Burns Nursing Care Plan

 

Nursing Diagnosis
Impaired Physical Mobility

May be related to

  • Neuromuscular impairment, pain/discomfort, decreased strength and endurance
  • Restrictive therapies, limb immobilization; contractures

Possibly evidenced by

  • Reluctance to move/inability to purposefully move
  • Limited ROM, decreased muscle strength control and/or mass
Desired Outcomes
  • Maintain position of function as evidenced by absence of contractures.
  • Maintain or increase strength and function of affected and/or compensatory body part.
  • Verbalize and demonstrate willingness to participate in activities.
  • Demonstrate techniques/behaviors that enable resumption of activities.
Nursing Interventions
  • Maintain proper body alignment with supports or splints, especially for burns over joints.
    • Rationale: Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
  • Note circulation, motion, and sensation of digits frequently.
    • Rationale: Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
  • Initiate the rehabilitative phase on admission.
    • Rationale: It is easier to enlist participation when patient is aware of the possibilities that exist for recovery.
  • Perform ROM exercises consistently, initially passive, then active.
    • Rationale: Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
  • Medicate for pain before activity or exercise.
    • Rationale: Reduces muscle and tissue stiffness and tension, enabling patient to be more active and facilitating participation.
  • Schedule treatments and care activities to provide periods of uninterrupted rest.
    • Rationale: Increases patient’s strength and tolerance for activity.
  • Encourage family/SO support and assistance with ROM exercises.
    • Rationale: Enables family/SO to be active in patient care and provides more consistent therapy.
  • Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
    • Rationale: Combining activities produces improved results by enhancing effects of each.
  • Encourage patient participation in all activities as individually able.
    • Rationale: Promotes independence, enhances self-esteem, and facilitates recovery process.
  • Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
    • Rationale: Combining activities produces improved results by enhancing effects of each.
  • Encourage patient participation in all activities as individually able.
    • Rationale:Promotes independence, enhances self-esteem, and facilitates recovery process.
Nursing Diagnosis
Knowledge Deficit

May be related to

  • Lack of exposure/recall
  • Information misinterpretation; unfamiliarity with resources

Possibly evidenced by

  • Questions/request for information, statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications
Desired Outcomes
  • Verbalize understanding of condition, prognosis, and potential complications.
  • Verbalize understanding of therapeutic needs.
  • Correctly perform necessary procedures and explain reasons for actions.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
  • Review condition, prognosis, and future expectations.
    • Rationale: Provides knowledge base from which patient can make informed choices.
  • Discuss patient’s expectations of returning home, to work, and to normal activities.
    • Rationale: Patient frequently has a difficult and prolonged adjustment after discharge. Problems often occur (sleep disturbances, nightmares, reliving the accident, difficulty with resumption of social interactions, intimacy and sexual activity, emotional lability) that interfere with successful adjustment to resuming normal life.
  • Review and have patient/SO demonstrate proper burn, skin-graft, and wound care techniques. Identify appropriate sources for outpatient care and supplies.
    • Rationale: Promotes competent self-care after discharge, enhancing independence.
  • Discuss skin care. Teach proper use of moisturizers, sunscreens, and anti-itching medications.
    • Rationale: Itching, blistering, and sensitivity of healing wounds or graft sites can be expected for an extended time, and injury can occur because of the fragility of the new tissue.
  • Explain scarring process and necessity for and proper use of pressure garments when used.
    • Rationale: Promotes optimal regrowth of skin, minimizing development of hypertrophic scarring and contractures and facilitating healing process. Note: Consistent use of the pressure garment over a long period can reduce the need for reconstructive surgery to release contractures and remove scars.
  • Encourage continuation of prescribed exercise program and scheduled rest periods.
    • Rationale: Maintains mobility, reduces complications, and prevents fatigue, facilitating recovery process.
  • Identify specific limitations of activity as individually appropriate.
    • Rationale: Imposed restrictions depend on severity and location of injury and stage of healing.
  • Emphasize importance of sustained intake of high-protein and high-calorie meals and snacks.
    • Rationale: Optimal nutrition enhances tissue regeneration and general feeling of well-being. Note: Patient often needs to increase caloric intake to meet calorie and protein needs for healing.
  • Review medications, including purpose, dosage, route, and expected and/or reportable side effects.
    • Rationale: Reiteration allows opportunity for patient to ask questions and be sure understanding is accurate.
  • Advise patient and/or SO of potential for exhaustion, boredom, emotional lability, adjustment problems. Provide information about possibility of discussion with appropriate professional counselors.
    • Rationale: Provides perspective to some of the problems patient and/or SO may encounter, and aids awareness that assistance is available when necessary.
  • Identify signs and symptoms requiring medical evaluation: inflammation, increase or changes in wound drainage, fever/chills; changes in pain characteristics or loss of mobility and/or function.
    • Rationale: Early detection of developing complications (infection, delayed healing) may prevent progression to more serious or life-threatening situations.
  • Stress importance of follow-up care and rehabilitation.
    • Rationale: Long-term support with continual reevaluation and changes in therapy is required to achieve optimal recovery.
  • Provide phone number for contact person.
    • Rationale: Provides easy access to treatment team to reinforce teaching, clarify misconceptions, and reduce potential for complications.
  • Ensure patient’s immunizations are current, especially tetanus.
    • Rationale: To prevent further injury.
  • Identify community resources: skin or wound care professionals, crisis centers, recovery groups, mental health, Red Cross, visiting nurse, Amblicab, homemaker service.
    • Rationale: Facilitates transition to home, provides assistance with meeting individual needs, and supports independence.
Nursing Diagnosis
Disturbed Body Image

