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Nursing Diagnosis for Burns | Risk for Ineffective Airway Clearance

Each year, more than 2 million burn injuries occur in the United States; approximately 100,000 people require hospital care. Thermal burns, which are the most common type, occur because of fires, motor vehicle crashes, home fires, hot liquid spills, electrical malfunctions, and war. Survival rates have risen because of newer treatments and skin barrier development; however, moderate and severe burns account for many dollars spent on physical and psychological rehabilitation.

Types of Burns
Thermal burns: Injuring agent can be flame, hot liquid, or contact with hot object. Flame burns are associated with smoke/inhalation injury.
Chemical burns: Occur from type/content of injuring agent, as well as concentration and temperature of agent.
Electrical burns: Occur from type/voltage of current that generates heat in proportion to resistance offered and travels the pathway of least resistance (i.e., nerves offer the least resistance and bones the greatest resistance). Underlying injury is more severe than visible injury.
Type of Burns According to the Degree of Damage
Superficial partial-thickness (first-degree) burns: Involve only the epidermis. Wounds appear bright pink to red with minimal edema and no blisters. The skin is often warm/dry.
Moderate partial-thickness (second-degree) burns: Involve the epidermis and dermis. Wounds appear red to pink with moderate edema and moist, weeping blisters.
Deep partial-thickness (second-degree) burns: Involve the deep dermis. Wounds appear pink to pale ivory with moderate edema and blisters. These wounds are dryer than moderate partial-thickness burns.
Full-thickness (third-degree) burns: Involve all layers of skin, subcutaneous fat, and may involve the muscle, nerves, and blood supply. Wound appearance varies from white to cherry red to brown or black, with blistering uncommon. These wounds have a dry, leathery texture.
Full-thickness (fourth-degree) burns: Involve all skin layers plus muscle, organ tissue, and bone. Charring occurs.

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.

1. Homeostasis achieved.
2. Pain controlled/reduced.
3. Complications prevented/minimized.
4. Dealing with current situation realistically.
5. Condition/prognosis and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

Nursing diagnosis for burns: Risk for ineffective airway clearance may be related to Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential fullthickness burns of the neck, thorax, and chest, with compression of the airway or limited chest excursion; Trauma: direct upper-airway injury by flame, steam, hot air, and chemicals/gases; Fluid shifts, pulmonary edema, decreased lung compliance.

Desired Outcome
1. Demonstrate clear breath sounds, respiratory rate within normal range, be free of dyspnea/cyanosis.

Nursing intervention with rationale:
1. Obtain history of injury. Note presence of preexisting respiratory conditions, history of smoking.
Rationale: Causative burning agent, duration of exposure, and occurrence in closed or open space predict probability of inhalation injury. Type of material burned (wood, plastic, wool, and so forth) suggests type of toxic gas exposure. Preexisting conditions increase the risk of respiratory complications.

2. Assess gag/swallow reflexes; note drooling, inability to swallow, hoarseness, wheezy cough.
Rationale: Suggestive of inhalation injury.

3. Monitor respiratory rate, rhythm, depth; note presence of pallor/cyanosis and carbonaceous or pink-tinged sputum.
Rationale: Tachypnea, use of accessory muscles, presence of cyanosis, and changes in sputum suggest developing respiratory distress/pulmonary edema and need for medical intervention.

4. Auscultate lungs, noting stridor, wheezing/crackles, diminished breath sounds, brassy cough.
Rationale: Airway obstruction/respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after burn.

5. Note presence of pallor or cherry-red color of unburned skin.
Rationale: Suggests presence of hypoxemia or carbon monoxide.

6. Investigate changes in behavior/mentation, e.g., restlessness, agitation, confusion.
Rationale: Although often related to pain, changes in consciousness may reflect developing/worsening hypoxia.

7. Elevate head of bed. Avoid use of pillow under head, as indicated.
Rationale: Promotes optimal lung expansion/respiratory function. When head/neck burns are present, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures.

8. Encourage coughing/deep-breathing exercises and frequent position changes.
Rationale: Promotes lung expansion, mobilization and drainage of secretions.

9. Administer humidified oxygen via appropriate mode, e.g., face mask.
Rationale: O2 corrects hypoxemia/acidosis. Humidity decreases drying of respiratory tract and reduces viscosity of sputum.

10. Prepare for/assist with intubation or tracheostomy, as indicated.
Rationale: Intubation/mechanical support is required when airway edema or circumferential burn injury interferes with respiratory function/oxygenation.
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