Care of Patients with Burns: Comprehensive Nursing Diagnosis and Management

Burn injuries represent a critical area of healthcare, requiring specialized and comprehensive nursing care. These injuries, caused by thermal, chemical, electrical, or radioactive sources, lead to significant damage to the body’s tissues and can profoundly impact a patient’s physical and psychological well-being. Effective nursing interventions are crucial from the moment of injury through rehabilitation, focusing on mitigating immediate threats, preventing complications, and fostering optimal recovery. This detailed guide is designed to provide healthcare professionals with an in-depth understanding of the Care Of Patients With Burns Nursing Diagnosis, encompassing assessment, planning, intervention, and evaluation. By understanding the nuances of burn pathophysiology and evidence-based nursing practices, nurses can significantly improve patient outcomes and quality of life. This article will explore the essential aspects of burn care, including classification, phases, and specific nursing care plans, empowering nurses to deliver patient-centered and effective care.

Understanding Burn Injuries

A burn injury is defined as damage to tissues caused by the transfer of energy from a heat source, chemicals, electricity, radiation, or sunlight. The severity of a burn depends on the depth of tissue damage and the extent of body surface area affected. Burns are a leading cause of morbidity and mortality worldwide, requiring extensive and often prolonged medical and nursing care. Common causes include scalds from hot liquids, flames from fires, contact with hot objects, and chemical or electrical exposures. The consequences of severe burns extend beyond the immediate physical trauma, often leading to long-term disfigurement, disability, and psychological distress.

A visual representation of different degrees of burn injuries on a human arm, highlighting the layers of skin affected in each type.

Classifying Burn Severity

Accurate classification of burns is fundamental to guiding treatment and predicting prognosis. Burns are primarily classified by depth and extent.

Depth of Burns

Burn depth indicates the layers of skin affected and is categorized into degrees:

• First-Degree Burns (Superficial): These burns affect only the epidermis, the outermost layer of skin. They are characterized by redness, pain, and dryness. A common example is sunburn. Healing typically occurs within a week without scarring.

• Second-Degree Burns (Partial Thickness): These burns involve the epidermis and part of the dermis, the second layer of skin. They are further divided into:

  • Superficial Partial Thickness: Affecting the epidermis and upper dermis, these burns are characterized by blisters, intense pain, and weeping. Healing usually occurs within 2-3 weeks with minimal scarring.
  • Deep Partial Thickness: Extending deeper into the dermis, these burns may appear waxy white or mottled, with less pain due to nerve damage, and blisters may be present but may break easily. Healing can take several weeks to months and may result in scarring and contractures. Skin grafting might be necessary in some cases.

• Third-Degree Burns (Full Thickness): These are severe burns that destroy the epidermis and dermis, and may extend into subcutaneous tissue, muscle, and bone. The skin appears white, leathery, charred, or waxy. There is often no pain in the burned area due to nerve destruction, although surrounding areas may be painful. Full-thickness burns require skin grafting for healing and will result in significant scarring and potential functional impairment.

• Fourth-Degree Burns: These are the most severe burns, extending beyond the skin into underlying tissues, including muscle, tendon, and bone. They are often caused by prolonged contact with flames, electricity, or chemicals. These burns have a charred appearance and require extensive surgical intervention, often including amputation or complex reconstruction.

Extent of Burns – The Rule of Nines

The “Rule of Nines” is a widely used tool to estimate the total body surface area (TBSA) affected by burns in adults. It assigns percentages to different body regions:

• Head and Neck: 9%
• Anterior Trunk: 18%
• Posterior Trunk: 18%
• Each Arm: 9% (4.5% anterior, 4.5% posterior)
• Each Leg: 18% (9% anterior, 9% posterior)
• Perineum: 1%

For children, the Lund-Browder chart is often preferred as it adjusts for the different body proportions in pediatric patients. Accurate TBSA estimation is crucial for fluid resuscitation and determining the severity of the burn.

