Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)

Understanding Burn Classifications:
- Define and differentiate between first, second, and third-degree burns, outlining the characteristics and depth of tissue involvement for each classification.
Identification of Burn Causes:
- Identify common causes of burn injuries, including thermal (heat), chemical, electrical, and radiation burns. Understand the importance of determining the cause for appropriate intervention.
Assessment of Burn Severity:
- Learn how to assess the severity of burns using tools such as the Rule of Nines or Lund and Browder chart. Understand the significance of assessing the extent of body surface area affected.
Emergency First Aid for Burns:
- Acquire knowledge and skills related to immediate first aid measures for burn injuries, including proper wound care, pain management, and the importance of seeking professional medical attention.
Psychosocial Support for Burn Patients:
- Recognize the psychological impact of burn injuries on patients and develop strategies to provide empathetic and supportive care. Understand the role of healthcare professionals in addressing both physical and emotional aspects of recovery.

Pathophysiology of Burn Injuries:

Tissue Damage and Inflammation:
- Burns lead to direct injury to skin cells and underlying tissues due to exposure to heat, chemicals, electricity, or radiation. This damage triggers an inflammatory response, causing redness, swelling, and pain.
Loss of Skin Barrier Function:
- Severe burns compromise the skin’s protective barrier, leading to increased permeability and loss of fluids. This can result in dehydration, electrolyte imbalances, and increased susceptibility to infections.
Systemic Response to Burns:
- Extensive burns can initiate a systemic inflammatory response, releasing pro-inflammatory mediators into the bloodstream. This systemic response may lead to complications such as organ dysfunction, sepsis, and respiratory distress.
Vasoconstriction and Hypoperfusion:
- Initially, burn injuries may cause blood vessels to constrict in an attempt to preserve fluid volume. However, as the injury progresses, widespread vasodilation can occur, leading to hypoperfusion of tissues and potential organ failure.
Formation of Scar Tissue:
- Healing in burn injuries involves the formation of scar tissue. Excessive scarring, especially in deep burns, can result in contractures and functional limitations. Scar tissue may also impact the cosmetic appearance of the healed area.

Etiology of Burn Injuries:

Thermal Burns:
- Caused by exposure to flames, hot liquids, steam, or hot surfaces. Common scenarios include house fires, scalds from boiling water, or contact with hot objects.
Chemical Burns:
- Result from contact with corrosive substances such as acids, alkalis, or industrial chemicals. Accidental spills or improper handling of chemicals can lead to chemical burns.
Electrical Burns:
- Occur when the body comes in contact with an electrical source. Electrical burns can damage internal tissues, and severity depends on factors like voltage, current, and duration of exposure.
Radiation Burns:
- Caused by exposure to ultraviolet light, X-rays, or other forms of ionizing radiation. Overexposure during medical procedures or industrial accidents can lead to radiation burns.
Friction Burns:
- Result from skin abrasion due to friction between surfaces. These burns often occur during accidents such as road abrasions or industrial incidents where the skin rubs against rough surfaces.

Desired Outcome for Burn Injury (First, Second, Third degree)

Pain Management:
- Alleviate pain through effective pain relief measures, ensuring the patient’s comfort and promoting a positive healing experience.
Wound Healing:
- Promote optimal wound healing to minimize scarring and reduce the risk of complications, such as infection or impaired function.
Prevention of Infection:
- Prevent infection by maintaining strict aseptic techniques during wound care, administering appropriate antibiotics if necessary, and monitoring for signs of infection.
Psychosocial Support:
- Provide emotional and psychological support to help the patient cope with the physical and emotional challenges associated with burn injuries, facilitating a positive outlook and mental well-being.
Functional Recovery:
- Support the patient in regaining optimal function and mobility through rehabilitation and physical therapy, ensuring a successful return to daily activities and minimizing long-term disability.

