Burns Nursing Care Plan Notes

Description

Burns are caused by a transfer of energy from a heat source to the body. The depth of the injury depends on the temperature of the burning agent and the duration of contact with it.
Burns disrupt the skin, which leads to increased ﬂuid loss; infection; hypothermia; scarring; compromised immunity; and changes in function, appearance, and body image. Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the prognosis.

Characteristics of Burn

The depth of a burn injury depends on the type of injury, causative agent, temperature of the burn agent, duration of contact with the agent, and the skin thickness. Burns are classiﬁed according to the depth of tissue destruction:

Superﬁcial partialthickness burns (similar to ﬁrstdegree), such as sunburn: The epidermis and possibly a portion of the dermis are destroyed.
Deep partialthickness burns (similar to seconddegree), such as a scald: The epidermis and upper to deeper portions of the dermis are injured.
Fullthickness burns (thirddegree), such as a burn from a ﬂame or electric current: The epidermis, entire dermis, and sometimes the underlying tissue, muscle, and bone are destroyed.

Extent of Body Surface Area Burned

How much total body surface area is burned is determined by one of the following methods:

Rule of Nines: an estimation of the total body surface area burned by assigning percentages in multiples of nine to major body surfaces.
Lund and Browder method: a more precise method of estimating the extent of the burn; takes into account that the percentage of the surface area represented by various anatomic parts (head and legs) changes with growth.
Palm method: used to estimate percentage of scattered burns, using the size of the patient’s palm (about 1% of body surface area) to assess the extent of burn injury.

Causes

Most burns result from preventable accidents. Thermal burns, which are the most common type,occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries.

Gender, Ethnic/Racial, and Life Span Considerations

Preschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart (Lund-Browder Chart) for children that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and in particular, young adult males ages 20 to 29 years of age, followed by children under 9 years of age. Individuals older than 50 years sustain the fewest number of serious burn injuries.

The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of
carelessness or risk-taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets.

Most adults are victims of house fires or workrelated accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat.

Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child Burns 167 experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. No specific gender and ethnic/racial considerations exist in burns.

Gerontologic Considerations

Elderly people are at higher risk for burn injury because of reduced coordination, strength, and sensation and changes in vision.
Predisposing factors and the health history in the older adult inﬂuence the complexity of care for the patient.
Pulmonary function is limited in the older adult and therefore airway exchange, lung elasticity, and ventilation can be affected.
This can be further affected by a history of smoking.
Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus orother endocrine disorders present nutritional challenges and require close monitoring.
Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team.
The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal.

Primary Nursing Diagnosis

Ineffective airway clearance related to airway edema

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Medical Management

MINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection.

MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social
work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition.Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine ormafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered, through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Nursing Management: Emergent/Resuscitative Phase

Assessment

Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues.
Assess circumstances surrounding the injury: time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma.
Monitor vital signs frequently; monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity.
Start cardiac monitoring if indicated (eg, history of cardiac or respiratory problems, electrical injury).
Check peripheral pulses on burned extremities hourly; use Doppler as needed.
Monitor ﬂuid intake (IV ﬂuids) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and ﬂuid status).
Assess body temperature, body weight, history of preburn weight, allergies, tetanus immunization, past medicalsurgical problems, current illnesses, and use of medications.
Arrange for patients with facial burns to be assessed for corneal injury.
Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partialthickness injury.
Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.
Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support system and coping skills.

Interventions

Promoting Gas Exchange and Airway Clearance

Provide humidiﬁed oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels.
Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions.
Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
Monitor mechanically ventilated patient closely.
Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using spirometry, and tracheal suctioning.
Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artiﬁcial airway as needed.

Restoring Fluid and Electrolyte Balance

Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output.
Note and report signs of hypovolemia or ﬂuid overload.
Maintain IV lines and regular ﬂuids at appropriate rates, as prescribed. Document intake, output, and daily weight.
Elevate the head of bed and burned extremities.
Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances.
Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.

Maintaining Normal Body Temperature

Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
Assess core body temperature frequently.
Work quickly when wounds must be exposed to minimize heat loss from the wound.

Minimizing Pain and Anxiety

Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness due to pain and restlessness due to hypoxia.
Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated.
Provide emotional support, reassurance, and simple explanations about procedures.
Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms.
Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.