Phases of Burn Injury Management

Burn care is typically divided into three overlapping phases, each with distinct priorities and nursing interventions:

1. Emergent (Resuscitative) Phase: This phase begins at the time of injury and continues for approximately 24-48 hours, or until fluid resuscitation is complete. The primary focus during this phase is on life-saving measures:

   • Airway management: Ensuring a patent airway and adequate ventilation is the absolute first priority, especially in patients with inhalation injuries.
   • Fluid resuscitation: Rapid and aggressive fluid replacement is critical to counteract burn shock caused by massive fluid shifts.
   • Circulation support: Monitoring and maintaining hemodynamic stability.
   • Pain management: Initiating pain relief measures.
   • Preventing hypothermia: Maintaining body temperature.
   • Initial wound assessment and care: Covering the burn wound with clean, dry dressings.

2. Acute (Wound Healing) Phase: This phase starts after fluid resuscitation is complete and continues until wound closure is achieved. The focus shifts to:

   • Wound care and infection prevention: Meticulous wound care, including cleansing, debridement, and dressing changes, is essential to prevent infection and promote healing.
   • Nutritional support: Meeting the hypermetabolic needs of the burn patient through enteral or parenteral nutrition.
   • Pain management: Ongoing pain control, often requiring multimodal approaches.
   • Physical and occupational therapy: Initiating early mobility and preventing contractures.
   • Psychological support: Addressing the emotional and psychological impact of the burn injury.

3. Rehabilitation Phase: This phase begins when the majority of the burn wounds are closed and continues for months or years. The goals are to:

   • Maximize functional recovery: Continuing physical and occupational therapy to improve strength, range of motion, and functional abilities.
   • Minimize scarring and contractures: Using pressure garments, silicone sheeting, and scar massage.
   • Psychosocial rehabilitation: Addressing body image issues, PTSD, and reintegration into social and vocational life.
   • Patient and family education: Providing ongoing education on skin care, scar management, and long-term follow-up.

Nursing Care Plans and Management for Burn Patients

Nursing care for burn patients is complex and requires a multidisciplinary approach. The following sections outline key nursing problem priorities, assessments, diagnoses, goals, and interventions relevant to the care of patients with burns nursing diagnosis.

Prioritizing Nursing Problems in Burn Care

Based on the phases of burn injury and common complications, nursing priorities for patients with burns include:

• Maintaining Airway and Breathing: Ensuring adequate oxygenation and ventilation, particularly in patients with potential inhalation injury.
• Fluid Resuscitation and Hemodynamic Stability: Administering intravenous fluids to prevent hypovolemic shock and maintain organ perfusion.
• Pain Management: Providing effective analgesia to manage severe burn pain and promote comfort.
• Infection Prevention: Implementing strict infection control measures to minimize the risk of wound and systemic infections.
• Wound Care Management: Promoting wound healing through cleansing, debridement, dressing changes, and skin grafting when necessary.
• Nutritional Support: Meeting the increased metabolic demands to support healing and prevent malnutrition.
• Maintaining Mobility and Preventing Contractures: Initiating early mobilization and implementing measures to prevent joint stiffness and contractures.
• Psychosocial Support: Addressing emotional distress, body image concerns, and facilitating coping mechanisms.

Comprehensive Nursing Assessment for Burn Patients

A thorough nursing assessment is crucial for identifying patient needs and guiding the development of individualized care plans. Assessment should be ongoing and encompass both subjective and objective data.

Subjective and Objective Data Assessment:

Observable Signs and Symptoms:

• Skin Changes: Redness, discoloration, blisters, peeling, open wounds, charred skin, edema around burn site.
• Pain: Reported pain intensity, location, and character.
• Respiratory Distress: Difficulty breathing, coughing, hoarseness, wheezing, soot in sputum, changes in voice.
• Gastrointestinal Issues: Nausea, vomiting.
• Systemic Effects: Weakness, dizziness, increased heart rate, decreased urine output, signs of infection (redness, swelling, pus), altered mental status, confusion.
• Smoke Inhalation Symptoms: Hoarseness, cough, difficulty swallowing.

Factors Related to Burn Injury Cause and Patient Condition:

• Neuromuscular Impairment: Limitations in movement or sensation.
• Pain and Discomfort: Impact on mobility and daily activities.
• Restrictive Therapies: Immobilization, dressings, splints.
• Skin Disruption: Depth and extent of burn, need for grafting.
• Psychological Impact: Traumatic event, disfigurement concerns, pain experience, fear of death or disability.
• Respiratory Factors: Smoke inhalation, edema, chest burns restricting breathing.
• Metabolic Changes: Hypermetabolic state, protein catabolism.
• Fluid and Electrolyte Imbalances: Edema formation, fluid shifts.
• Wound Care Procedures: Pain associated with debridement and dressing changes.
• Compromised Defenses: Loss of skin barrier, suppressed immune response.

