NCP Nursing Care Plans for Burns Injury.
A major burn is a devastating injury, requiring painful treatment and a long period of
rehabilitation. Burns have a catastrophic effect on people in terms of human life, suffering,
disability, and financial loss. Burns can be fatal, permanently disfiguring, and incapacitating,
both emotionally and physically. Infections are a major cause of morbidity and mortality in
seriously burned patients. The skin injury from burns has six different mechanisms of injury:
scalds, contact burns, fire, chemical, electrical, and radiation.
Causes for Burns Injury
Thermal burns, the most common type, result from preventable accidents occur because of fires
from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions.
Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkali, or
vesicants. Electrical burns commonly occur after contact with faulty electrical wiring or highvoltage power lines. Friction, or abrasion, burns happen when the skin is rubbed harshly against
a coarse surface. Sunburn follows excessive exposure to sunlight and improper use of tanning
lights.
Complications for Burns Injury
Leading causes of death in burn patients are respiratory complications and sepsis.
Other possible complications include:
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Hypovolemic shock
Anemia
Malnutrition
Multisystem organ dysfunction.
Nursing Assessment Nursing Care Plans for Burns Injury
Patient history. Obtain a complete description of the burn injury, including the time, the
situation, the burning agent, and the actions of witnesses. The time of injury is extremely
important since any delay in treatment may result in a minor or moderate burn becoming a major
injury. Elicit specific information about the location of the accident, since closed-space injuries
are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a
variety of people who are involved with the child. The injury may be suspect if there is a delay in
seeking health care, if there are burns that are not consistent with the story, or if there are bruises
at different stages of healing. Note whether the description of the injury changes or differs
among family or household members.
Basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the
ABCs are stabilized, perform a complete examination of the burn wound to determine burn
severity. First, determine the depth of tissue damage. A partial-thickness burn damages the
epidermis and part of the dermis; a full-thickness burn also affects the subcutaneous tissue. The
more traditional method is to gauge burns by degree. Most burns include a combination of
degrees and thicknesses
RULE OF NINES
The “rule of nines” is a practical technique used to estimate the extent of TBSA total body
surface area involved in a burn. The technique divides the major anatomic areas of the body into
percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is
each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the
perineum and genitalia. Clinicians use the patient’s palm area to represent approximately 1% of
TBSA. Serial assessments of wound healing determine the patient’s response to treatment.
Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn
patient. Fluid balance, daily weights, vital signs, and intake and outpu
Nursing diagnosis Nursing Care Plans for Burns Injury
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Impaired gas exchange
Ineffective airway clearance
Acute pain
Decreased cardiac output
Deficient fluid volume
Ineffective tissue perfusion: Peripheral
Hypothermia
Impaired skin integrity
Impaired physical mobility
Disturbed body image
Risk for infection
Nursing outcomes Nursing Care Plans for Burns Injury
Nursing Key outcomes Nursing Care Plans for Burns Injury, Patient will:
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Ventilation will remain adequate.
Airway will remain patent
Achieve pain relief with analgesia or other measures.
Maintain adequate cardiac output.
Fluid volume will remain within the acceptable range.
Exhibit signs of adequate peripheral perfusion
Communicate understanding of special dietary needs.
Maintain normal body temperature.
Wounds and incisions will appear clean, pink, and free of purulent drainage.
Attain the highest degree of mobility possible within the confines of the injury.
Express positive feelings about self.
Express that he feels less anxious.
Demonstrate effective coping mechanisms.
Remain free from signs and symptoms of infection.
Express his feelings and fears about the traumatic event.
Nursing interventions Nursing Care Plans for Burns Injury
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Provide immediate, aggressive burn treatment to increase the patient's chance for
survival.
Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway
insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning;
Respiratory monitoring
Airway Management Facilitation of patency of air passages
Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is
acceptable to the patient. Analgesic Administration Use of pharmacologic agents to
reduce or eliminate pain. Environmental Management Manipulation of the patient’s
surroundings for promotion of optimal comfort
Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility.
Circulatory Care Mechanical Assist Devices: Temporary support of the circulation
through the use of mechanical devices or pumps
Fluid Management Promotion of fluid balance and prevention of complications resulting
from abnormal or undesired fluid levels. Hypovolemia Management Reduction in
extracellular and/or intracellular fluid volume. Shock Management: Volume: Promotion
of adequate tissue perfusion for a patient with severely compromised intravascular
volume.
Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of
complications resulting from abnormal or undesired fluid/serum electrolyte levels.
Circulatory Care Arterial/Venous Insufficiency: Promotion of arterial/venous circulation
Hypothermia Treatment Rewarming and surveillance of a patient whose core body
temperature is below 35C. Temperature Regulation: Attaining and/or maintaining body
temperature within a normal range
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Wound Care Prevention of wound complications and promotion of wound healing
Exercise Therapy Use of active or passive body movement to maintain or restore
flexibility; use of specific activity or exercise protocols to enhance or restore controlled
body movement
Body Image Enhancement improving a patient’s conscious and unconscious perceptions
and attitudes toward his/her body. Self Esteem Enhancement Assisting a patient to
increase his/her personal judgment of self worth.
Infection Protection Prevention and early detection of infection in a patient at risk.
Infection Control Minimizing the acquisition and transmission of infectious agents.
Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient
data for clinical decision making
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