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

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Outline

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.

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

A Nursing Care Plan (NCP) for Burn Injury (First, Second, Third degree) starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

This is a nursing care plan for burn injuries. So, a burn injury is tissue damage caused by heat, chemicals, electricity, radiation, or sunlight. The degree of the burn depends upon the depth and the area that they cover. Deep burns heal slowly. It can be difficult to treat and to have a high risk of complications, such as infection, amputation, and even death. Some nursing considerations. So, we want to assess this patient’s respiratory status. We want to manage their pain. We want to take a look at their vital signs and manage those . We may need to do some fluid resuscitation. We want to prevent infection and administer any medications as they are ordered. The desired outcome for this patient is that this patient is going to maintain a patent airway and oxygenation of tissue. We want to restore fluid and electrolyte balance. We want to maintain body temperature and control pain and prevent any further complications. 

So, when a burn patient comes to you, there’s going to be one thing that they are going to complain about. One thing, and that is going to be pain. Now, that pain can be mild to severe depending on the degree of burn. And, there also may be a situation where the third degree burns, where there is no pain because the, uh, nerve endings have been singed or burned. Some objective data that we’re going to collect for these patients coming in is we are going to see, uh, redness, swelling. We’ll see peeling of the skin and tissue. We may see blisters. We may see charred tissue. 

So the first thing we want to do with this patient is we want to take a look at our A, B and C’s. We want to assess their airway. We want to assess the breathing, and we want to assess their circulation. So, we want to make sure that we do A,B,C assessment. And the reason why is we want to note any signs of smoke inhalation. We want to look for signs like smoking inhalation or lung damage. We may see singed hairs, nose hairs, dark sputum when they cough, soot around the nose or the mouth. We may listen when we auscultate. We may hear wheezing or stridor. We may hear crackles. Remember, exposure to chemicals and flame can cause smoke inhalation, which can cause smoke burns and damage the inner lining and tissues of the trachea and the lungs. So, these are things that we want to do at the beginning of our presentation with the patient. The next thing we want to do is we want to monitor their vital signs. We want to look at their vital signs. We also want to take mention of their capillary refill, their pulses, and we want to take a look for signs of infection. This is going to help determine if fluid replacement is needed. And this is going to also help monitor tissue perfusion. Remember, capillary refill is helping us monitor perfusion. Remember this patient, depending on the severity of the burns will have open wounds, so, this patient is at an increased risk for infection. 

We want to make sure that we monitor them because of this impaired skin integrity. The next thing we want to do is we want to get them some oxygen, regardless of if they’re sounding fine or not on the monitor, we want to get them some supplemental o2. We want to make sure that that o2 is humidified, humidified oxygen. And we also want to administer via a face mask. We want to correct the hypoxemia and acidosis from the burn or inhalation. We may use a humidifier for comfort. That’s going to be for comfort, and we want to thin the mucus and we want to prevent atelectasis. 

The next thing we want to do that’s very important for this patient is we want to obtain IV access. We want a large bore IV, large bore IV, 18 gauge or better is preferable. So, the reason why is we’re going to need to, uh, instill IV fluids, medications, blood products. We’re going to need to give those quickly. If fluid resuscitation is required, we want to utilize the appropriate formula based off of their body square. And then, we also want to assess for infiltration since the fluids are going to be going so rapidly. And finally, uh, we want to manage that pain. These patients are going to be in pain. So we want to manage pain. We want to administer any medication, especially prior to dressing changes, before dressing changes. This is a very painful time for these patients. Pain is usually present to some varying degree and it should be addressed and managed appropriately. 

Let’s take a look at the key points. So, a burn injury is tissue damage. It can be caused by heat chemicals, electricity, radiation, or sunlight. Remember this patient’s pain on the subjective end is going to be mild to severe. This patient is going to have a complaint of pain. It’s going to be either mild or severe. What we’re going to see in our objective data is, we’re going to see some redness. We are going to also see some swelling. We may see some blisters, charred tissue or peeling skin. What are some things that we can do? Well, this patient is probably going to need some fluid resuscitation. So we’re going to make sure that they have large bore IVs, at least two 18 gauges or bigger. We’re going to calculate the BSA and we are going to assess for infiltration, signs of fluid overload, like crackles, or edema third spacing. We’re going to also want to prevent an infection. These patients are at high risk for infection. We are going to assess for signs of infections. We’re going to draw blood cultures. We’re going to do skin cultures, and we’re going to provide antibiotics, uh, as needed. But, we want to make sure we get those blood cultures prior. 

We love you guys! Go out and be your best self today, and as always, happy nursing.

 

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