Formulating Nursing Diagnoses for Burn Patients

Based on the assessment data, several nursing diagnoses may be relevant for patients with burn injuries. These diagnoses provide a framework for planning and implementing nursing care. It’s important to note that in clinical practice, nursing diagnoses are used to guide care, but the specific labels may be less emphasized than the overall individualized care plan.

Potential Nursing Diagnoses:

• Impaired Skin Integrity related to destruction of skin layers by thermal injury.
• Acute Pain related to tissue and nerve damage from burns and wound care procedures.
• Risk for Infection related to loss of protective skin barrier and invasive procedures.
• Deficient Fluid Volume related to fluid shifts and evaporative losses from burn wounds.
• Ineffective Airway Clearance related to edema, secretions, and potential inhalation injury.
• Impaired Physical Mobility related to pain, edema, restrictive dressings, and potential contractures.
• Disturbed Body Image related to disfigurement, scarring, and functional limitations.
• Anxiety and Fear related to pain, uncertainty of prognosis, and traumatic experience.
• Imbalanced Nutrition: Less Than Body Requirements related to hypermetabolic state and decreased oral intake.
• Risk for Ineffective Peripheral Tissue Perfusion related to edema and circumferential burns.

Setting Nursing Goals and Expected Outcomes

Nursing goals for burn patients are aimed at promoting healing, preventing complications, and supporting the patient’s physical and emotional recovery. Goals should be specific, measurable, achievable, relevant, and time-bound (SMART).

Example Nursing Goals and Expected Outcomes:

• Maintaining Function: The patient will maintain optimal functional positioning and range of motion, preventing contractures.
• Improving Mobility: The patient will demonstrate increased strength and function in affected and compensatory body parts.
• Resuming Activities: The patient will participate in activities of daily living (ADLs) and demonstrate techniques to resume desired activities.
• Adapting to Body Image Changes: The patient will express acceptance of body changes and demonstrate positive self-esteem.
• Communicating Feelings: The patient will discuss their situation and changes with family and support persons.
• Planning for the Future: The patient will develop realistic goals and plans for rehabilitation and life after discharge.
• Maintaining Respiratory Function: The patient will exhibit clear breath sounds, a respiratory rate within normal limits, and be free from dyspnea and cyanosis.
• Managing Emotional Distress: The patient will verbalize feelings, demonstrate healthy coping mechanisms, and report reduced anxiety and fear.
• Problem-Solving and Resource Utilization: The patient will demonstrate effective problem-solving skills and utilize available resources.
• Promoting Wound Healing: The patient will exhibit tissue regeneration and timely healing of burn wounds.
• Meeting Nutritional Needs: The patient will demonstrate adequate nutritional intake, maintain stable weight, and exhibit positive nitrogen balance.
• Controlling Pain: The patient will report pain relief or control and demonstrate relaxed facial expressions and body posture.
• Rest and Sleep: The patient will participate in activities and achieve appropriate sleep and rest patterns.
• Preventing Infection: The patient will achieve timely wound healing without purulent exudate, remain afebrile, and exhibit no signs of infection.
• Understanding Condition and Treatment: The patient will verbalize understanding of their condition, prognosis, and therapeutic needs, and correctly perform necessary procedures.

Nursing Interventions and Actions for Burn Patients

Nursing interventions for burn patients are multifaceted and tailored to the individual patient’s needs and the phase of burn recovery. The following sections detail interventions categorized by common nursing diagnoses.

1. Enhancing Physical Mobility

Impaired physical mobility is a common issue due to pain, edema, neuromuscular impairment, and restrictive therapies.

