Nursing Diagnosis and Care Plan for Burns: Restoring Skin Integrity

The skin, our body’s first line of defense, is crucial in protecting us from external threats and maintaining overall health. When this protective barrier is compromised by burns, the risk of infection and complications significantly increases. Burns are traumatic injuries that damage the skin and underlying tissues, ranging from minor superficial injuries to severe, life-threatening conditions. Effective nursing care is paramount in managing burn wounds, preventing complications, and promoting healing. This article delves into the Nursing Diagnosis And Care Plan For Burns, providing a comprehensive guide for healthcare professionals to deliver optimal patient care.

Causes (Related to Burns)

Burns are primarily caused by the transfer of energy from a heat source to the body, leading to tissue damage. The severity of a burn depends on the temperature of the heat source, the duration of exposure, and the area of the body affected. Common causes of burns include:

Thermal Burns:

• Scalds: Contact with hot liquids or steam.
• Flame Burns: Direct contact with fire.
• Contact Burns: Touching hot objects.

Chemical Burns:

• Exposure to strong acids, alkalis, or other corrosive substances.

Electrical Burns:

• Contact with electrical currents.

Radiation Burns:

• Exposure to ionizing radiation, such as from radiation therapy or prolonged sun exposure.

Friction Burns:

• Caused by skin rubbing against a rough surface.

Signs and Symptoms (As Evidenced by Burns)

The signs and symptoms of burns vary depending on the depth and extent of the injury. Assessing these signs is crucial for determining the severity of the burn and guiding appropriate nursing interventions.

Subjective: (Patient reports)

• Pain: Can range from mild discomfort to excruciating pain, depending on the burn depth and nerve involvement.
• Increased Pain with Air Exposure: Burned skin is highly sensitive, and exposure to air can exacerbate pain.
• Itching: Common during the healing phase as new skin regenerates.

Objective: (Nurse assesses)

• First-Degree Burns (Superficial):
  • Redness (erythema)
  • Painful to touch
  • Dry skin
  • Blanches with pressure
  • No blisters (or small blisters)
• Second-Degree Burns (Partial-Thickness):
  • Blisters (superficial and deep)
  • Intense pain
  • Moist, weeping skin
  • Red to mottled white
  • Blanches with pressure
• Third-Degree Burns (Full-Thickness):
  • Dry, leathery skin
  • White, charred, brown, or black color
  • Little to no pain (due to nerve damage)
  • Does not blanch
  • Thrombosed vessels may be visible
• Fourth-Degree Burns (Subdermal):
  • Extends into muscle and bone
  • Charred or skeletonized appearance
  • No pain
  • Dry
  • May involve tendons and bones

Expected Outcomes

The primary goals of nursing care for patients with burns are to promote healing, prevent complications, and restore skin integrity. Expected outcomes include:

• Patient will achieve timely wound healing and skin regeneration.
• Patient will remain free from infection throughout the healing process.
• Patient will experience effective pain management and comfort.
• Patient will demonstrate understanding of burn wound care and prevention of further injury.
• Patient will regain optimal functional ability and minimize scarring.

Nursing Assessment for Burn Patients

A thorough and ongoing assessment is vital in managing burn patients effectively. It guides the nursing care plan and helps monitor the patient’s progress.

1. Assess Burn Depth and Extent: Determine the depth of the burn (first, second, third, or fourth degree) and the total body surface area (TBSA) affected using the Rule of Nines or Lund-Browder chart. This assessment is critical for fluid resuscitation, wound care, and overall management.

2. Evaluate Airway, Breathing, and Circulation (ABCs): In major burns, especially those involving the face and neck, airway compromise can occur due to edema. Assess for signs of respiratory distress, such as stridor, hoarseness, or difficulty breathing. Monitor vital signs, including heart rate, blood pressure, and oxygen saturation, to assess circulatory status and fluid balance.

3. Pain Assessment: Burns are extremely painful injuries. Assess pain intensity, quality, location, and aggravating/relieving factors using a pain scale. Effective pain management is essential for patient comfort and cooperation with treatment.

