nursing Interventions and Rationales:
- Maintain a strict aseptic technique
Rationale: Prevents cross-contamination - Monitor wound appearance
Rationale: Enables early detection of infection - Administer prescribed antimicrobials
Rationale: Prevents or treats infection
Desired Outcomes:
- The wound will remain free from infection
- The patient will demonstrate an understanding of infection prevention
- The patient will maintain a normal temperature
Nursing Care Plan 3: Risk for Fluid Volume Deficit
Nursing Diagnosis Statement:
Risk for Fluid Volume Deficit related to increased fluid loss through burned areas as evidenced by decreased urine output and poor skin turgor.
Related Factors:
- Increased fluid loss
- Altered cellular membrane
- Increased metabolic demands
- Decreased oral intake
- Third-spacing
Nursing Interventions and Rationales:
- Monitor fluid balance strictly
Rationale: Ensures adequate hydration - Administer IV fluids as prescribed
Rationale: Maintains fluid volume - Track intake and output
Rationale: Identifies fluid balance status
Desired Outcomes:
- The patient will maintain adequate hydration
- The patient will demonstrate stable vital signs
- The patient will maintain appropriate urine output
Nursing Care Plan 4: Impaired Skin Integrity
Nursing Diagnosis Statement:
Impaired Skin Integrity related to thermal injury as evidenced by disruption of the skin surface and underlying tissues.
Related Factors:
- Thermal damage
- Chemical exposure
- Altered circulation
- Edema
- Mechanical factors
Nursing Interventions and Rationales:
- Perform wound care as prescribed
Rationale: Promotes healing and prevents complications - Monitor wound healing progress
Rationale: Ensures appropriate healing - Maintain optimal wound environment
Rationale: Facilitates healing process
Desired Outcomes:
- Wound healing will progress as expected
- The patient will demonstrate proper wound care
- The patient will maintain intact surrounding skin
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to trauma and changes in body image as evidenced by expressed concerns and increased tension.
Related Factors:
- Traumatic experience
- Pain
- Changed appearance
- Treatment procedures
- Uncertain prognosis
Nursing Interventions and Rationales:
- Provide emotional support
Rationale: Reduces anxiety and promotes coping - Teach coping strategies
Rationale: Helps manage stress - Include the patient in care planning
Rationale: Increases sense of control
Desired Outcomes:
- The patient will demonstrate reduced anxiety
- The patient will use effective coping strategies
- The patient will express optimism about recovery
References
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- Botman M, Hendriks TCC, de Haas LEM, Mtui GS, Binnerts J, Nuwass EQ, Niemeijer AS, Jaspers MEH, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. Access to Burn Care in Low- and Middle-Income Countries: An Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania. J Burn Care Res. 2022 May 17;43(3):657-664. doi: 10.1093/jbcr/irab191. PMID: 34643726; PMCID: PMC9113785.
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- Wu H, Xi M, Xie W. Epidemiological and clinical characteristics of older adults with burns: a 15-year retrospective analysis of 2554 cases in Wuhan Institute of Burns. BMC Geriatr. 2023 Mar 22;23(1):162. doi: 10.1186/s12877-023-03883-5. PMID: 36949418; PMCID: PMC10035179.