Nursing Interventions:

• Frequent Circulation, Motion, and Sensation Checks: Assess digits frequently to detect early signs of circulatory compromise due to edema.
• Proper Body Alignment and Support: Utilize supports and splints to maintain functional body alignment, especially for burns over joints, to prevent contractures.
• Range of Motion (ROM) Exercises: Implement consistent ROM exercises, starting with passive and progressing to active as tolerated, to prevent contractures and maintain joint function.
• Encourage Patient Participation: Promote patient involvement in all activities to the extent possible to foster independence and self-esteem.
• Family/SO Involvement: Encourage family and significant others to assist with ROM exercises to provide consistent therapy.
• Pre-Activity Pain Management: Administer pain medication before activity or exercise to reduce stiffness and facilitate participation.
• Rest Periods: Schedule treatments and activities to include periods of uninterrupted rest to improve strength and tolerance for activity.
• Integrate ADLs with Therapy: Combine ADLs with physical therapy and hydrotherapy to enhance therapeutic effects.
• Early Rehabilitation Phase Initiation: Begin rehabilitation planning upon admission to encourage patient participation and awareness of recovery potential.

2. Improving Body Image and Self-Esteem

Burn injuries can significantly alter body image and self-esteem due to scarring and functional changes.

Nursing Interventions:

• Assess Meaning of Loss: Understand the patient’s and SO’s perception of loss and change, including cultural and religious beliefs.
• Acknowledge and Accept Feelings: Allow and validate expressions of frustration, anger, grief, and hostility. Recognize withdrawn behavior and denial as coping mechanisms.
• Set Limits on Maladaptive Behavior: Maintain a nonjudgmental attitude while setting limits on disruptive behaviors and encourage positive coping strategies.
• Realistic and Positive Approach: Be realistic yet positive during treatments and teaching, setting achievable goals within limitations to build trust.
• Encourage Wound Viewing and Care Participation: Facilitate acceptance of reality by encouraging the patient and SO to view wounds and participate in care.
• Provide Hope, Avoid False Reassurance: Offer hope within realistic parameters and avoid giving false reassurance.
• Identify Extent of Actual Change: Help the patient identify the actual extent of changes in appearance and body function to begin future planning.
• Positive Reinforcement: Positively reinforce progress and encourage rehabilitation efforts.
• Visual Aids and Discussion: Use pictures or videos of burn care and patient outcomes (selectively) and encourage discussion about feelings.
• Family Interaction: Promote family interaction with each other and the rehabilitation team for mutual support.
• Support Groups for SOs: Provide support groups and information for SOs on how to be helpful to the patient.
• Role-Play Social Situations: Prepare the patient for social interactions by role-playing situations of concern.
• Thorough Teaching and Aftercare Instructions: Provide comprehensive teaching and aftercare instructions, emphasizing dressing care and hygiene.
• Referrals: Refer to physical and occupational therapy, vocational counseling, psychiatric services, social services, and reconstructive surgery as needed.

3. Enhancing Airway Clearance

Airway compromise is a critical concern, especially with inhalation injuries.

Nursing Interventions:

• Assess Airway, Breathing, Circulation (ABCs): Be vigilant for signs of smoke inhalation: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in mouth/nose, darkened sputum.
• Obtain Injury History: Note burning agents, exposure duration, and location (closed/open space) to assess inhalation injury risk.
• Assess Gag and Swallow Reflexes: Note drooling, inability to swallow, hoarseness, and wheezy cough as indicators of inhalation injury.
• Monitor Respiratory Status: Assess respiratory rate, rhythm, depth, pallor, cyanosis, and sputum characteristics.
• Auscultate Lungs: Note stridor, wheezing, crackles, diminished breath sounds, and brassy cough, indicating potential airway obstruction or respiratory distress.
• Observe Skin Color: Note pallor or cherry-red color of unburned skin, suggesting hypoxemia or carbon monoxide poisoning.
• Monitor Mental Status Changes: Investigate restlessness, agitation, altered LOC, which may indicate hypoxia.
• Monitor Fluid Balance: Track 24-hour fluid balance, noting variations, as fluid shifts increase pulmonary edema risk, especially with inhalation injury.
• Blood Samples for Labs: Draw blood for CBC, type and crossmatch, electrolytes, glucose, BUN, creatinine, and ABGs to establish baseline data.
• Serial ABGs or Pulse Oximetry: Monitor and graph serial ABGs or pulse oximetry to assess oxygenation status.
• Review Chest X-rays: Monitor serial chest x-rays for signs of pulmonary complications.
• Elevate Head of Bed: Elevate the head of the bed to promote lung expansion. Avoid pillows under the head for neck/head burns.
• Coughing and Deep Breathing Exercises: Encourage coughing and deep breathing exercises and frequent position changes.
• Suctioning: Suction carefully if necessary, using sterile technique to maintain a clear airway.
• Voice Rest and Swallow Assessment: Promote voice rest but periodically assess the ability to speak and swallow oral secretions.
• Humidified Oxygen: Administer humidified oxygen via appropriate mode (face mask) to correct hypoxemia and reduce sputum viscosity.
• Chest Physiotherapy and Incentive Spirometry: Provide chest physiotherapy and incentive spirometry to improve lung expansion and secretion mobilization.
• Prepare for Intubation/Tracheostomy: Prepare for and assist with intubation or tracheostomy if respiratory function is compromised.