4. Wound Assessment: Regularly assess the burn wound for:

• Size and Depth: Measure and document wound dimensions.
• Color: Observe wound bed color (red, pink, white, black, etc.).
• Drainage: Note the amount, color, and odor of exudate.
• Signs of Infection: Monitor for increased redness, swelling, warmth, purulent drainage, foul odor, and fever.
• Surrounding Skin: Assess for maceration, excoriation, or breakdown.

5. Assess Fluid Status: Burns cause significant fluid shifts and loss. Monitor for signs of dehydration (e.g., dry mucous membranes, decreased urine output, tachycardia) and fluid overload (e.g., edema, crackles in lungs). Closely monitor urine output as an indicator of adequate fluid resuscitation.

6. Nutritional Assessment: Burn patients have increased metabolic needs for wound healing. Assess nutritional status, including weight, pre-albumin levels, and dietary intake. Collaborate with a dietitian to ensure adequate caloric and protein intake.

7. Psychosocial Assessment: Burns can be emotionally traumatic. Assess the patient’s emotional response, coping mechanisms, and support system. Address anxiety, fear, and body image concerns.

Nursing Interventions for Burn Patients

Nursing interventions for burns are multifaceted and aim to address the patient’s physiological and psychological needs throughout the recovery process.

1. Initiate Fluid Resuscitation: For major burns (typically >20% TBSA in adults and >10% in children), fluid resuscitation is critical to prevent hypovolemic shock. Follow established guidelines, such as the Parkland formula, to calculate and administer intravenous fluids. Monitor urine output closely to guide fluid administration.

2. Wound Care Management:

• Wound Cleansing: Gently cleanse the burn wound with mild soap and water or a prescribed antiseptic solution.
• Debridement: Remove nonviable tissue (eschar) to promote wound healing. Debridement can be surgical, enzymatic, mechanical, or autolytic, depending on the wound characteristics and facility protocols.
• Dressing Application: Apply appropriate dressings to protect the wound, prevent infection, and promote moisture balance. Dressings may include topical antimicrobial agents, biologic dressings, synthetic dressings, or traditional gauze dressings. Change dressings as prescribed, typically once to twice daily.
• Monitor for Infection: Observe for signs of wound infection and obtain wound cultures if infection is suspected. Administer antibiotics as ordered.

3. Pain Management:

• Pharmacological Interventions: Administer analgesics as prescribed, including opioids, non-opioids, and adjuvant medications. Utilize a multimodal approach to pain management. Provide pain medication prior to dressing changes and procedures.
• Non-Pharmacological Interventions: Employ non-pharmacological pain relief measures, such as positioning, elevation, distraction, relaxation techniques, and guided imagery.

4. Infection Prevention:

• Maintain Aseptic Technique: Practice strict aseptic technique during wound care and invasive procedures to minimize the risk of infection.
• Monitor for Signs of Sepsis: Be vigilant for systemic signs of infection, such as fever, tachycardia, tachypnea, and altered mental status.
• Prophylactic Measures: Consider prophylactic measures such as tetanus immunization and topical or systemic antibiotics as prescribed.

5. Promote Nutrition: Provide high-calorie, high-protein diet to meet increased metabolic demands. Consider enteral or parenteral nutrition if oral intake is inadequate.

6. Maintain Thermoregulation: Burn patients are at risk for hypothermia due to skin loss. Maintain a warm room temperature and use warming blankets as needed.

7. Prevent Contractures: Encourage active and passive range of motion exercises to prevent contractures and maintain joint mobility. Collaborate with physical and occupational therapists for rehabilitation.

8. Psychosocial Support: Provide emotional support and address psychological needs. Encourage patient and family involvement in care. Offer resources for counseling and support groups.

9. Patient Education: Educate the patient and family about:

• Wound care techniques and dressing changes.
• Pain management strategies.
• Signs and symptoms of infection.
• Importance of nutrition and hydration.
• Rehabilitation and scar management.
• Prevention of future burns.

