eNursing Care Plan 24-1

Patient with a Thermal Burn Injury

Nursing Diagnosis*
Fluid Imbalance
Etiology: Fluid shifts and evaporative fluid loss
Supporting data: Decreased blood pressure, increased pulse rate, altered mental status,
thirst, decreased urine output

Patient Goals
1. Has no signs of hypovolemia or hypervolemia
2. Maintains fluid and electrolyte balance required for metabolic needs

Outcomes (NOC) Interventions (NIC) and Rationales

Fluid Balance
 Blood pressure ___
 Radial pulse rate ___
 Central venous pressure
___
 Peripheral pulses ___
 Hourly urine output ___
 24-hr intake and output
balance ___
 Serum electrolytes ___
 Hematocrit ___
 Urine specific gravity ___
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Fluid/Electrolyte Management
Emergent Phase
 Monitor hemodynamic status, including central venous
pressure, to determine fluid status.
 Monitor laboratory results relevant to fluid balance
(e.g., hematocrit, blood urea nitrogen [BUN], albumin,
total protein, serum osmolality, and urine specific
gravity levels) to detect changes in fluid/electrolyte
balance.
 Keep an accurate record of intake and output to monitor
fluid loss and gain.
 Monitor for manifestations of electrolyte imbalance to
detect early signs of electrolyte abnormalities.
 Administer IV therapy, as prescribed, to replace fluid
losses.
 Administer supplemental electrolytes, as prescribed, to
correct electrolyte imbalances.
 Weigh patient daily and monitor trends to detect early
changes in fluid balance.
 Consult health care provider if signs and symptoms of
fluid and/or electrolyte imbalance persist or worsen to
provide additional therapy as needed.

Acute Phase
 Use emergent phase interventions as necessary.
 Promote oral intake to promote normal fluid intake and
patient comfort.

*Nursing diagnoses listed in order of priority.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan
Nursing Diagnosis
Acute Pain
Etiology: Burn injury, treatments
Supporting data: Patient’s report of pain and nonverbal behaviors indicating pain
Patient Goals
1. Reports adequate pain relief as a result of pain management interventions
2. Reports satisfaction with pain management program
Outcomes (NOC)
Pain Level
 Reported pain ___
 Length of pain episodes
___
 Moaning and crying ___
 Facial expressions of pain
___
 Restlessness ___
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
 Blood pressure ___
 Apical heart rate ___
 Radial pulse rate ___
 Respiratory rate ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
range
5 = No deviation from normal
range
Copyright © 2020 by Elsevier, Inc. All rights reserved.
24-2
Interventions (NIC) and Rationales
Pain Management
Emergent Phase
 Provide optimal pain relief with prescribed analgesics
to manage pain.
 Use pain control measures before pain becomes severe
to avoid pain escalation.
 Ensure pretreatment analgesia prior to painful
procedures to prevent breakthrough pain.
 Teach the use of nonpharmacologic techniques (e.g.,
biofeedback, hypnosis, relaxation, guided imagery,
computer gaming devices, music therapy, distraction)
before, after, and—if possible—during painful
activities; before pain occurs or increases; and along
with other pain relief measures to augment analgesics
for pain relief.
 Evaluate the effectiveness of pain control measures by
performing ongoing assessment of the pain experience.
 Observe for nonverbal cues of discomfort (e.g.,
grimacing, guarding, increase in heart rate or blood
pressure), especially in those unable to communicate
effectively.
 Institute and modify pain control measures on the basis
of the patient’s response.
Acute Phase
 Reduce or eliminate factors that precipitate or increase
the pain experience (e.g., fear, fatigue, monotony, lack
of knowledge).
 Promote adequate rest/sleep to facilitate pain relief.
 Teach the use of nonpharmacologic techniques before,
after, and—if possible—during painful activities; before
pain occurs or increases; and along with other pain
relief measures to augment analgesics for pain relief.
 Medicate prior to an activity to increase participation,
but evaluate the hazard of sedation.
 Encourage patient to monitor own pain and to intervene
eNursing Care Plan 24-3

Outcomes (NOC) Interventions (NIC) and Rationales

appropriately.
 Monitor patient satisfaction with pain management at
regular, specified intervals.

Rehabilitative Phase
 Determine the impact of the pain experience on quality
of life (e.g., sleep, appetite, activity, cognition, mood,
relationships, performance of job, and role
responsibilities) to plan long-term pain management.
 Assist patient, caregiver(s), and family member(s) to
seek and obtain support to manage residual pain.

Nursing Diagnosis
Impaired Tissue Integrity
Etiology: Temperature extremes
Supporting data: Damaged and destroyed skin and subcutaneous tissue

Patient Goals
1. Wound is free of debris and necrotic tissue
2. Wound heals with absence of infection

Outcomes (NOC) Interventions (NIC) and Rationales

Wound Healing: Secondary Infection Protection
Intention All Phases
 Granulation ___  Monitor for systemic and localized signs and symptoms
 Scar formation ___ of infection to provide early detection and treatment.
 Decreased wound size ___  Administer an immunizing agent (i.e., tetanus booster)
to prevent systemic infection.
Measurement Scale  Obtain cultures to identify infectious agents.
1 = None  Promote sufficient nutritional intake to promote
2 = Limited immune function.
3 = Moderate
4 = Substantial
Wound Care: Burns
5 = Extensive
All Phases
 Use physical isolation measures (e.g., mask, gown,
 Purulent drainage ___
sterile gloves and cap) to prevent infection.
 Wound inflammation ___
 Evaluate the wound, examining its depth, extension,
 Blistered skin ___
localization, pain, causative agent, exudation,
 Necrosis ___ granulation or necrotic tissue, epithelialization, and
 Sloughing ___ signs of infection to determine effectiveness of
 Foul wound odor ___ treatment.
 Position to preserve functionality of limbs and joints to
Measurement Scale
avoid contracture.
1 = Extensive
2 = Substantial

