Diagnosis

 Impaired gas exchange related to carbon monoxide

poisoning, smoke inhalation, and upper airway obstruction.
 Ineffective airway clearance related to edema and effects
of smoke inhalation.
 Fluid volume deficit related to increased capillary
permeability and evaporative losses from burn wound.
 Hypothermia related to loss of skin microcirculation and
open wounds.
 Pain related to tissue and nerve injury.
 Anxiety related to fear and the emotional impact of burn
injury.
Planning & Goals
To implement the plan of care for a burn injury patient effectively, there
should be goals that should be set:

 Maintenance of adequate tissue oxygenation.

 Maintenance of patent airway and adequate airway
clearance.
 Restoration of optimal fluid and electrolyte balance and
perfusion of vital organs.
 Maintenance of adequate body temperature.
 Control of pain.
 Minimization of patient’s and family’s anxiety.
Nursing Priorities
1. Maintain patent airway/respiratory function.
2. Restore hemodynamic stability/circulating volume.
3. Alleviate pain.
4. Prevent complications.
5. Provide emotional support for patient/significant other
(SO).
6. Provide information about condition, prognosis, and
treatment.
Nursing Interventions
Nursing care of a patient with burn injury needs to be precise and
effective.

Promoting Gas Exchange and Airway Clearance

 Provide humidified oxygen, and monitor arterial blood

gases (ABGs), pulse oximetry, and carboxyhemoglobin
levels.
 Assess breath sounds and respiratory rate, rhythm,
depth, and symmetry; monitor for hypoxia.
 Observe for signs of inhalation injury: blistering of lips
or buccal mucosa; singed nostrils; burns of face, neck, or
chest; increasing hoarseness; or soot in sputum or
respiratory secretions.
 Report labored respirations, decreased depth of
respirations, or signs of hypoxia to physician immediately;
prepare to assist with intubation and escharotomies.
 Monitor mechanically ventilated patient closely.
 Institute aggressive pulmonary care measures:
turning, coughing, deep breathing, periodic forceful
inspiration using spirometry, and tracheal suctioning.
 Maintain proper positioning to promote removal of
secretions and patent airway and to promote optimal
chest expansion; use artificial airway as needed.
Restoring fluid and Electrolyte Balance

 Monitor vital signs and urinary output (hourly), central

venous pressure (CVP), pulmonary artery pressure, and
cardiac output.
 Note and report signs of hypovolemia or fluid overload.
 Maintain IV lines and regular fluids at appropriate rates,
as prescribed. Document intake, output, and daily weight.
 Elevate the head of bed and burned extremities.
 Monitor serum electrolyte levels (eg, sodium, potassium,
calcium, phosphorus, bicarbonate); recognize developing
electrolyte imbalances.
 Notify physician immediately of decreased urine
output; blood pressure; central venous, pulmonary artery,
or pulmonary artery wedge pressures; or increased pulse
rate.
Maintaining Normal Body Temperature

 Provide warm environment: use heat shield, space

blanket, heat lights, or blankets.
 Assess core body temperature frequently.
 Work quickly when wounds must be exposed to
minimize heat loss from the wound.
Minimizing Pain and Anxiety

 Use a pain scale to assess pain level (ie, 1 to 10);

differentiate between restlessness due to pain and
restlessness due to hypoxia.
 Administer IV opioid analgesics as prescribed, and
assess response to medication; observe for
respiratory depression in patient who is not mechanically
ventilated.
 Provide emotional support, reassurance, and simple
explanations about procedures.
 Assess patient and family understanding of burn injury,
coping strategies, family dynamics, and anxiety levels.
Provide individualized responses to support patient and
family coping; explain all procedures in clear, simple terms.
 Provide pain relief, and give antianxiety medications
if patient remains highly anxious and agitated after
psychological interventions.
Monitoring and Managing Potential Complications

