Phases of Burn Injury: Patient Care
Time Period:
Goals:
Nursing Dx:
Emergent
24-72 hours
Acute
7-21 days
Secure airway, support circulation by
fluid replacement, keep the patient
comfortable with analgesics, prevent
infection through meticulous wound
care, maintain body temp, provide
emotional support
Ineffective airway clearance related to
secretions, tracheobronchial edema
and obstruction
Deficient fluid volume related to
intervascular fluid shift and
evaporation
Hypothermia related to impaired
temperature regulation and wound
exposure
Risk for infection related to impaired
skin integrity
Impaired skin integrity related to
impaired profusion and burn injured
skin
Acute pain related to exposed nerve
endings and associated trauma
Anxiety related to situational crises
and threat of death
Treatment of the burn and
avoidance, detection and
treatment of complications
Impaired skin integrity related to
burn injury and nutritional
deficits
Risk for infection related to
impaired skin integrity and
altered immune response
Imbalanced nutrition: less than
body requirements related to
increased metabolic needs,
protein loss and decreased
appetite
Acute pain related to exposed
nerve endings and immobility
Deficient fluid volume related to
increased insensible loss and
evaporation
Impaired physical mobility
related to decreased strength and
endurance, activity intolerance,
and depression
Rehab
Wound closure- the patient
returns to the highest level of
functioning
Maintaining proper healing to
get the patient back to the
highest functioning level
Impaired physical mobility
related to pain, decreased
strength and endurance, and
contractures
Disturbed body image related
to altered body function and
visualization
Risk for impaired skin integrity
related to nutritional deficits
and fragile new tissue
Chronic pain related to joint
and tissue contractures
Ineffective coping related to
situational crises and
ineffective support systems
Disturbed body image related to
altered body appearance or
function
Assessment:
Assess airway, fluid volume, initial
wound care, pain control, comfort,
emotional support, patient and family
education
Interventions:
Monitor vital signs, assess pain,
administer fluids, monitor urinary
output, replace electrolytes, wound
care, medication therapy, surgery,
patient and family teachings
Monitoring skin integrity,
preventing infection, providing
nutrition, managing comfort and
pain, maintaining fluid balance,
relieving anxiety, promoting
activity, supporting and
encouraging coping and selfcare, preventing hypothermia
Management of the pain
Identifying nursing diagnosis
Implementation of patient care
interventions, and evaluation
of outcomes
Help to maintain range of joint
motion to prevent scars
Emotional evaluation
Assessing response to
positioning, splinting, and
exercise ability of the patient
and family to preform daily
wound care after discharge
Proper nutrition, monitoring vital Splints to prevent/correct
signs, monitor wounds/dressings contractures
Exercises, ambulation
Repositioning
Promotion of mobility, selfcare, a positive body image,
skin integrity, comfort and
facilitation of patient and
family coping through teaching