Most burns result from preventable accidents. Thermal burns, which are the most common type, occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries.
Nursing care plan assessment and examination
Obtain a complete description of the burn injury, including the time, the situation,
the burning agent, and the actions of witnesses. The time of injury is extremely important since
any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit
specific information about the location of the accident, since closed-space injuries are related to
smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people
who are involved with the child. The injury may be suspect if there is a delay in seeking health
care, if there are burns that are not consistent with the story, or if there are bruises at different
stages of healing. Note whether the description of the injury changes or differs among family or
Although the wounds of a serious burninjury may be dramatic, a basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine the severity of injury. The American Burn Association (ABA) establishes the severity of injury by calculating the total body surface area (TBSA) of partial and full-thickness injury along with the age of the patient and other special factors. The “rule of nines” is a practical technique used to estimate the extent of TBSA involved in a burn. The technique divides the major anatomic areas of the body into percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patient’s palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patient’s response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and output monitoring are essential to ensure that the patient is responding appropriately to treatment.
Even small burns temporarily change the appearance of the skin. Major burns will have a permanent effect on the family unit. A complete assessment of the family’s psychological health before the injury is essential. Expect preexisting issues to magnify.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to airway edema.
Nursing care plan intervention and treatment
The nursing care of the patient with a burn is complex and collaborative, with overlapping interventions among the nurse, the physician, and a variety of therapists. However, independent nursing interventions are also an important focus for the nurse. The highest priority for the burnpatient is to maintain the airway, breathing, and circulation. The airway can be maintained in some patients by an oral or nasal airway, or by the jaw lift-chin thrust maneuver. Patency of the
airway is maintained by endotracheal suctioning, whose frequency is dictated by the character and amount of secretions. If the patient is apneic, maintain breathing with a manual resuscitator bag before intubation and mechanical ventilation.
If the patient is bleeding from burn sites, apply pressure until the bleeding can be controlled surgically. Remove all constricting clothing and jewelry to allow for adequate circulation to the extremities. Implement fluid resuscitation protocols as appropriate to support the patient’s circulation. If any clothing is still smoldering and adhering to the patient, soak the area with normal saline solution and remove the material. Wound care includes collaborative management and other strategies. Cover wounds with clean, dry, sterile sheets. Do not cover large burn wounds with saline-soaked dressings, which lower the patient’s temperature. If the patient has ineffective thermoregulation, use warming or cooling blankets as needed and control the room
temperature to support the patient’s optimum temperature. If the patient is hypothermic, limit
traffic into the room to decrease drafts and keep the patient covered with sterile sheets. Help the patient manage pain and distress by providing careful explanations and teaching distraction and
As the wounds heal, use strategies such as tubbing, débridement, and dressing changes to
limit infection, promote wound healing, and limit physical impairment. If impaired physical
mobility is a risk, place the patient in antideformity positions at all times. Implement active and
passive range of motion as needed. Get the patient out of bed on a regular basis to limit physical
debilitation and decrease the risk of infection. Implement strategies to limit stress and anxiety.