 Acute respiratory failure: Assess for increasing dyspnea,

stridor, changes in respiratory patterns; monitor pulse
oximetry and ABG values to detect problematic oxygen
saturation and increasing CO2; monitor chest xrays; assess
for cerebral hypoxia (eg, restlessness, confusion); report
deteriorating
 respiratory status immediately to physician; and assist
as needed with intubation or escharotomy.
 Distributive shock: Monitor for early signs of shock
(decreased urine output, cardiac output, pulmonary artery
pressure, pulmonary capillary wedge pressure, blood
pressure, or increasing pulse) or progressive edema.
 Administer fluid resuscitation as ordered in response to
physical findings; continue monitoring fluid status.
 Acute renal failure: Monitor and report abnormal urine
output and quality, blood urea nitrogen (BUN)
and creatinine levels; assess for urine hemoglobin or
myoglobin; administer increased fluids as prescribed.
 Compartment syndrome: Assess peripheral pulses
hourly with Doppler; assess neurovascular status of
extremities hourly (warmth, capillary refill, sensation, and
movement); remove blood pressure cuff after each reading;
elevate burned extremities; report any extremity pain, loss
of peripheral pulses or sensation; prepare to assist
with escharotomies.
 Paralytic ileus: Maintain nasogastric tube on low
intermittent suction until bowel sounds resume; auscultate
abdomen regularly for distention and bowel sounds.
 Curling’s ulcer: Assess gastric aspirate for blood and
pH; assess stools for occult blood; administer antacids and
histamine blockers (eg, ranitidine [Zantac]) as prescribed.
Restoring Normal fluid Balance

 Monitor IV and oral fluid intake; use IV infusion pumps.

 Measure intake and output and daily weight.
 Report changes (e.g., blood pressure, pulse rate) to
physician.
Preventing Infection

 Provide a clean and safe environment; protect patient

from sources of cross contamination (e.g., visitors, other
patients, staff, equipment).
 Closely scrutinize wound to detect early signs of infection.
Monitor culture results and white blood cell counts.

 Practice clean technique for wound care procedures and

aseptic technique for any invasive procedures. Use
meticulous hand hygiene before and after contact with
patient.
 Caution patient to avoid touching wounds or
dressings; wash unburned areas and change linens
regularly.
Maintaining Adequate Nutrition

 Initiate oral fluids slowly when bowel sounds resume;

record tolerance—if vomiting and distention do not occur,
fluids
 may be increased gradually and the patient may be
advanced to a normal diet or to tube feedings.
 Collaborate with dietitian to plan a protein and calorie-
rich diet acceptable to patient. Encourage family to bring
nutritious and patient’s favorite foods. Provide nutritional
and vitamin and mineral supplements if prescribed.
 Document caloric intake. Insert feeding tube if caloric
goals cannot be met by oral feeding (for continuous or
bolus feedings); note residual volumes.
 Weigh patient daily and graph weights.
Promoting  Skin Integrity
 Assess wound status.
 Support patient during distressing and painful wound care.
 Coordinate complex aspects of wound care and
dressing changes.
 Assess burn for size, color, odor, eschar, exudate,
epithelial buds (small pearl-like clusters of cells on the
wound surface), bleeding, granulation tissue, the status of
graft take, healing of the donor site, and the condition of
the surrounding skin; report any significant changes to the
physician.
 Inform all members of the health care team of latest
wound care procedures in use for the patient.
 Assist, instruct, support, and encourage patient and
family to take part in dressing changes and wound care.
 Early on, assess strengths of patient and family in
preparing for discharge and home care.
Relieving Pain and Discomfort

 Frequently assess pain and discomfort; administer

analgesic agents and anxiolytic medications, as prescribed,
before the pain becomes severe. Assess and document the
patient’s response to medication and any other
interventions.
  Teach patient relaxation techniques. Give some control
over wound care and analgesia. Provide frequent
reassurance.
 Use guided imagery and distraction to alter patient’s
perceptions and responses to pain; hypnosis, music
therapy, and virtual reality are also useful.
 Assess the patient’s sleep patterns daily; administer
sedatives, if prescribed.
 Work quickly to complete treatments and dressing
changes.
Encourage the patient to use analgesic medications before painful
procedures.