Burn Injury (First, Second, Third degree) Nursing Care Plan

Subjective Data:

Pain (mild to severe)

Objective Data:

Redness
Swelling
Peeling of skin and tissue
Blisters
Charred tissue

Nursing Assessment for Burn Injury (First, Second, Third Degree)

Extent and Depth of Burn:
- Assess the size, location, and depth of the burn to determine the severity of the injury and guide appropriate treatment interventions.
Pain Assessment:
- Evaluate the patient’s pain level using a pain scale to tailor pain management strategies effectively and ensure the patient’s comfort.
Circulatory Status:
- Monitor vital signs, capillary refill, and peripheral pulses to assess the patient’s circulatory status and detect any signs of compromised blood flow.
Respiratory Assessment:
- Evaluate respiratory status, especially in cases where burns involve the face or inhalation injury, to identify potential airway compromise or respiratory distress.
Neurological Assessment:
- Conduct a neurological assessment to detect any signs of altered mental status, confusion, or neurological deficits resulting from the burn injury.
Temperature Regulation:
- Monitor the patient’s body temperature and assess for signs of hyperthermia or hypothermia, as burn injuries can impact the body’s ability to regulate temperature.
Psychosocial Assessment:
- Assess the patient’s emotional and psychological well-being, understanding their coping mechanisms, fears, and concerns related to the burn injury.
Nutritional Assessment:
- Evaluate the patient’s nutritional status to address potential deficiencies and support optimal wound healing, considering the increased metabolic demands associated with burn injuries.

Implementation for Burn Injury (First, Second, Third degree)

Airway management
- If burns affect the face or respiratory system, monitor closely to ensure airway is patent. Administer supplemental oxygen as needed. Collaborate with respiratory therapy and healthcare team if advanced airway management is indicated.
Wound Care:
- Initiate and maintain meticulous wound care to prevent infection and promote healing. Depending on the severity, this may involve cleaning, debridement, and dressing changes. Consider pain management prior to and during wound care.
Pain Management:
- Administer prescribed analgesics and implement non-pharmacological pain management strategies, such as positioning, distraction, or relaxation techniques, to address and alleviate pain.
Fluid and Electrolyte Balance:
- Monitor and manage fluid and electrolyte imbalances caused by the burn injury, implementing intravenous fluids and electrolyte replacement as prescribed to maintain homeostasis.
Infection Prevention:
- Implement infection prevention techniques. Monitor patient’s white blood cell count and vital signs due to increased susceptibility to infection.
Nutritional Support:
- Collaborate with a dietitian to develop and implement a nutrition plan that addresses increased metabolic needs, promoting wound healing and preventing malnutrition.
Psychosocial Support:
- Provide emotional support, education, and counseling to the patient and their family to help them cope with the emotional and psychological impact of the burn injury.
Prevention of Complications:
- Implement preventive measures, such as turning and repositioning, to avoid pressure ulcers, and educate the patient on the importance of mobility and maintaining good hygiene.
Collaboration with Multidisciplinary Team:
- Work collaboratively with other healthcare professionals, including physical therapists, occupational therapists, and psychologists, to address the diverse needs of the patient during the recovery process.

Nursing Interventions and Rationales

Assess skin for location, type, and degree of burn

Knowing what type of burn and the degree will provide information on how to treat the burn

Monitor vital signs; capillary refill; peripheral pulses (invasive monitoring may be necessary for severe burns)

Helps determine if a fluid replacement is needed and monitor tissue perfusion

Assess airway, breathing, and circulation.
- Auscultate breath sounds
- Note respiratory rate
- Note signs of smoke inhalation or lung damage, singed hairs, darkened sputum, coughing, soot in or around mouth or nose
- Assess gag and swallow reflexes
- Wheezing, stridor crackles

Exposure to chemicals and flame can cause smoke inhalation in which case the smoke burns and damages the inner lining and tissue of the trachea and lungs. Tachypnea, cyanosis, and changes in the color of sputum may indicate respiratory distress or pulmonary edema

Determine weight and TBSA burned

Used to determine initial fluid resuscitation requirements.