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eNursing Care Plan 24-4

Outcomes (NOC) Interventions (NIC) and Rationales

3 = Moderate Wound Care
4 = Limited  Maintain sterile dressing technique when performing
5 = None wound care to prevent wound contamination.
 Cleanse wound with normal saline or nontoxic cleanser
to remove old agents, wound debris, and medium for
bacterial growth.
 Apply an appropriate burn cream and/or dressing to the
wound to promote healing and prevent infection.
 Regularly compare and record any changes in the
wound to evaluate treatment regimen.
 Teach patient, caregiver(s), and family member(s)
wound care procedures to ensure proper technique and
increase their sense of control.
 Teach patient and caregiver signs and symptoms of
infection so early treatment can be initiated.

Nursing Diagnosis
Impaired Nutritional Status
Etiology: Hypermetabolic state, inability to ingest increased requirements
Supporting data: Weight loss, negative nitrogen balance

Patient Goals
1. Demonstrates positive nitrogen balance (tissue formation and growth)
2. Ingests nutrients sufficient to meet metabolic needs

Outcomes (NOC) Interventions (NIC) and Rationales

Nutritional Status: Energy
 Stamina ___
 Muscle tone ___
 Tissue healing ___
 Infection resistance ___
Measurement Scale
1 = Severe deviation from
normal range
2 = Substantial deviation from
normal range
3 = Moderate deviation from
normal range
4 = Mild deviation from normal
range
5 = No deviation from normal
range
Nutritional Status:
Nutrition Therapy
Emergent Phase
 Determine in collaboration with the dietitian the
number of calories and type of nutrients needed to meet
metabolic needs to promote wound healing and tissue
growth.
 Administer parenteral nutrition to provide calories and
protein if the gastrointestinal system is not functional.
 Begin enteral feedings as soon as possible to provide
nutrition until oral intake can be resumed.
 Discontinue use of enteral feedings when oral intake is
tolerated to promote normal nutrition patterns.
 Monitor food/fluid ingested and calculate daily caloric
intake to assess adequacy of diet.
Acute Phase
 Provide patient with high-protein, high-calorie,
nutritious finger foods and drinks that can be readily

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eNursing Care Plan 24-5

Outcomes (NOC) Interventions (NIC) and Rationales

Nutrient Intake
 Caloric intake ___
 Protein intake ___
 Vitamin intake ___
 Mineral intake ___
Measurement Scale
1 = Not adequate
2 = Slightly adequate
3 = Moderately adequate
4 = Substantially adequate
5 = Totally adequate
consumed to meet nutritional needs.
 Select nutritional supplements to increase nutrient
intake.
 Determine food preferences with consideration of
cultural and religious preferences to promote food
intake.
 Monitor food/fluid ingested and calculate daily caloric
intake to assess adequacy of diet.
Rehabilitative Phase
 Refer for dietary teaching and planning to meet long-
term nutritional needs.
 Monitor appropriateness of diet orders to meet daily
nutritional needs to prevent excessive weight gain.

Nursing Diagnosis
Disturbed Body Image
Etiology: Disfigurement resulting from burn
Supporting data: States negative comments about appearance, unwillingness to look at
self, unwilling to take part in self-care

Patient Goals
1. Sets realistic goals regarding future lifestyle
2. States acceptance of altered appearance

Outcomes (NOC) Interventions (NIC) and Rationales

Body Image
 Congruence among body
reality, body ideal, and
body presentation ___
 Attitude toward using
strategies to enhance
appearance ___
 Adjustment to changes in
physical appearance ___
 Adjustment to changes in
body function ___
Measurement Scale
1 = Never positive
2 = Rarely positive
3 = Sometimes positive
4 = Often positive
5 = Consistently positive
Body Image Enhancement
All Phases
 Determine patient’s, caregiver(s),’ and family
member(s)’ perceptions of the alteration in body image
versus reality to promote congruence of perceptions.
 Assist patient to separate physical appearance from
feelings of personal worth to foster sense of support.
 Use anticipatory guidance to prepare patient for
predictable changes in body image to decrease
misconceptions.
 Monitor whether patient can look at the changed body
part to assess patient’s response.
 Assist patient to identify actions that will enhance
appearance to promote positive perceptions.
 Identify support groups available to patient to reduce
sense of isolation and the impact of burn event on the
patient’s life.

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eNursing Care Plan
Outcomes (NOC)
Adaptation to Physical
Disability
 Identifies ways to cope
with life changes ___
 Reports decrease in
negative body image ___
 Verbalizes ability to adjust
to disability ___
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Copyright © 2020 by Elsevier, Inc. All rights reserved.
24-6
Interventions (NIC) and Rationales
Coping Enhancement
All Phases
 Encourage an attitude of realistic hope as a way of
dealing with feelings of helplessness to promote
acceptance of body changes.
 Encourage the identification of specific life values to
promote decision making.
 Assist the patient to grieve and work through the losses
of chronic illness and/or disability to enhance
adaptation to injury.
 Assist the patient to identify positive strategies to deal
with limitations and manage needed lifestyle or role
changes to facilitate adaptive process.