Promote comfort during healing phase with the following:

 oral antipruritic agents, a cool environment, frequent
lubrication of the skin with water or a silica-based lotion,
exercise and splinting to prevent skin contracture, and
diversional activities.
Promoting Physical Mobility

 Prevent complications of immobility

(atelectasis, pneumonia, edema, pressure ulcers, and
contractures) by deep breathing, turning, and proper
repositioning.
 Modify interventions to meet patient’s needs.
Encourage early sitting and ambulation. When legs are
involved, apply elastic pressure bandages before assisting
patient to upright position.
 Make aggressive efforts to prevent contractures and
hypertrophic scarring of the wound area after wound
closure for a year or more.
 Initiate passive and active range-of-motion exercises
from admission until after grafting, within prescribed
limitations.
 Apply splints or functional devices to extremities for
contracture control; monitor for signs of vascular
insufficiency, nerve compression, and skin breakdown.
Strengthening Coping Strategies
  Assist patient to develop effective coping strategies: Set
specific expectations for behavior, promote truthful
communication to build trust, help patient practice coping
strategies, and give positive reinforcement when
appropriate.
 Demonstrate acceptance of patient. Enlist a non
involved person for patient to vent feelings without fear of
retaliation.
 Include patient in decisions regarding care.
Encourage patient to assert individuality and preferences.
Set realistic expectations for self care.

Supporting Patient and Family Processes

 Support and address the verbal and nonverbal concerns

of the patient and family.
 Instruct family in ways to support patient.
 Make psychological or social work referrals as needed.
 Provide information about burn care and expected course
of treatment.
 Initiate patient and family education during burn
management. Assess and consider preferred learning styles;
assess ability to grasp and cope with the information;
determine barriers to learning when planning and
executing teaching.
 Remain sensitive to the possibility of changing
family dynamics.
Monitoring and Managing Potential Complications

 Heart failure: Assess for fluid overload, decreased

cardiac output, oliguria, jugular vein distention, edema, or
onset of S3 or S4 heart sounds.
 Pulmonary edema: Assess for increasing CVP,
pulmonary artery and wedge pressures, and crackles; report
promptly. Position comfortably with head elevated unless
contraindicated. Administer medications and oxygen as
prescribed and assess response.
 Sepsis: Assess for increased temperature, increased
pulse, widened pulse pressure, and flushed, dry skin in
unburned areas (early signs), and note trends in the data.
 Perform wound and blood cultures as prescribed. Give
scheduled antibiotics on time.
 Acute respiratory failure and acute respiratory distress
syndrome (ARDS): Monitor respiratory status for
dyspnea, change in respiratory pattern, and onset of
adventitious sounds. Assess for decrease in tidal volume
and lung compliance in patients on mechanical ventilation.
The hallmark of onset of ARDS is hypoxemia on 100%
oxygen, decreased lung compliance, and significant
shunting; notify physician of deteriorating respiratory
status.
 Visceral damage (from electrical burns): Monitor
electrocardiogram (ECG) and report dysrhythmias; pay
attention to pain related to deep muscle ischemia and
report. Early detection may minimize severity of this
complication. Fasciotomies may be necessary to relieve
swelling and ischemia in the muscles and fascia; monitor
patient for excessive blood loss and hypovolemia
after fasciotomy.
 Contractures: Provide early and aggressive physical
and occupational therapy; support patient if surgery is
needed to achieve full range of motion.
 Impaired psychological adaptation to the burn injury:
 Obtain psychological or psychiatric referral as soon as
evidence of major coping problems appears.
Promoting Activity Tolerance

 Schedule care to allow periods of uninterrupted

sleep. Administer hypnotic agents, as prescribed, to
promote sleep.
 Communicate plan of care to family and other caregivers.
 Reduce metabolic stress by relieving pain,
preventing chilling or fever, and promoting integrity of all
body systems to help conserve energy. Monitor fatigue,
pain, and fever to determine amount of activity to be
encouraged daily.
 Incorporate physical therapy exercises to prevent
muscular atrophy and maintain mobility required for daily
activities.
  Support positive outlook, and increase tolerance for activity
by scheduling diversion activities in periods of increasing
duration.
Improving Body Image and Self-Concept