Encourage coughing and deep breathing exercises, suction as necessary

Promotes lung expansion and helps drain secretions

Administer humidified oxygen with a face mask

Correct hypoxemia and acidosis from burn or inhalation; use a humidifier for comfort, to thin mucus and to prevent atelectasis

Assist with intubation or tracheostomy as necessary

Maintain the airway. The ventilator may be required in case of pulmonary edema or injury affects lung function

Obtain IV access, large bore

IV fluids, medications, and blood products may need to be infused quickly

Monitor fluid balance
- Urinary output- average should be 30 – 50 ml/hr (adult)
- Estimate wound drainage
- Monitor amount of fluid intake
- Daily weights
- Measure the circumference of burned extremity

Determine need for and effectiveness of fluid replacement; measure inflammation and retention if any

Monitor labs
- Hemoglobin
- Hematocrit
- Sodium
- Potassium
- Magnesium

Determine if fluid or electrolyte replacement is appropriate and if there is any heart, kidney or liver functionality impairment

Assess and monitor for signs/symptoms of infection
- Fever
- Decreased platelet count
- Hyperglycemia

Prevent complications from infections; treat as appropriate

Administer medications, fluids and blood products as appropriate
- Analgesics, opioids
- Diuretics (mannitol)
- Potassium
- Antacids
- Histamine inhibitors (cimetidine)

Medications will be given for pain and may be given to encourage urinary output and prevent renal failure; electrolyte balance may require supplementation; reduce gastric acidity

Provide wound care, prepare for and maintain skin grafts as necessary
- Maintain dressings
- Occlusive, synthetic or biosynthetic dressings as required
- Debridement of necrotic or loose tissue
- Administer topical agents (silver sulfadiazine)

Maintain and restore skin integrity, protection from infection

Assess and manage pain
- Administer medication (especially prior to dressing changes)
- Elevate burned extremities
- Change positions frequently
- Provide diversional activities as available

Pain is usually present to some varying degree and should be addressed and managed appropriately. Provide comfort, avoid friction or contact with sheets or other items to avoid further tissue damage and pain

Burn prevention education
- Wear sunscreen and reapply frequently
- Keep children and pets out of the kitchen when cooking
- Turn pot handles to the back of the stove
- Test smoke detectors monthly
- Measure bath water temperature and lower water heater temp to 120 deg.
- Check electrical cords/outlets
- Keep chemicals out of reach and use protective equipment when working with chemicals
- Clean out dryer lint traps regularly

Teach patients and families how to prevent burn injuries from occurring in the future.

Evaluation for Burn Injury (First, Second, Third degree)

Wound Healing Progress:
- Regularly assess the wound healing process, monitoring for signs of infection, and evaluating the effectiveness of the implemented wound care regimen.
Pain Management Effectiveness:
- Evaluate the effectiveness of pain management strategies by assessing the patient’s pain levels and adjusting interventions accordingly.
Fluid and Electrolyte Balance:
- Monitor fluid and electrolyte levels through regular assessments and laboratory tests, ensuring that balance is maintained within normal ranges.
Nutritional Status:
- Assess the patient’s nutritional status and weight regularly, ensuring that the prescribed nutrition plan is supporting recovery and preventing malnutrition.
Psychosocial Well-being:
- Evaluate the patient’s psychological and emotional well-being, assessing coping mechanisms and the impact of the burn injury on their overall quality of life. Address any emerging mental health concerns or adjustment issues.

Content Reviewed

9/14/2023 by Jon Haws

References

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Transcript

This is a nursing care plan for burn injuries. So, a burn injury is tissue damage caused by heat, chemicals, electricity, radiation, or sunlight. The degree of the burn depends upon the depth and the area that they cover. Deep burns heal slowly. It can be difficult to treat and to have a high risk of complications, such as infection, amputation, and even death. Some nursing considerations. So, we want to assess this patient’s respiratory status. We want to manage their pain. We want to take a look at their vital signs and manage those . We may need to do some fluid resuscitation. We want to prevent infection and administer any medications as they are ordered. The desired outcome for this patient is that this patient is going to maintain a patent airway and oxygenation of tissue. We want to restore fluid and electrolyte balance. We want to maintain body temperature and control pain and prevent any further complications.

