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Nursing care plan burns

Written by ncp nursing care plan on April 25th, 2012

I. Pathophysiology—Local and systemic response affecting
skin and/or other tissues depending on cause of burn injury
and physiological response (Hettiaratchy, 2004)
a. Local responses
i. Coagulation: Occurs at the point of maximum damage,
causing irreversible tissue loss due to coagulation of the
constituent proteins.
ii. Stasis: Area characterized by decreased tissue perfusion
that is potentially salvageable unless additional insults,
such as prolonged hypotension, infection, or edema,
occur, converting this zone into an area of complete
tissue loss.
iii. Hyperemia: Outermost area has increased tissue
perfusion, and tissue will recover unless severe sepsis
or prolonged hypoperfusion occurs.
b. Systemic response—Cytokines and other inflammatory
mediators are released at the site of burn injuries with total
body surface area (TBSA) of 30% or greater.
i. Cardiovascular: Increased capillary permeability leads
to shift of intravascular proteins and fluids into the
interstitial space, followed by vasoconstriction and
decreased myocardial contractility; combined with fluid
loss from the burn wound, systemic hypotension and
organ hypoperfusion occur.
ii. Respiratory: Bronchoconstriction occurs in response to
inflammatory mediators, which, in severe burns, can
cause acute respiratory distress syndrome (ARDS).
iii. Metabolic—Rate increases up to three times the baseline
rate, resulting in breakdown of muscle tissue.
iv. Immunological—Immune suppression response occurs.

II. Classification by burn wound and depth
a. Superficial partial-thickness (first-degree) burns: affect only
the epidermis, skin is often warm and dry, and wounds
appear bright pink to red with minimal edema and fine
blisters, if present
b. Moderate partial-thickness (second-degree) burns: include
the epidermis and dermis; wounds appear red to pink with
moderate edema and blisters that may be intact or draining
c. Deep partial-thickness (second-degree) burns: extend in
to the deep dermis; wounds are dryer than moderate
partial-thickness burns and appear pale-pink to pale-ivory,
with moderate edema and blisters
d. Full-thickness (third-degree) burns: include all layers of
skin and subcutaneous fat and may involve the muscle,
nerves, and blood supply; wounds have a dry, leathery
texture and appearance varies from white to cherry-red to
brown or black, with blistering uncommon; absence of pain
in the center, but the edges of the burn wound may have
heightened sensation
e. Full-thickness, subdermal (fourth-degree) burns: involve all
skin layers as well as muscle, organ tissue, and bone, with
charring

III. Etiology
a. Thermal burns: flame, hot fluids or gases, friction, or exposure
to extremely cold objects (e.g., snow, nitrogen, dry
ice); flame burns are often associated with smoke/inhalation
injury
b. Chemical burns: contact with a caustic substance (acid or
alkaline); degree of injury dependent on type and content as
well as concentration and temperature of injuring agent
c. Electral burns: current travels through the body along the
pathway of least resistance (i.e., nerves offer the least resistance
and bones the greatest resistance), generating heat in
proportion to resistance offered; degree of injury dependent
on type/voltage of current with underlying injury more
severe than visible injury
d. Radiation burns: exposure to ionizing radiation, most commonly
protracted and overexposure to ultraviolet rays—
UVA and UVG (e.g., the sun, sunlamps, tanning booths), or
high exposure to x-rays including radiotherapy (e.g., cancer
therapy)
e. Risk factors: substance abuse, careless smoking, cultural
practices, socioeconomic status (e.g., overcrowded living
conditions, insufficient parental supervision of children,
lack of safety precautions), and violence, including child
abuse and neglect, such as with those aged 4 years and
under or those aged 65 years and older
IV. Statistics (American Burn Association, 2007)
a. Morbidity: 500,000 burn injuries require medical attention
in the United States annually, with approximately 40,000
requiring hospitalization; approximately 25,000 are classified
as major burns, involving at least 30% of TBSA.
b. Mortality: There are approximately 4,000 deaths annually.
c. Cost: $7.5 billion is spent annually for fire and burn injuries
(Centers for Disease Control and Prevention [CDC], 2007).

Care Setting
The following adult clients are admitted for acute care and,
during the rehabilitation phase, may be cared for in a subacute
or rehabilitation unit: those with partial-thickness burns
more than 15% to 25% of TBSA or whose age is considered
high risk (older than 50 years and younger than 10 years);
full-thickness burns more than 2% to 10% of TBSA; and
those clients with second- and third-degree burns of face,
both hands, perineum, or both feet; or inhalation and all electrical
burns, including lightning injury (Edlich et al, 2006).

Related Concerns
Disaster considerations
Fluid and electrolyte imbalances
Metabolic acidosis—primary base bicarbonate deficiency
Psychosocial aspects of care
Respiratory acidosis (primary carbonic acid excess)
Sepsis/septicemia
Surgical intervention
Total nutritional support: parenteral and enteral feeding
Upper gastrointestinal/esophageal bleeding

Nursing Priorities
1. Maintain patent airway and respiratory function.
2. Restore hemodynamic stability and circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for client and significant other
(SO).
6. Provide information about condition, prognosis, and
treatment.

Discharge Goals
1. Homeostasis achieved.
2. Pain controlled or reduced.
3. Complications prevented or minimized.
4. Current situation dealt with realistically.
5. Condition, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

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Source Credits: Nursing Care Planning Guides: For Adults in Acute, Extended and Home Care Settings by S. P. Ulrich and S. W. Canale BSN MSN / Nursing Care Plans by M. Doenges MF Moorehouse Alice Murr