4. Reducing Fear and Anxiety

Burn injuries are traumatic events that can lead to significant fear and anxiety.

Nursing Interventions:

• Assess Mental Status: Evaluate mood, affect, comprehension of events, and thought content. Recognize denial and dissociation as initial coping mechanisms.
• Investigate Mentation Changes: Monitor for hypervigilance, hallucinations, sleep disturbances, nightmares, agitation, apathy, disorientation, and labile affect, which may indicate extreme anxiety or delirium.
• Identify Coping Mechanisms: Determine past coping strategies to help manage current stress.
• Frequent Explanations: Provide frequent explanations and information about care procedures, repeating as needed to reduce fear and promote cooperation.
• Active Listening: Demonstrate willingness to listen and talk to the patient during non-painful times to offer support.
• Involve Patient in Decision-Making: Include the patient and SO in decision-making to promote control and reduce helplessness.
• Constant Orientation: Provide consistent orientation to surroundings and reality.
• Encourage Discussion of Burn Circumstances: Encourage the patient to talk about the burn event when ready, to process the trauma.
• Explain What Happened: Provide honest and compassionate explanations about the event and answer questions.
• Restful Environment and Relaxation Techniques: Create a restful environment and use guided imagery and relaxation exercises to reduce anxiety.
• Support Family Feelings: Help the family express grief and guilt, acknowledging their concerns.
• Empathy and Nonjudgmental Approach: Be empathetic and nonjudgmental in dealing with patients and families.
• Encourage Family Visits: Encourage family visits and discussion of familiar events to maintain connection to reality.
• Multidisciplinary Team Involvement: Involve the entire burn team, including social workers and psychiatric resources, for comprehensive support.

5. Promoting Wound Care and Skin Integrity

Maintaining skin integrity and preventing infection in burn wounds is paramount.

Nursing Interventions:

• Wound Assessment and Documentation: Assess and document wound size, color, depth, necrotic tissue, and surrounding skin condition as baseline data.
• Graft and Donor Site Evaluation: Evaluate the color of grafted and donor sites for healing progress and complications.
• Appropriate Burn Care and Infection Control: Provide proper burn care and implement infection control measures to prepare tissues for grafting and prevent infection.
• Maintain Wound Covering: Keep wounds covered as indicated by treatment plan.
• Graft Site Elevation and Immobilization: Elevate grafted areas when possible and maintain desired position and immobility to promote graft adherence.
• Dressing Management: Maintain dressings over grafted areas and donor sites as indicated (mesh, petroleum, nonadhesive).
• Pressure Relief: Keep skin free from pressure to promote circulation and prevent graft failure.
• Wound Washing and Lubrication: Wash sites with mild soap, rinse, and lubricate with cream after dressings are removed and healing occurs to maintain flexibility.
• Bleb Aspiration: Aspirate blebs under sheet grafts with a sterile needle or roll with a sterile swab to ensure graft adherence.
• Prepare for Surgical Grafting and Biological Dressings: Assist with surgical grafting or application of biological dressings:
  • Homograft (Allograft): Temporary covering using skin from cadavers or living donors.
  • Heterograft (Xenograft, Porcine): Animal skin grafts for temporary coverage.
  • Cultured Epithelial Autograft (CEA): Skin grafts grown from the patient’s own skin in a lab.