 Take time to listen to patient’s concerns and provide

realistic support; refer patient to a support group to
develop coping strategies to deal with losses.
 Assess patient’s psychosocial reactions; provide
support and develop a plan to help the patient handle
feelings.
 Promote a healthy body image and selfconcept by helping
patient practice responses to people who stare or ask about
the injury.
 Support patient through small gestures such as providing
a birthday cake, combing patient’s hair before visitors,
and sharing information on cosmetic resources to
enhance appearance.
 Teach patient ways to direct attention away from a
disfigured body to the self within.
 Coordinate communications of consultants, such
as psychologists, social workers, vocational counselors,
and teachers, during rehabilitation.
Teaching Self-care

 Throughout the phases of burn care, make efforts to

prepare patient and family for the care they will perform
at home. Instruct them about measures and procedures.
 Provide verbal and written instructions about wound care,
prevention of complications, pain management,
and nutrition.
 Inform and review with patient specific exercises and use of
elastic pressure garments and splints; provide
written instructions.
 Teach patient and family to recognize abnormal signs
and report them to the physician.
 Assist the patient and family in planning for the
patient’s continued care by identifying and acquiring
supplies and equipment that are needed at home.
 Encourage and support followup wound care.
  Refer patient with inadequate support system to home
care resources for assistance with wound care and
exercises.
 Evaluate patient status periodically for modification
of home care instructions and/or planning for
reconstructive surgery.
Evaluation
In a patient with burn injury, the expected outcomes are:

 Absence of dyspnea.
 Respiratory rate between 12 and 20 breaths/min.
 Lungs clear on auscultation,
 Arterial oxygen saturation greater than 96% by pulse
oximetry.
 ABG levels within normal limits.
 Patent airway
 Respiratory secretions are minimal, colorless, and thin.
 Urine output between 0.5 and 1.0 mL/kg/h.
 Blood pressure higher than 90/60 mmHg.
 Heart rate less than 120 bpm.
 Body temperature remains between 36.1ºC and 38.3ºC
Gerontologic Considerations
The following are interventions you must consider when caring elderly
people with burn injury.

 Elderly people are at higher risk for burn injury because

of reduced coordination, strength, and sensation and
changes in vision.
 Predisposing factors and the health history in the
older adult influence the complexity of care for the patient.
 Pulmonary function is limited in the older adult and
therefore airway exchange, lung elasticity, and ventilation
can be affected.
 This can be further affected by a history of smoking.
 Decreased cardiac function and coronary
artery disease increase the risk of complications in elderly
patients with burn injuries. Malnutrition and presence
 of diabetes mellitus or other endocrine disorders present
nutritional challenges and require close monitoring.
 Varying degrees of orientation may present themselves on
admission or through the course of care making
assessment of pain and anxiety a challenge for the burn
team.
 The skin of the elderly is thinner and less elastic, which
affects the depth of injury and its ability to heal.
Discharge and Home Care Guidelines
The focus of rehabilitative interventions is directed towards outpatient
care, home care, or care in a rehabilitation center.

 Wound care. The patient and the family are instructed to

wash small clean, open wounds daily with mild soap and
water and to apply the prescribed topical agent or dressing.
 Education. The patient and the family require careful
written and verbal instructions about pain management,
nutrition, prevention of complications, specific exercises,
and the use of pressure garments and splints.
 Follow up care. Patients who receive care in a burn center
usually return to the burn clinic periodically for evaluation,
modification of burn care instructions, and planning for
reconstructive surgery.
 Referral. Patients who return home after a severe burn
injury, those who cannot manage their own burn care, and
those with inadequate support systems need referral for
home care.
Documentation Guidelines
The nurse should document the following data to ensure that each care
documented is a care that is done.

 Breath sounds and character of secretions.

 Respiratory rate, pulse oximetry/O2 saturation, vital signs.
 Plan of care and those involved in the planning.
 Teaching plan.
 Client’s response to interventions, teachings, and actions
performed.
 Use of respiratory devices or adjuncts.
 Conditions that may interfere with oxygen supply.
 I&O, fluid balance, changes in weight, urine specific gravity.
 Attainment or progress toward desired outcomes.
 Modifications to the plan of care.