Nursing Diagnoses for Burns

 Five examples of nursing diagnoses for burns include:

• Impaired physical mobility related to neuromuscular impairment, pain/discomfort, and restrictive therapies as evidenced by limited ROM and muscular strength

• Disturbed body image related to traumatic event and disfigurement as evidenced by self-reported negative feelings about self and worry concerning others' reactions

• Imbalanced nutrition related to hyper-metabolic state as evidenced by decreased body weight and loss of muscle mass

• At risk for ineffective tissue perfusion related to reduction/interruption of arterial/venous blood flow from circumferential burns

• Acute pain related to tissue damage as evidenced by report of pain and non-verbal pain responses (ex. grimacing, guarding, fetal position, etc.)

Detailed Nursing Diagnosis Example

• Impaired skin integrity related to disruption of skin surface and destruction of skin layers as evidenced by absence of viable tissue
• Actual and potential: at times the absence of viable tissue will be obvious but other times the integrity of the tissue will be questionable
• Impaired skin integrity is both an actual and potential problem

• Related to: absence of viable tissue that is capable of being a barrier between the internal environment of the body and the external environment surrounding the body
• Plan and outcome: provide alternative barriers to act as a barrier between the internal and external environments of the body
• alternative barriers need to aid in wound healing and prevent infection
• assessments should identify progress of wound healing and identify early infection or tissue necrosis

• Nursing interventions: Assessment, wound care, and infection prevention

•  Assess and document wound characteristics, size, color, depth, changes, and note condition of surrounding tissue and necrotic tissue
• Remove necrotic tissue and unnecessary xenograft (underlying tissue must be healed and xenograft must be dried out) from wound bed
• Change wound dressings, apply antibiotic ointments, maintain skin grafts and synthetic dressings
• Administer antibiotic therapies as ordered

For further nursing diagnoses concerning burns please see the site below.
http://nurseslabs.com/11-burn-injury-nursing-care-plans/

Vera, Matt. 11 Burn Injury Nursing Care Plans. Nurseslabs.com, n.d. Web. 20 May 2015. <http://nurseslabs.com/11-burn-injury-nursing-care-plans/>. 

Nursing Care of Burns

There are three overlapping staging stages of nursing care of burns; resuscitation (emergent),  acute (wound healing), and rehabilitation (restorative).

Resuscitation/Emergent

 Priorities for treatment can be highlighted using the ABCD acronym. These steps are taken from the journal of Nursing Critical Care (2013).

 

https://www.youtube.com/watch?v=vVFQNlAchNU

Airway
Maintaining the patient's airway is the primary concern. Due to smoke inhalation and the complex inflammatory cascade that accompanies burns there is often a great danger that the patient's airway could close. For this reason, many patients with large TBSA and burns of the face and neck will be intubated in order to maintain their airway.

Breathing
This ties in very closely to maintaining an airway but breathing refers more to in-depth respiratory adequacy and assessment. This is where nurses will monitor oxygen saturation and respiratory sounds, to name just a few assessments.

Circulation
Nurses will assess aspects of the cardiovascular system, especially the rate and rhythm of pulses. Additionally, capillary refill, skin color, temperature, and bleeding will be assessed.

Disability
Disability indicates even further assessments to determine any disabilities that the patient may be suffering from. For example, neurological status, level of consciousness, and cerebral perfusion pressures will be assessed. 

Fluid Resuscitation
Fluid resuscitation also should be addressed as soon as possible. Obviously, issues of airway, breathing, and circulation take priority because they have more potential for mortality in the first few hours of a burn injury. However, fluid imbalance also has great potential to send large TBSA burn patients into hypovolemic shock within hours of injury. Please take a look at my post titled "Fluid Imbalance as a Symptom of Burns" for more information on fluid resuscitation practiced for large TBSA burns. 

Acute/Wound Healing

Nursing care of burns in the acute/wound healing stage will address debridement, skin grafting, and escharotomy. I think it goes without saying but a major part of caring for burns, in addition to caring for the associated complications (fluid imbalance and potential organ failure), is providing the wound bed with a clean and sterile environment. Wound dressing need to be changed regularly and depending on the type of wound different dressings will be used.

http://media.jrn.com/images/660*439/28941952-mjs_burnunit-_nws-_sears-_1.jpg

Rehabilitation 

It is misleading that rehabilitation is listed last in the stages of nursing care of burns. Rehabilitation of individuals following large and small burns begins day one and can continue for years. On the burn unit that I work on nurses work very closely with physical and occupational therapy to ensure that patients retain as much range of motion and functionality of their body as possible. With prolonged hospital stays, immobility, and large scale tissue damage and scaring it is not uncommon that burn victims will suffer from contractures. Contractures result from tissues losing their elasticity. This loss of elasticity can result in limited range of motion of joints. Early therapy targets these tissues and helps these tissues to retain elasticity as they heal.