So, when a burn patient comes to you, there’s going to be one thing that they are going to complain about. One thing, and that is going to be pain. Now, that pain can be mild to severe depending on the degree of burn. And, there also may be a situation where the third degree burns, where there is no pain because the, uh, nerve endings have been singed or burned. Some objective data that we’re going to collect for these patients coming in is we are going to see, uh, redness, swelling. We’ll see peeling of the skin and tissue. We may see blisters. We may see charred tissue.

So the first thing we want to do with this patient is we want to take a look at our A, B and C’s. We want to assess their airway. We want to assess the breathing, and we want to assess their circulation. So, we want to make sure that we do A,B,C assessment. And the reason why is we want to note any signs of smoke inhalation. We want to look for signs like smoking inhalation or lung damage. We may see singed hairs, nose hairs, dark sputum when they cough, soot around the nose or the mouth. We may listen when we auscultate. We may hear wheezing or stridor. We may hear crackles. Remember, exposure to chemicals and flame can cause smoke inhalation, which can cause smoke burns and damage the inner lining and tissues of the trachea and the lungs. So, these are things that we want to do at the beginning of our presentation with the patient. The next thing we want to do is we want to monitor their vital signs. We want to look at their vital signs. We also want to take mention of their capillary refill, their pulses, and we want to take a look for signs of infection. This is going to help determine if fluid replacement is needed. And this is going to also help monitor tissue perfusion. Remember, capillary refill is helping us monitor perfusion. Remember this patient, depending on the severity of the burns will have open wounds, so, this patient is at an increased risk for infection.

We want to make sure that we monitor them because of this impaired skin integrity. The next thing we want to do is we want to get them some oxygen, regardless of if they’re sounding fine or not on the monitor, we want to get them some supplemental o2. We want to make sure that that o2 is humidified, humidified oxygen. And we also want to administer via a face mask. We want to correct the hypoxemia and acidosis from the burn or inhalation. We may use a humidifier for comfort. That’s going to be for comfort, and we want to thin the mucus and we want to prevent atelectasis.

The next thing we want to do that’s very important for this patient is we want to obtain IV access. We want a large bore IV, large bore IV, 18 gauge or better is preferable. So, the reason why is we’re going to need to, uh, instill IV fluids, medications, blood products. We’re going to need to give those quickly. If fluid resuscitation is required, we want to utilize the appropriate formula based off of their body square. And then, we also want to assess for infiltration since the fluids are going to be going so rapidly. And finally, uh, we want to manage that pain. These patients are going to be in pain. So we want to manage pain. We want to administer any medication, especially prior to dressing changes, before dressing changes. This is a very painful time for these patients. Pain is usually present to some varying degree and it should be addressed and managed appropriately.

Let’s take a look at the key points. So, a burn injury is tissue damage. It can be caused by heat chemicals, electricity, radiation, or sunlight. Remember this patient’s pain on the subjective end is going to be mild to severe. This patient is going to have a complaint of pain. It’s going to be either mild or severe. What we’re going to see in our objective data is, we’re going to see some redness. We are going to also see some swelling. We may see some blisters, charred tissue or peeling skin. What are some things that we can do? Well, this patient is probably going to need some fluid resuscitation. So we’re going to make sure that they have large bore IVs, at least two 18 gauges or bigger. We’re going to calculate the BSA and we are going to assess for infiltration, signs of fluid overload, like crackles, or edema third spacing. We’re going to also want to prevent an infection. These patients are at high risk for infection. We are going to assess for signs of infections. We’re going to draw blood cultures. We’re going to do skin cultures, and we’re going to provide antibiotics, uh, as needed. But, we want to make sure we get those blood cultures prior.

Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree)

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Lesson Objective for Burn Injury Nursing Care Plan: