Burns Nursing Diagnosis & Care Plan - NurseStudy.Net (2024)

Burns are traumatic injuries to the skin and underlying tissues caused by thermal, chemical, electrical, or radiation exposure. This nursing diagnosis focuses on identifying burn severity, preventing complications, managing pain, and promoting optimal wound healing.

Causes (Related to)

Burns can affect patients in various ways, with several factors contributing to their severity and healing process:

  • Thermal exposure (flame, hot liquids, steam)
  • Chemical exposure (acids, alkalis)
  • Electrical burns
  • Radiation exposure
  • Friction burns

Contributing factors include:

  • Duration of exposure
  • Temperature/concentration of burning agent
  • Pre-existing medical conditions
  • Age (very young or elderly)
  • Delayed treatment

Risk factors affecting outcomes:

  • Diabetes
  • Immunocompromised status
  • Poor nutrition
  • Chronic diseases
  • Limited access to care

Signs and Symptoms (As evidenced by)

Burn injuries present with distinctive signs and symptoms that nurses must accurately assess for proper treatment.

Subjective: (Patient reports)

  • Pain at the burn site
  • Numbness or tingling
  • Difficulty moving the affected area
  • Anxiety and distress
  • Difficulty breathing (in cases of inhalation burns)
  • Changes in sensation
  • Emotional disturbance

Objective: (Nurse assesses)

  • Visible tissue damage
  • Changes in skin color and texture
  • Blistering
  • Edema
  • Altered peripheral pulses
  • Circumferential burns
  • Signs of infection
  • Changes in the range of motion

Expected Outcomes

The following outcomes indicate successful management of burns:

  • Pain will be effectively managed
  • Wound healing will progress without complications
  • The patient will maintain adequate fluid balance
  • The patient will demonstrate proper wound care techniques
  • The patient will maintain adequate nutrition
  • The patient will show no signs of infection
  • The patient will demonstrate improved functional ability
  • The patient will show psychological adjustment to the injury

Nursing Assessment

Evaluate Burn Characteristics

  • Determine burn depth
  • Calculate total body surface area (TBSA)
  • Assess burn location
  • Document burn appearance
  • Note circumferential burns

Monitor Vital Signs

  • Check temperature
  • Monitor blood pressure
  • Assess heart rate
  • Track respiratory rate
  • Monitor oxygen saturation

Assess Fluid Status

  • Monitor intake and output
  • Check skin turgor
  • Assess mucous membranes
  • Track urine output
  • Monitor electrolyte balance

Evaluate Pain

  • Assess pain levels
  • Document pain characteristics
  • Monitor response to interventions
  • Note breakthrough pain
  • Evaluate anxiety levels

Check for Complications

  • Monitor for infection signs
  • Assess circulation
  • Check for compartment syndrome
  • Evaluate respiratory status
  • Monitor nutritional status

Nursing Care Plans

Nursing Care Plan 1: Acute Pain

Nursing Diagnosis Statement:
Acute Pain related to tissue damage and inflammatory response as evidenced by verbal reports of pain, guarding behavior, and altered vital signs.

Related Factors:

  • Tissue damage
  • Inflammatory response
  • Wound care procedures
  • Anxiety
  • Movement

Nursing Interventions and Rationales:

  1. Administer prescribed pain medications
    Rationale: Provides comfort and facilitates participation in care
  2. Position the affected area appropriately
    Rationale: Minimizes pressure and promotes comfort
  3. Assess pain regularly using the appropriate scale
    Rationale: Ensures effective pain management

Desired Outcomes:

  • The patient will report decreased pain levels
  • Patient will demonstrate improved participation in care
  • The patient will maintain an optimal comfort level

Nursing Care Plan 2: Risk for Infection

Nursing Diagnosis Statement:
Risk for Infection related to compromised skin integrity and invasive procedures as evidenced by the presence of burn wounds.

Related Factors:

  • Disrupted skin barrier
  • Invasive procedures
  • Decreased immune response
  • Environmental exposure
  • Nutritional deficits

Nursing Interventions and Rationales:

  1. Maintain a strict aseptic technique
    Rationale: Prevents cross-contamination
  2. Monitor wound appearance
    Rationale: Enables early detection of infection
  3. Administer prescribed antimicrobials
    Rationale: Prevents or treats infection

Desired Outcomes:

  • The wound will remain free from infection
  • The patient will demonstrate an understanding of infection prevention
  • The patient will maintain a normal temperature

Nursing Care Plan 3: Risk for Fluid Volume Deficit

Nursing Diagnosis Statement:
Risk for Fluid Volume Deficit related to increased fluid loss through burned areas as evidenced by decreased urine output and poor skin turgor.

Related Factors:

  • Increased fluid loss
  • Altered cellular membrane
  • Increased metabolic demands
  • Decreased oral intake
  • Third-spacing

Nursing Interventions and Rationales:

  1. Monitor fluid balance strictly
    Rationale: Ensures adequate hydration
  2. Administer IV fluids as prescribed
    Rationale: Maintains fluid volume
  3. Track intake and output
    Rationale: Identifies fluid balance status

Desired Outcomes:

  • The patient will maintain adequate hydration
  • The patient will demonstrate stable vital signs
  • The patient will maintain appropriate urine output

Nursing Care Plan 4: Impaired Skin Integrity

Nursing Diagnosis Statement:
Impaired Skin Integrity related to thermal injury as evidenced by disruption of the skin surface and underlying tissues.

Related Factors:

  • Thermal damage
  • Chemical exposure
  • Altered circulation
  • Edema
  • Mechanical factors

Nursing Interventions and Rationales:

  1. Perform wound care as prescribed
    Rationale: Promotes healing and prevents complications
  2. Monitor wound healing progress
    Rationale: Ensures appropriate healing
  3. Maintain optimal wound environment
    Rationale: Facilitates healing process

Desired Outcomes:

  • Wound healing will progress as expected
  • The patient will demonstrate proper wound care
  • The patient will maintain intact surrounding skin

Nursing Care Plan 5: Anxiety

Nursing Diagnosis Statement:
Anxiety related to trauma and changes in body image as evidenced by expressed concerns and increased tension.

Related Factors:

  • Traumatic experience
  • Pain
  • Changed appearance
  • Treatment procedures
  • Uncertain prognosis

Nursing Interventions and Rationales:

  1. Provide emotional support
    Rationale: Reduces anxiety and promotes coping
  2. Teach coping strategies
    Rationale: Helps manage stress
  3. Include the patient in care planning
    Rationale: Increases sense of control

Desired Outcomes:

  • The patient will demonstrate reduced anxiety
  • The patient will use effective coping strategies
  • The patient will express optimism about recovery

References

  1. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023).Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
  2. Botman M, Hendriks TCC, de Haas LEM, Mtui GS, Binnerts J, Nuwass EQ, Niemeijer AS, Jaspers MEH, Winters HAH, Nieuwenhuis MK, van Zuijlen PPM. Access to Burn Care in Low- and Middle-Income Countries: An Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania. J Burn Care Res. 2022 May 17;43(3):657-664. doi: 10.1093/jbcr/irab191. PMID: 34643726; PMCID: PMC9113785.
  3. Gregg D, Patil S, Singh K, Marano MA, Lee R, Petrone SJ, Chamberlain RS. Clinical outcomes after burns in elderly patients over 70 years: A 17-year retrospective analysis. Burns. 2018 Feb;44(1):65-69. doi: 10.1016/j.burns.2017.09.018. Epub 2017 Oct 20. PMID: 29066003.
  4. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
  5. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
  6. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
  7. Silvestri, L. A. (2023).Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
  8. Wu H, Xi M, Xie W. Epidemiological and clinical characteristics of older adults with burns: a 15-year retrospective analysis of 2554 cases in Wuhan Institute of Burns. BMC Geriatr. 2023 Mar 22;23(1):162. doi: 10.1186/s12877-023-03883-5. PMID: 36949418; PMCID: PMC10035179.
Burns Nursing Diagnosis & Care Plan - NurseStudy.Net (2024)
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