Burn scar tissue taken from https://www.turkeltaub.com/wp-content/uploads/2011/08/Burn-scars-300x224.jpg

It should also be noted that rehabilitation is physical but it is also psychological and social. Hopefully, in later posts we will have more opportunity to discuss these important domains further. 

http://www.sunshine.org.tw/english/images/phy03.jpg

Procter, F. (2010). Rehabilitation of the burn patient. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 43(Suppl), S101–S113. doi:10.4103/0970-0358.70730

Culleiton, A., Simko, L., (2013). Caring for patients with burn injuries. Nursing Critical Care, 8(1), 14-22.

Surgical Treatment of Burns

Debridement

Surgical treatment of burns begins with debridment (cleaning and clearing) of the necrotic tissue from the wound bed. This debridement reduces the incidence of infection and also serves to decrease the inflammatory response (when compared to what the inflammatory response would be with the necrotic tissue remaining). The sooner this debridement takes place the better. Surgical debridment or removal of eschar commonly occurs in the operating room but some of this debridement will be a continuous process that continues throughout the patient's stay. Obviously removal of this necrotic tissue will leave large percentages of the body open. These open areas need to be closed in order to facilitate healing and prevent infection. Skin grafting is used to close these open wounds (Sanford & Herndon).

Types of Skin Grafting

Autograft: skin taken from one area of the burn victim's body that is grafted over the open burn wound

• Four-to-one mesh grafting is often practiced with patients that have large TBSA burns. Little incisions are made in the graft taken from the patient and the skin is stretched to cover approximately four times the area from which it was taken (hence the name four-to-one mesh). While this makes very effective use of the donored skin, its main drawback is that it does not heal as uniformly as normal one-to-one autograft. 

Healed 4:1 Mesh Autograft

Allograft: skin transplant from another person

• The tissue taken from another individual (typically from a cadaver) needs to be viable or alive. These allografts are often rejected by the burn patient's body within 10 days at which point autografting or skin substitutes are applied if needed.

Xenograft: skin taken from another species, typically from pig

• Xenograft is not expected to adhere and grow into the burn patient's natural skin. It's purpose is to provide a desirable environment for healing. Once the burn patient's immune system rejects the xenograft it will be mechanically removed. In my experience, xenograft is the grafting form that is used most commonly for burn patients with very large TBSA burns.

Synthetic skin: manufactured by man

• There are different types of synthetic skin. For example, Integra is synthetic skin that is manufactured using proteins from cows (collagen) and carbohydrates (Halim, Khoo, & Mohd. Yussof).

Escharotomy

When full thickness burns are circumferential escharotomy may need to be performed. When the entire (or near entire) circumference of a body part is damaged by full thickness burns the tissue becomes rigid and less pliable than healthy, viable skin. This added rigidity, in addition to increased interstitial edema, results in internal body pressures that are sustainable. If the pressure is not relieved blood flow can be limited. If full thickness burns encapsulate the areas of the neck, chest, and abdomen the patient may no be able to breath due to the lack of compliance that is normally found in the thorax and neck. Escharotomy is the process of making elongated incisions through the eschar (non-viable tissue) in order to provide the tissue with the flexibility needed to sustain blood flow, respirations, and cellular life (Pal par 1-3).

 

Works Cited

Halim, A. S., Khoo, T. L., & Mohd. Yussof, S. J. (2010). Biologic and synthetic skin substitutes: An overview. Indian Journal of Plastic Surgery : Official Publication of the Association of Plastic Surgeons of India, 43(Suppl), S23–S28. doi:10.4103/0970-0358.70712  

 

Pal, N. (2015, May 4). Emergency Escharotomy. In Medscape. Retrieved May 6, 2015, from http://emedicine.medscape.com/article/80583-overview

Sanford AP, Herndon DN. Current therapy of burns. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6954/

Images

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