6. Ensuring Adequate Nutrition

Hypermetabolism in burn patients requires significant nutritional support to promote healing.

Nursing Interventions:

• Auscultate Bowel Sounds: Monitor bowel sounds, noting hypoactive or absent sounds, which may indicate ileus.
• Assess Food Preferences: Determine food likes and dislikes and encourage family to bring appropriate food from home to improve intake.
• Monitor Muscle Mass and Fat: Monitor muscle mass and subcutaneous fat to assess nutritional status.
• Calorie Count and Daily Weight: Maintain a strict calorie count and weigh daily to monitor nutritional intake and adjust dietary needs.
• Monitor Laboratory Studies: Review serum albumin, prealbumin, creatinine, transferrin, and urine urea nitrogen to assess nutritional status.
• Fingerstick Glucose and Urine Testing: Monitor glucose levels as hyperglycemia can occur due to stress.
• Small, Frequent Meals: Provide small, frequent meals and snacks to prevent gastric distension and improve intake.
• Diet as Treatment Education: Educate the patient to view diet as part of treatment and choose high-calorie, high-protein foods.
• Upright Position for Meals: Encourage sitting up for meals to prevent aspiration and aid digestion.
• Oral Hygiene Before Meals: Provide oral hygiene before meals to enhance taste and appetite.
• Nasogastric Tube Insertion: Insert a nasogastric tube if needed to decompress the stomach and prevent aspiration.
• High-Calorie, High-Protein Diet: Provide a diet high in calories and protein with vitamin and trace element supplements.
• Enteral Feedings: Consider enteral feedings via feeding tube if oral intake is insufficient.
• Parenteral Nutrition (TPN): Administer TPN if enteral feeding is not possible due to complications.
• Insulin Administration: Administer insulin as indicated for hyperglycemia.
• Dietitian Referral: Refer to a dietitian or nutrition support team for personalized nutritional plans.

7. Minimizing Pain and Enhancing Comfort

Pain management is a critical aspect of burn care due to the severity of burn pain.

Nursing Interventions:

• Pain Assessment: Assess and document pain reports including location, character, and intensity (0-10 scale).
• Wound Coverage: Cover wounds as soon as possible to minimize pain from air movement and temperature changes.
• Extremity Elevation: Elevate burned extremities periodically to reduce edema and discomfort.
• Bed Cradle: Use a bed cradle to keep linens off wounds, reducing pain.
• Functional Positioning: Wrap digits and extremities in functional positions using splints and footboards to prevent contractures and enhance comfort.
• Frequent Position Changes and ROM: Change position frequently and assist with active and passive ROM exercises.
• Comfortable Environment: Maintain a comfortable environmental temperature and provide heat lamps or heat-retaining coverings to prevent chilling.
• Pre-Procedure Medication and Hydrotherapy: Provide medication and/or hydrotherapy before dressing changes and debridement to reduce pain.
• Encourage Expression of Feelings: Encourage verbalization of feelings about pain to enhance coping.
• Patient Involvement in Scheduling: Involve the patient in scheduling activities and treatments to enhance control.
• Procedure Explanation: Explain procedures and provide information, especially during debridement, to alleviate fear and pain.
• Basic Comfort Measures: Provide massage of uninjured areas and frequent position changes.
• Stress Management Techniques: Encourage stress management techniques like relaxation, deep breathing, guided imagery, and visualization.
• Diversional Activities: Provide age-appropriate diversional activities to shift focus away from pain.
• Promote Sleep: Ensure uninterrupted sleep periods as sleep deprivation increases pain perception.
• Analgesic Administration: Administer analgesics (narcotics and non-narcotics) as prescribed, often around-the-clock, titrating doses as needed, especially initially via IV route.

8. Preventing Infection

Burn patients are highly susceptible to infections due to compromised skin barrier and immune response.