Monitoring and Managing Potential Complications

Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg, restlessness, confusion); report deteriorating
respiratory status immediately to physician; and assist as needed with intubation or escharotomy.
Distributive shock: Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse) or progressive edema. Administer ﬂuid resuscitation as ordered in response to physical ﬁndings; continue monitoring ﬂuid status.
Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased ﬂuids as prescribed.
Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly (warmth, capillary refill, sensation, and movement); remove blood pressure cuff after each reading; elevate burned extremities; report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with escharotomies.
Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds.
Curling’s ulcer: Assess gastric aspirate for blood and pH; assess stools for occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed.

Nursing Management: Acute/ Intermediate Phase

The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage.

Assessment

Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications.
Measure vital signs frequently; respiratory and ﬂuid status remains highest priority.
Assess peripheral pulses frequently for ﬁrst few days after the burn for restricted blood ﬂow.
Closely observe hourly ﬂuid intake and urinary output, as well as blood pressure and cardiac rhythm; changes should be reported to the burn surgeon promptly.
For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and ability to ventilate; if patient is intubated and placed on a ventilator, frequent suctioning and assessment of the airway are priorities.

Interventions

Restoring Normal Fluid Balance

Monitor IV and oral ﬂuid intake; use IV infusion pumps.
Measure intake and output and daily weight.
Report changes (eg, blood pressure, pulse rate) to physician.

Preventing Infection

Provide a clean and safe environment; protect patient from sources of crosscontamination (eg, visitors, other patients, staff, equipment).
Closely scrutinize wound to detect early signs of infection.

Monitor culture results and white blood cell counts.

Practice clean technique for wound care procedures and aseptic technique for any invasive procedures. Use meticulous hand hygiene before and after contact with patient.
Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens regularly.

Maintaining Adequate Nutrition

Initiate oral ﬂuids slowly when bowel sounds resume; record tolerance—if vomiting and distention do not occur, ﬂuids
may be increased gradually and the patient may be advanced to a normal diet or to tube feedings.
Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements if prescribed.
Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes.
Weigh patient daily and graph weights.

Promoting Skin Integrity

Assess wound status.
Support patient during distressing and painful wound care.
Coordinate complex aspects of wound care and dressing changes.
Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearllike clusters of cells on the wound surface), bleeding, granulation tissue, the status of graft take, healing of the donor site, and the condition of the surrounding skin; report any signiﬁcant changes to the physician.
Inform all members of the health care team of latest wound care procedures in use for the patient.
Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound care.
Early on, assess strengths of patient and family in preparing for discharge and home care.

Relieving Pain and Discomfort

Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as prescribed, before the pain becomes severe. Assess and document the patient’s response to medication and any other interventions.
Teach patient relaxation techniques. Give some control over wound care and analgesia. Provide frequent reassurance.
Use guided imagery and distraction to alter patient’s perceptions and responses to pain; hypnosis, music therapy, and virtual reality are also useful.
Assess the patient’s sleep patterns daily; administer sedatives, if prescribed.
Work quickly to complete treatments and dressing changes.

Encourage patient to use analgesic medications before painful procedures.

Promote comfort during healing phase with the following:
oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silicabased lotion, exercise and splinting to prevent skin contracture, and diversional activities.

Promoting Physical Mobility

Prevent complications of immobility (atelectasis, pneumonia, edema, pressure ulcers, and contractures) by deep breathing, turning, and proper repositioning.
Modify interventions to meet patient’s needs. Encourage early sitting and ambulation. When legs are involved, apply elastic pressure bandages before assisting patient to upright position.
Make aggressive efforts to prevent contractures and hypertrophic scarring of the wound area after wound closure for a year or more.
Initiate passive and active range-of-motion exercises from admission until after grafting, within prescribed limitations.
Apply splints or functional devices to extremities for contracture control; monitor for signs of vascular insufﬁciency, nerve compression, and skin breakdown.

Strengthening Coping Strategies

Assist patient to develop effective coping strategies: Set speciﬁc expectations for behavior, promote truthful communication to build trust, help patient practice coping strategies, and give positive reinforcement when appropriate.
Demonstrate acceptance of patient. Enlist a noninvolved person for patient to vent feelings without fear of retaliation.
Include patient in decisions regarding care. Encourage patient to assert individuality and preferences. Set realistic expectations for selfcare.

Supporting Patient and Family Processes

Support and address the verbal and nonverbal concerns of the patient and family.
Instruct family in ways to support patient.
Make psychological or social work referrals as needed.
Provide information about burn care and expected course of treatment.
Initiate patient and family education during burn management. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching.
Remain sensitive to the possibility of changing family dynamics.

