Introduction
Burns are one type of injury to the skin caused by heat, electricity, chemicals, sunlight, or radiation. The main types of burns include thermal (heat/flame), electrical, chemical, and radiation. Nursing care plan for burns helps to ensure that the patient’s wounds are adequately treated and monitored for infection.
Assessment
- Severity: It is determined from the depth and degree of injury. The severity of the burn is assessed in terms of the percentage of the body area affected.
- Pain: The intensity of pain and its character vary, depending on the extent and depth of the burn.
- Skin temperature: The skin temperature depends on the amount of edema as well as the nature of the burn.
- Circulation: Poor circulation can lead to poor healing and delays in wound closure.
- Infection: The risk of infection increases with the spreading of bacteria into the burn. Proper hygiene is essential.
Nursing Diagnosis
- Fluid Volume Deficit: caused by excessive fluid loss through burn damage, exudates and evaporation.
- Pain: caused by tissue damage, manipulation of the wound, dressing changes and movement.
- Skin Integrity: caused by destruction of the epidermis through thermal, electrical, chemical and radiation sources.
- Infection: caused by entry of potentially pathogenic organisms into the skin.
Outcomes
- The patient will be free from infection.
- The patient will experience minimal pain.
- The patient will retain adequate body fluid volume.
- The patient will maintain skin integrity.
Interventions
- Administer prescribed analgesics to relieve pain.
- Assess the burn wound daily to evaluate healing.
- Monitor vital signs and intake and output.
- Provide wound care as appropriate.
- Initiate measures to maintain fluid volume balance.
- Teach proper self-care of the burn.
Rationales
- Analgesics help to relieve pain and discomfort.
- Assessment of the wound helps to monitor healing progress and detect infection.
- Fluid and electrolytes may be lost resulting in imbalance.
- Wound care helps to reduce pain and limit risk of further damage.
- Patients need to be taught how to care for their burn to ensure proper healing.
Evaluation
Evaluation of the effectiveness of the nursing care plan will be based on the patient's pain level, fluid balance, wound healing, and general condition. The patient should be monitored regularly and adjustments to the nursing care plan should be made accordingly.
Conclusion
The nursing care plan for burns is an important component of the overall medical management of the patient. By providing comprehensive assessment, accurate diagnosis, and effective interventions and outcomes, it helps to ensure successful treatment and recovery.
FAQs
- What are the types of burns?
Thermal (heat/flame), electrical, chemical, and radiation. - What is the main goal of Nursing care plan for burns?
The main goal of Nursing care plan for burns is to ensure that the patient’s wounds are adequately treated and monitored for infection. - How are burns assessed?
Burns are assessed in terms of severity, pain, skin temperature, and circulation. - What nursing diagnosis should be included in a nursing care plan for burns?
Fluid Volume Deficit, Pain, Skin Integrity, Infection. - What are the interventions for nursing care plan for burns?
Administer prescribed analgesics, assess the burn wound daily, monitor vital signs and intake and output, provide wound care, initiate measures to maintain fluid volume balance, and teach proper self-care of the burn.
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