Nursing Interventions:

• Daily Wound Examination: Examine wounds daily, noting changes in appearance, odor, or drainage, which may indicate sepsis.
• Unburned Area Examination: Inspect unburned areas (groin, neck creases, mucous membranes) and vaginal discharge routinely for signs of infection.
• Vital Sign Monitoring: Monitor vital signs for fever, increased respiratory rate, and depth, associated with changes in sensorium, diarrhea, decreased platelets, and hyperglycemia with glycosuria.
• Wound Photography: Photograph wounds initially and periodically to document healing progression.
• Routine Wound Cultures: Obtain routine cultures and sensitivities of wounds and drainage for early infection detection and targeted treatment.
• Isolation Techniques: Implement appropriate isolation techniques based on wound type and treatment method to prevent cross-contamination.
• Hand Hygiene: Emphasize and model good handwashing for all personnel and visitors.
• Aseptic Technique and Protective Gear: Use gowns, gloves, masks, and strict aseptic technique during wound care and provide sterile linens.
• Visitor Management: Monitor and limit visitors if necessary, explaining isolation protocols to visitors.
• Hair Management: Shave or clip hair around burned areas and shampoo hair daily to reduce microbial load.
• Eye Care: Provide special eye care with covers and tear formulas as needed to prevent corneal damage.
• Prevent Skin-to-Skin Contact: Prevent skin-to-skin contact between burned surfaces (digits, ears) by wrapping separately.
• Hydrotherapy and Wound Cleansing: Remove dressings and cleanse burned areas in hydrotherapy, whirlpool, or shower with mild cleansing agents at 100°F (37.8°C).
• Debridement: Debride necrotic or loose tissue and ruptured blisters, leaving small, intact, uninfected blisters alone.
• Topical Agents: Administer topical antimicrobial agents as prescribed.
• Systemic Medications: Administer systemic antibiotics, tetanus toxoid, or clostridial antitoxin as indicated.
• IV and Invasive Line Placement: Place IV and invasive lines in non-burned areas to reduce infection risk.

9. Patient Education and Health Teachings

Patient education is crucial for successful recovery and long-term management after discharge.

Nursing Interventions:

• Review Condition and Prognosis: Discuss condition, prognosis, and future expectations to provide a knowledge base for informed choices.
• Discuss Home and Activity Expectations: Discuss expectations for returning home, work, and normal activities, addressing potential adjustment challenges.
• Medication Review: Review medications including purpose, dosage, route, and expected side effects to ensure understanding and adherence.
• Symptom Recognition: Identify signs and symptoms requiring medical evaluation: inflammation, wound changes, fever, pain changes, mobility loss.
• Skin Care Education: Teach proper skin care, moisturizer use, sunscreen application, and anti-itching medication use for healing skin.
• Burn and Wound Care Techniques: Review and have patient/SO demonstrate burn, skin graft, and wound care techniques and identify outpatient resources.
• Scarring Process and Pressure Garments: Explain the scarring process and the necessity and use of pressure garments to minimize scarring.
• Exercise Program and Rest: Encourage continuation of prescribed exercise program and scheduled rest periods.
• Activity Limitations: Identify specific activity limitations based on individual needs and healing stage.
• Nutritional Guidance: Emphasize sustained intake of high-protein and high-calorie meals and snacks for optimal healing.
• Potential Adjustment Problems: Advise patient and SO of potential exhaustion, emotional lability, and adjustment problems, and provide information about counseling.
• Follow-Up Care Importance: Stress the importance of follow-up care and rehabilitation for optimal recovery.
• Contact Person Information: Provide a contact phone number for the treatment team for ongoing support and clarification.
• Immunization Status: Ensure immunizations, especially tetanus, are current.
• Community Resources: Identify community resources such as wound care professionals, crisis centers, support groups, and home health services.

10. Managing Fluid Volume

Fluid management is critical in the emergent phase to prevent hypovolemic shock.

Nursing Interventions:

