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

Pathophysiology

A burn injury is tissue damage caused by heat, chemicals, electricity, radiation or sunlight. The degree of burn depends upon the depth and area that they cover.  Deep burns heal slowly, can be difficult to treat and have a high risk of complications such as infection, amputation and even death.

Etiology

There are four main causes of burns:

  • Thermal – caused by fire, explosions, steam, hot objects, hot liquids, etc.
    • Flash- explosions from gas / flammable liquids / thermal radiation
    • Flame- exposure to prolonged, intense heat (fire)
    • Scald- contact with hot liquids (water/oil)
    • Contact- contact with heated materials (metals / glass / plastic)
  • Chemical – Contact with strong acids or alkaline substances
  • Electrical – Electricity (electrocution)
  • Radiation – Most commonly caused UV radiation

Desired Outcome

Maintain patent airway and oxygenation of tissue, restore fluid and electrolyte balance, maintain body temperature, control pain, prevent complications

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 Interventions and Rationales

  1. Assess skin for location, type and degree of burn

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

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

  4. Helps determine if fluid replacement is needed and monitor tissue perfusion

  5. 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
  6. 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

  7. Determine weight and TBSA burned

  8. Used to determine initial fluid resuscitation requirements.

  9. Encourage coughing and deep breathing exercises; suction as necessary

  10. Promotes lung expansion and helps drain secretions

  11. Administer humidified oxygen with face mask

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

  13. Assist with intubation or tracheostomy as necessary

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

  15. Obtain IV access, large bore

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

  17. Monitor fluid balance

    • Urinary output- average should be 30 – 50 ml/hr (adult)
    • Estimate wound drainage
    • Monitor amount of fluid intake
    • Daily weights
    • Measure circumference of burned extremity
  18. Determine need for and effectiveness of fluid replacement; measure inflammation and retention if any

  19. Monitor labs

    • Hemoglobin
    • Hematocrit
    • Sodium
    • Potassium
    • Magnesium
  20. Determine if fluid or electrolyte replacement is appropriate and if there is any heart, kidney or liver functionality impairment

  21. Assess and monitor for signs / symptoms of infection

    • Fever
    • Decreased platelet count
    • Hyperglycemia
  22. Prevent complications from infections; treat as appropriate

  23. Administer medications, fluids and blood products as appropriate

    • Analgesics, opioids
    • Diuretics (mannitol)
    • Potassium
    • Antacids
    • Histamine inhibitors (cimetidine)
  24. 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

  25. 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)
  26. Maintain and restore skin integrity; protection from infection

  27. Assess and manage pain

    • Administer medication (especially prior to dressing changes)
    • Elevate burned extremities
    • Change positions frequently
    • Provide diversional activities as available
  28. 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

  29. Burn prevention education

    • Wear sunscreen and reapply frequently
    • Keep children and pets out of 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
  30. Teach patients and families how to prevent burn injuries from occurring in the future.


References

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