Nursing Care Plans for Burns

Nursing care plans provide a structured framework for delivering individualized care based on the patient’s specific needs and nursing diagnoses. Here are examples of nursing care plans relevant to burn patients:

Care Plan #1: Impaired Skin Integrity related to burn injury as evidenced by partial-thickness burns and tissue damage.

Expected Outcomes:

• Patient will demonstrate progressive wound healing and skin regeneration within [specific timeframe].
• Patient will maintain a clean and protected wound environment.
• Patient will verbalize understanding of wound care instructions and preventative measures.

Assessment:

1. Assess burn wound characteristics: Determine the depth, size, location, and appearance of the burn wound.
2. Monitor for signs of infection: Assess for redness, swelling, warmth, drainage, odor, and fever.
3. Evaluate pain level: Assess pain intensity and response to pain management interventions.

Interventions:

1. Perform wound care as prescribed: Cleanse the wound, debride as needed, and apply prescribed topical medications and dressings using aseptic technique.
2. Maintain a sterile wound environment: Ensure dressings are intact and changed as scheduled.
3. Educate the patient on wound care: Instruct on proper wound cleansing, dressing changes, and signs of complications.
4. Administer pain medication as ordered: Provide analgesics to manage burn pain effectively.
5. Promote optimal nutrition: Encourage a high-protein, high-calorie diet to support wound healing.

Care Plan #2: Risk for Infection related to compromised skin integrity secondary to burn injury.

Expected Outcomes:

• Patient will remain free from signs and symptoms of wound infection throughout hospitalization.
• Patient will demonstrate understanding of infection prevention measures.

Assessment:

1. Monitor vital signs: Assess temperature, heart rate, respiratory rate, and blood pressure for signs of systemic infection.
2. Inspect wound site regularly: Observe for redness, swelling, warmth, purulent drainage, and foul odor.
3. Review laboratory results: Monitor white blood cell count and wound cultures for indicators of infection.

Interventions:

1. Maintain aseptic technique: Practice strict hand hygiene and sterile technique during wound care and invasive procedures.
2. Administer antibiotics as prescribed: Provide prophylactic or therapeutic antibiotics as ordered by the physician.
3. Promote adequate nutrition and hydration: Support the immune system through optimal nutritional intake.
4. Educate the patient on infection prevention: Instruct on hand hygiene, wound care, and recognizing signs of infection to report.
5. Ensure proper wound dressing: Apply dressings that provide a barrier against bacterial contamination.

Care Plan #3: Acute Pain related to tissue and nerve damage secondary to burn injury.

Expected Outcomes:

• Patient will report pain is managed to a tolerable level (using a pain scale).
• Patient will demonstrate effective use of pain management techniques.
• Patient will participate in activities of daily living with minimal pain interference.

Assessment:

1. Assess pain characteristics: Determine pain location, intensity, quality, duration, and aggravating/relieving factors.
2. Utilize pain scales: Employ appropriate pain assessment tools (e.g., numeric rating scale, visual analog scale) to quantify pain.
3. Evaluate effectiveness of pain relief measures: Monitor the patient’s response to pain medications and non-pharmacological interventions.

Interventions:

1. Administer analgesics as prescribed: Provide pain medications on a regular schedule and as needed for breakthrough pain.
2. Implement non-pharmacological pain relief measures: Utilize positioning, elevation, distraction, relaxation techniques, and thermal therapies.
3. Educate the patient on pain management: Teach about pain medication options, non-pharmacological strategies, and pain reporting.
4. Promote comfort measures: Provide a comfortable environment, reduce anxiety, and offer emotional support.
5. Coordinate with pain management team: Consult with pain specialists for complex pain management needs.

References

[Original article references, if deemed relevant, or replace with burn-specific reputable sources. Example:]

• Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.). Wolters Kluwer.
• Morton, P.G., & Fontaine, D.K. (2018). Critical care nursing: A holistic approach (11th ed.). Wolters Kluwer.
• National Institute of Burn Medicine. (n.d.). Burn classifications. https://www.ameriburn.org/burn-center-referral/burn-classification/