• Vital Signs and CVP Monitoring: Monitor vital signs and central venous pressure (CVP) to guide fluid replacement and assess cardiovascular response.
• Urinary Output Monitoring: Monitor urinary output and specific gravity, observing urine color and testing for myoglobin, aiming for 30-50 mL/hr output (adults), higher if myoglobinuria is present.
• Wound Drainage and Insensible Loss Estimation: Estimate wound drainage and insensible losses to guide fluid replacement.
• Daily Weight Monitoring: Weigh daily to track fluid balance and guide fluid resuscitation.
• Mental Status Evaluation: Assess mental status changes as deterioration may indicate inadequate circulating volume.
• Extremity Circumference Measurement: Measure burned extremity circumference to estimate edema.
• Gastric Distension and GI Bleeding Observation: Observe for gastric distension, hematemesis, and tarry stools, and test NG drainage and stools for blood.
• Laboratory Studies Monitoring: Monitor Hb/Hct, electrolytes, and random urine sodium to assess fluid and electrolyte balance.
• Fluid Intake Record: Maintain a cumulative record of fluid intake type and amount.
• Urinary Catheter Insertion: Insert and maintain an indwelling urinary catheter for accurate output monitoring.
• Large-Bore IV Catheter Insertion: Insert large-bore IV catheters to accommodate rapid fluid infusion.
• Fluid Replacement Administration: Administer calculated IV fluid replacement, electrolytes, plasma, and albumin based on burn extent, urinary output, and weight.
• Diuretic, Potassium, Antacid, and Histamine Inhibitor Administration: Administer diuretics, potassium, antacids, and histamine inhibitors as indicated.
• Electrolyte Addition to Debridement Water: Add electrolytes to water used for wound debridement to minimize osmotic fluid shifts.

11. Pharmacologic Support and Medication Administration

Pharmacologic interventions are essential for pain management, infection control, and supporting physiological functions.

Medications Used:

• Wound Coverings:
  • Biosynthetic Dressing (Biobrane): Nylon/silicon membrane with porcine peptides for partial-thickness burns.
  • Synthetic Dressings (DuoDerm): Hydroactive dressing for small partial-thickness burns.
  • Opsite, Acuderm: Transparent, occlusive dressings for partial-thickness wounds and donor sites.
• Insulin: To manage hyperglycemia due to stress response and metabolic changes.
• Topical Antimicrobial Agents:
  • Silver Sulfadiazine (Silvadene): Broad-spectrum, intermediate penetration.
  • Mafenide Acetate (Sulfamylon): For invasive wound infections, effective against Gram-negative/positive organisms.
  • Silver Nitrate: Effective against S. aureus, E. coli, Pseudomonas, poor penetration.
  • Bacitracin: For superficial and facial burns, effective against Gram-positive organisms.
  • Povidone-Iodine (Betadine): Broad-spectrum, but can be painful and damage tissues.
  • Hydrogels (Transorb, Burnfree): For partial and full-thickness burns, promotes autolytic debridement.
• Systemic Antibiotics: For general infections identified by culture and sensitivity. Subeschar clysis for localized infection.
• Tetanus Toxoid and Clostridial Antitoxin: To prevent tetanus infection.
• Diuretics (Mannitol/Osmitrol): To enhance urinary output and prevent renal failure.
• Potassium: For potassium replacement due to urinary losses.
• Antacids (Calcium Carbonate/Titralac, Magaldrate/Riopan): To reduce gastric acidity.
• Histamine Inhibitors (Cimetidine/Tagamet, Ranitidine/Zantac): To decrease hydrochloric acid production and prevent GI bleeding.

12. Diagnostic and Laboratory Procedure Monitoring

Laboratory and diagnostic tests are crucial for assessing patient status and guiding treatment.

Monitored Procedures and Tests:

• Arterial Blood Gases (ABGs): Baseline and serial ABGs to assess respiratory status and guide treatment for hypoxemia and hypercapnia.
• Chest X-rays: Serial chest x-rays to monitor for pulmonary complications like atelectasis and edema.
• Serum Albumin, Prealbumin, Creatinine, Transferrin, Urine Urea Nitrogen: To assess nutritional status and adequacy of therapy.
• Hemoglobin/Hematocrit, Electrolytes, Random Urine Sodium: To monitor blood loss, fluid and electrolyte balance, and guide fluid replacement.
• Fingerstick Glucose and Urine Testing: To monitor for hyperglycemia.
• Wound Culture and Sensitivity: To identify and treat wound infections.

Recommended Resources for Burn Care

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health

References and Sources

• Black, J. M., & Hawks, J. H. (2009). Medical-surgical nursing: Clinical management for positive outcomes (Vol. 1). A. M. Keene (Ed.). Saunders Elsevier.
• Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2017). Medical-surgical nursing: Assessment and management of clinical problems.