Monitoring and Managing Potential Complications

Heart failure: Assess for ﬂuid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds.
Pulmonary edema: Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles; report promptly. Position comfortably with head elevated unless contraindicated. Administer medications and oxygen as prescribed and assess response.
Sepsis: Assess for increased temperature, increased pulse, widened pulse pressure, and ﬂushed, dry skin in unburned areas (early signs), and note trends in the data. Perform wound and blood cultures as prescribed. Give scheduled antibiotics on time.
Acute respiratory failure and acute respiratory distress syndrome (ARDS): Monitor respiratory status for dyspnea, change in respiratory pattern, and onset of adventitious sounds. Assess for decrease in tidal volume and lung compliance in patients on mechanical ventilation. The hallmark of onset of ARDS is hypoxemia on 100% oxygen, decreased lung compliance, and signiﬁcant shunting; notify physician of deteriorating respiratory status.
Visceral damage (from electrical burns): Monitor electrocardiogram (ECG) and report dysrhythmias; pay attention to pain related to deep muscle ischemia and report. Early detection may minimize severity of this complication. Fasciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia; monitor patient for excessive blood loss and hypovolemia after fasciotomy.

Nursing Process: Rehabilitation Phase

Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining ﬂuid and electrolyte balance and improving nutrition status continue to be important.

Assessment

In early assessment, obtain information about patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions.
Assess selfconcept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern.
Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin.
Document participation and selfcare abilities in ambulation, eating, wound cleaning, and applying pressure wraps.
Maintain comprehensive and continuous assessment for early detection of complications, with speciﬁc assessments as needed for speciﬁc treatments, such as postoperative assessment of patient undergoing primary excision.

Diagnosis

Nursing Diagnoses

Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting, and limited endurance
Disturbed body image related to altered appearance and selfconcept
Deﬁcient knowledge of postdischarge home care and recovery needs

Collaborative Problems/Potential Complications

Contractures
Inadequate psychological adaptation to burn injury

Planning and Goals

Goals include increased participation in ADLs; increased understanding of the injury, treatment, and planned followup care; adaptation and adjustment to alterations in body image, selfconcept, and lifestyle; and absence of complications.

Nursing Interventions

Promoting Activity Tolerance

Schedule care to allow periods of uninterrupted sleep. Administer hypnotic agents, as prescribed, to promote sleep.
Communicate plan of care to family and other caregivers.
Reduce metabolic stress by relieving pain, preventing chilling or fever, and promoting integrity of all body systems to help conserve energy. Monitor fatigue, pain, and fever to determine amount of activity to be encouraged daily.
Incorporate physical therapy exercises to prevent muscular atrophy and maintain mobility required for daily activities.
Support positive outlook, and increase tolerance for activity by scheduling diversion activities in periods of increasing duration.

Improving Body Image and Self-Concept

Take time to listen to patient’s concerns and provide realistic support; refer patient to a support group to develop coping strategies to deal with losses.
Assess patient’s psychosocial reactions; provide support and develop a plan to help the patient handle feelings.
Promote a healthy body image and selfconcept by helping patient practice responses to people who stare or ask about the injury.
Support patient through small gestures such as providing a birthday cake, combing patient’s hair before visitors, and sharing information on cosmetic resources to enhance appearance.
Teach patient ways to direct attention away from a disﬁgured body to the self within.
Coordinate communications of consultants, such as psychologists, social workers, vocational counselors, and teachers, during rehabilitation.

Monitoring and Managing Potential Complications

Contractures: Provide early and aggressive physical and occupational therapy; support patient if surgery is needed to achieve full range of motion.
Impaired psychological adaptation to the burn injury:
Obtain psychological or psychiatric referral as soon as evidence of major coping problems appears.

Teaching Self-care

Throughout the phases of burn care, make efforts to prepare patient and family for the care they will perform at home. Instruct them about measures and procedures.
Provide verbal and written instructions about wound care, prevention of complications, pain management, and nutrition.
Inform and review with patient speciﬁc exercises and use of elastic pressure garments and splints; provide written instructions.
Teach patient and family to recognize abnormal signs and report them to the physician.
Assist the patient and family in planning for the patient’s continued care by identifying and acquiring supplies and equipment that are needed at home.
Encourage and support followup wound care.
Refer patient with inadequate support system to home care resources for assistance with wound care and exercises.
Evaluate patient status periodically for modiﬁcation of home care instructions and/or planning for reconstructive surgery.

Evaluation

Expected Patient Outcomes

Demonstrates activity tolerance required for desired daily activities
Adapts to altered body image
Demonstrates knowledge of required selfcare and followup care
Exhibits no complications