May be related to

  • Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

  • Negative feelings about body/self, fear of rejection/reaction by others
  • Focus on past appearance, abilities; preoccupation with change/loss
  • Change in physical capacity to resume role; change in social involvement
Desired Outcomes
  • Incorporate changes into self-concept without negating self-esteem.
  • Verbalize acceptance of self in situation.
  • Talk with family/SO about situation, changes that have occurred.
  • Develop realistic goals/plans for the future.
Nursing Interventions
  • Assess meaning of loss or change to patient and SO, including future expectations and impact of cultural or religious beliefs.
    • Rationale: Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.
  • Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.
    • Rationale: Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with situation. Denial may be prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems.
  • Set limits on maladaptive behavior. Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery.
    • Rationale: Patient and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting and not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver.
  • Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.
    • Rationale: Enhances trust and rapport between patient and nurse.
  • Encourage patient and SO to view wounds and assist with care as appropriate.
    • Rationale: Promotes acceptance of reality of injury and of change in body and image of self as different.
  • Provide hope within parameters of individual situation; do not give false reassurance.
    • Rationale:Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
  • Assist patient to identify extent of actual change in appearance and body function.
    • Rationale: Helps begin process of looking to the future and how life will be different.
  • Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.
    • Rationale: Words of encouragement can support development of positive coping behaviors.
  • Show pictures or videos of burn care and/or other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen.
    • Rationale: Allows patient and SO to be realistic in expectations. Also assists in demonstration of importance of and/or necessity for certain devices and procedures.
  • Encourage family interaction with each other and with rehabilitation team.
    • Rationale: To opens lines of communication and provides ongoing support for patient and family
  • Provide support group for SO. Give information about how SO can be helpful to patient.
    • Rationale: Promotes ventilation of feelings and allows for more helpful responses to patient.
  • Role-play social situations of concern to patient.
    • Rationale: Prepares patient and SO for reactions of others and anticipates ways to deal with them.
  • Refer to physical and occupational therapy, vocational counselor, psychiatric counseling, clinical specialist psychiatric nurse, social services, and psychologist, as needed.
    • Rationale: Helpful in identifying ways/devices to regain and maintain independence. Patient may need further assistance to resolve persistent emotional problems.
  • Provide referral to reconstructive surgeon for the patient disfigured by burns.
    • Rationale: Reconstructive surgery can help patient gain self-esteem and confidence.
  • Provide through teaching and complete aftercare instructions for the patient. Stress importance of keeping the dressing dry and clean, elevating
    • Rationale: Reinforcing teaching can help patient achieve self-care.
Nursing Diagnosis
Fear/Anxiety

May be related to

  • Situational crises: hospitalization/isolation procedures, interpersonal transmission and contagion, memory of the trauma experience, threat of death and/or disfigurement

