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

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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 a 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

  • Assess skin for location, type, and degree of burn
  Knowing what type of burn and the degree will provide information on how to treat the burn  
  • Monitor vital signs; capillary refill; peripheral pulses (invasive monitoring may be necessary for severe burns)
  Helps determine if a fluid replacement is needed and monitor tissue perfusion  
  • 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
  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  
  • Determine weight and TBSA burned
  Used to determine initial fluid resuscitation requirements.  
  • Encourage coughing and deep breathing exercises; suction as necessary
  Promotes lung expansion and helps drain secretions  
  • Administer humidified oxygen with a face mask
  Correct hypoxemia and acidosis from burn or inhalation; use a humidifier for comfort, to thin mucus and to prevent atelectasis  
  • Assist with intubation or tracheostomy as necessary
  Maintain the airway. The ventilator may be required in case of pulmonary edema or injury affects lung function  
  • Obtain IV access, large bore
  IV fluids, medications, and blood products may need to be infused quickly  
  • Monitor fluid balance
    • Urinary output- average should be 30 – 50 ml/hr (adult)
    • Estimate wound drainage
    • Monitor amount of fluid intake
    • Daily weights
    • Measure the circumference of burned extremity
  Determine need for and effectiveness of fluid replacement; measure inflammation and retention if any  
  • Monitor labs
    • Hemoglobin
    • Hematocrit
    • Sodium
    • Potassium
    • Magnesium
  Determine if fluid or electrolyte replacement is appropriate and if there is any heart, kidney or liver functionality impairment  
  • Assess and monitor for signs/symptoms of infection
    • Fever
    • Decreased platelet count
    • Hyperglycemia
  Prevent complications from infections; treat as appropriate  
  • Administer medications, fluids and blood products as appropriate
    • Analgesics, opioids
    • Diuretics (mannitol)
    • Potassium
    • Antacids
    • Histamine inhibitors (cimetidine)
  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  
  • 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)
  Maintain and restore skin integrity; protection from infection  
  • Assess and manage pain
    • Administer medication (especially prior to dressing changes)
    • Elevate burned extremities
    • Change positions frequently
    • Provide diversional activities as available
  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  
  • Burn prevention education
    • Wear sunscreen and reapply frequently
    • Keep children and pets out of the 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
  Teach patients and families how to prevent burn injuries from occurring in the future.  

References

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  • Question 1 of 5

The nurse is triaging a three-year-old that has come in with burns from a house fire. The nurse knows that the severity of the burns is primarily based on which of the following? Select all that apply.

  • Question 2 of 5

A nurse is caring for a client in the ICU who has been severely burned. According to Maslow’s hierarchy of needs, which of the following actions demonstrates that the nurse is meeting the client’s highest priority needs? Select all that apply.

  • Question 3 of 5

A 7-year-old child was brought into the emergency department with 2nd and 3rd degree burns over 36% of his body. What is the priority during this initial emergency department phase in caring for this client?

  • Question 4 of 5

A nurse is caring for a client who is recovering from a severe burn injury. The nurse keeps track of the client’s intake and output each day throughout the shift. Which choice best describes the purpose of monitoring intake and output for a burn client?

  • Question 5 of 5

A client with a burn injury is brought in to the urgent care clinic and the nurse begins an initial assessment. Which signs or symptoms from the client would the nurse attend to as highest priority? Select all that apply.

Module 0 – Nursing Care Plans Course Introduction
Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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