Possibly evidenced by

  • Expressed concern regarding changes in life, fear of unspecific consequences
  • Apprehension; increased tension
  • Feelings of helplessness, uncertainty, decreased self-assurance
  • Sympathetic stimulation, extraneous movements, restlessness, insomnia
Desired Outcomes
  • Verbalize awareness of feelings and healthy ways to deal with them.
  • Report anxiety/fear reduced to manageable level.
  • Demonstrate problem-solving skills, effective use of resources.
Nursing Interventions
  • Give frequent explanations and information about care procedures. Repeat information as needed.
    • Rationale: Knowing what to expect usually reduces fear and anxiety, clarifies misconceptions, and promotes cooperation. Because of the shock of the initial trauma, many people do not recall information provided during that time.
  • Demonstrate willingness to listen and talk to patient when free of painful procedures.
    • Rationale: Helps patient and SO know that support is available and that healthcare provider is interested in the person, not just care of the burn.
  • Involve patient and SO in decision making process whenever possible. Provide time for questioning and repetition of proposed treatments.
    • Rationale: Promotes sense of control and cooperation, decreasing feelings of helplessness or hopelessness.
  • Assess mental status, including mood and affect, comprehension of events, and content of thoughts.
    • Rationale: Initially, patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
  • Investigate changes in mentation and presence of hypervigilance, hallucinations, sleep disturbances, nightmares, agitation, apathy, disorientation, and labile affect, all of which may vary from moment to moment.
    • Rationale: Indicators of extreme anxiety and delirium state in which patient is literally fighting for life. Although cause can be psychologically based, pathological life-threatening causes must be ruled out.
  • Provide constant and consistent orientation.
    • Rationale: Helps patient stay in touch with surroundings and reality.
  • Encourage patient to talk about the burn circumstances when ready.
    • Rationale: Patient may need to tell the story of what happened over and over to make some sense out of a terrifying situation. Adjustment to the impact of the trauma, grief over losses and disfigurement can easily lead to clinical depression, psychosis, and posttraumatic stress disorder (PTSD).
  • Explain to patient what happened. Provide opportunity for questions and give honest answers.
    • Rationale: Compassionate statements reflecting the reality of the situation can help patient and SO acknowledge that reality and begin to deal with what has happened.
  • Identify previous methods of coping and handling of stressful situations.
    • Rationale: Past successful behavior can be used to assist in dealing with the present situation.
  • Create a restful environment, use guided imagery and relaxation exercises.
    • Rationale: Patients experience severe anxiety associated with burn trauma and treatment. These interventions are soothing and helpful for positive outcomes.
  • Assist the family to express their feelings of grief and guilt.
    • Rationale: The family may initially be most concerned about patient’s dying and/or feel guilty, believing that in some way they could have prevented the incident.
  • Be empathic and nonjudgmental in dealing with patient and family.
    • Rationale: Family relationships are disrupted; financial, lifestyle or role changes make this a difficult time for those involved with patient, and they may react in many different ways.
  • Encourage family/SO to visit and discuss family happenings. Remind patient of past and future events.
    • Rationale: Maintains contact with a familiar reality, creating a sense of attachment and continuity of life.
  • Involve entire burn team in care from admission to discharge, including social worker and psychiatric resources.
    • Rationale: Provides a wider support system and promotes continuity of care and coordination of activities.
Nursing Diagnosis
Impaired Skin Integrity

May be related to

  • Disruption of skin surface with destruction of skin layers (partial-/full-thickness burn) requiring grafting

Possibly evidenced by

  • Absence of viable tissue
Desired Outcomes
  • Wound Healing: Secondary Intention (NOC)
  • Demonstrate tissue regeneration.
  • Achieve timely healing of burned areas.
Nursing Interventions
  • Assess and document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin.
    • Rationale: Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft.
  • Provide appropriate burn care and infection control measures.
    • Rationale: Prepares tissues for grafting and reduces risk of infection/graft failure.

Maintain wound covering as indicated

  • Biosynthetic dressing (Biobrane);
    • Rationale: Nylon fabric and/or silicon membrane containing collagenous porcine peptides that adheres to wound surface until removed or sloughed off by spontaneous skin reepithelialization. Useful for eschar-free partial-thickness burns awaiting autografts because it can remain in place 2–3 wk or longer and is permeable to topical antimicrobial agents.
  • Synthetic dressings: DuoDerm;
    • Rationale: Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and that interacts with wound exudate to form a soft gel that facilitates debridement.
  • Opsite, Acuderm.
    • Rationale: Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that is used to cover clean partial-thickness wounds and clean donor sites.
      Reduces swelling/limits risk of graft separation.
  • Elevate grafted area if possible. Maintain desired position and immobility of area when indicated.
    • Rationale: Movement of tissue under graft can dislodge it, interfering with optimal healing.
  • Maintain dressings over newly grafted area and/or donor site as indicated: mesh, petroleum, nonadhesive.
    • Rationale: Areas may be covered by translucent, nonreactive surface material (between graft and outer dressing) to eliminate shearing of new epithelium and protect healing tissue. The donor site is usually covered for 4–24 hr, then bulky dressings are removed and fine mesh gauze is left in place.
  • Keep skin free from pressure
    • Rationale: Promotes circulation and prevents ischemia or necrosis and graft failure.
  • Evaluate color of grafted and donor site(s); note presence or absence of healing.
    • Rationale: Evaluates effectiveness of circulation and identifies developing complications.
  • Wash sites with mild soap, rinse, and lubricate with cream several times daily after dressings are removed and healing is accomplished.
    • Rationale: Newly grafted skin and healed donor sites require special care to maintain flexibility.
  • Aspirate blebs under sheet grafts with sterile needle or roll with sterile swab.
    • Rationale:Fluid-filled blebs prevent graft adherence to underlying tissue, increasing risk of graft failure.

Prepare for/assist with surgical grafting or biological dressings: 

  • Homograft (allograft);
    • Rationale: Skin grafts obtained from living persons or cadavers are used as a temporary covering for extensive burns until person’s own skin is ready for grafting (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.
  • Heterograft (xenograft, porcine);
    • Rationale: Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts.
  • Cultured epithelial autograft (CEA);
    • Rationale: Skin graft obtained from uninjured part of patient’s own skin and prepared in a laboratory; may be full-thickness or partial-thickness. Note: This process takes 20–30 days from harvest to application. The new CEA sheets are 1–6 cell layers thick and thus are very fragile.
  • Artificial skin (Integra).
    • Rationale: Wound covering approved by the Food and Drug Administration (FDA) for full-thickness and deep partial-thickness burns. It provides a permanent, immediate covering that reproduces the skin’s normal functions and stimulates the regeneration of dermal tissue.