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Nursing Care Plan

Client initials
Nursing Care Plan
Long term goals: The client will achieve optimal wound healing as manifested by wound closure and no evidence of infection.
Nursing Diagnosis: Impaired Skin Integrity related to burn injury


Outcome/Short Term Patient Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

The client will achieve optimal wound healing as manifested by wound closure and no evidence of infection.

 

 

 

 During the first 24-48 of injury continually assess the injury for evidence of adequate perfusion, edema and depth of injury. Check capillary refill, pulses (via palpation or Doppler ultrasound) every hour or as ordered.

 

 

 

Change burn dressing using the topicals and dressing materials ordered, at the prescribed frequency.

 

Frequently reassess the integrity of the dressing. Reinforce dressing as needed. Monitor for change in amount, type, odor and frequency of drainage and need for reinforcement.

 

 

With each dressing change maintain sterile technique.

 

With each dressing change observe the burn area for evidence of healing (i.e. sloughing of burn eschar, bleeding, “budding” evidence of new skin cell regeneration and wound closure).

 

 

With each dressing change closely observe the burn wound for evidence of infection (i.e. foul smelling drainage, green or purulent drainage, if the burn has been grafted-evidence that the graft is sloughing and pulling away from the wound bed).
Alert the practitioner to any changes in the burn wound. Obtain cultures as needed to confirm infection. Consult with practitioner about need to change burn topical or consider graft or re-grafting area.

 During this time frame the burn is declaring itself and the initial trauma to the skin is developing. The biggest risk to the tissue and overall circulation is compartment syndrome as discussed in this chapter. Sometimes it is difficult to distinguish initially if the burn is deep or superficial partial thickness. Carefully assessment and reassessment of the wound bed and surrounding tissue can help determine the level of injury. Closely assessing the burn during the first 24-48 hours also helps determine the type of wound therapy, topicals, dressings and if grafting or escharotomies are needed.
Some topicals perform better if they are change once a day or twice a day, etc. It is important to follow the prescribed order and the company's recommendation regarding the topical ordered.
Some topicals will cause drainage as part of their cleaning process. Educate yourself on topicals used for side effects and expected results. Reinforcing a dressing is important so that the drainage does not contaminate other areas of the patient’s room. A complete dressing change may not be necessary or in fact frequent disturbing of the wound bed may be harmful to the wound and healing process.

Infection is the biggest risk that compromises wound healing. Standard precautions are essential when providing all aspects of care, but good sterile technique during dressing changes assists in preventing burn wound infections.
As the burn heals the practitioner may need to change the burn topical or skin care regimen. Evidence of poor wound healing may indicate the burn is becoming infected or the patient’s nutritional status needs to be improved. Poor wound healing can also denote that the burn is deeper than originally assessed and may need grafting.

An infected burn wound can lead to sepsis if not treated promptly. Any indication that the graft is not adhering or has sloughed off should be reported to the prescribing practitioner and burn surgeon as soon as possible.

Wound cultures provide a tool to determine if infection is present and which organism(s) has populated in the wound bed. Culture results should be checked frequently to ensure the correct topical (or antibiotic) is being used.

 

Date: ________________
Client initials
Nursing Care Plan
Long-term goals:
Nursing Diagnosis: Risk for Imbalanced Nutrition less than body requirements due to increased metabolic needs following burn injury.


Outcome/Short Term Patient Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

The patient will achieve optimal nutritional status as evidenced by wound healing, weight stability and laboratory results (i.e. albumin, electrolytes, pre-albumin) within normal limits.

Request a consult with registered dietician when patient is admitted to assess nutritional status as soon as possible, develop nutritional goals and nutritional plan.

 

 

Encourage the patient to eat a balance diet, but emphasize that protein is essential to wound healing and recovery.

 

If the patient has burns on their face, hands, or mouth; try modifications to their food to make the food easier and more palatable to ingest. Consult with PT/OT as needed to implement strategies to help the patient eat and gain a sense of independence with eating.

 

Check patient’s weight per unit recommendations. Some units do weekly, twice weekly or daily weights for at risk or high-risk patients.

 

 

 

Check laboratory work per dietary or unit protocol.

 

 

 

 

Keep accurate I+O and/or calorie counts.

Consider the need for tube feeding or TPN if patient cannot take in the nutrients needed by mouth.

 

Studies have shown that optimal nutrition is essential to burn wounds healing and to the burn patient’s recovery. Burn patients often enter a hyper-metabolic state as a result of the burn injury. Maximizing the patient’s nutritional status and supplementing the patient’s diet if needed should begin as soon as possible. The consultation of a dietician is critical in developing this plan.
Studies have shown that adequate protein intake along with a balance diet is essential for wound healing and recovery. Studies have also shown that burn patients often have protein malnutrition as a result of the burn injury and the burn’s systemic effect on the body.
Often times the physical barriers and disabilities that burns cause; affect the patient’s ability to ingest food or make the feeding process difficulty. Finding palatable ways to modify the patient’s food or working with PT/OT to modify utensils may help increase the patient’s intake and give them a sense of independence.
Keeping a routine record of the patient’s weight is a good tool to see if dietary goals are being met and if the patient is losing weight (due to hyper-metabolism) if any supplementation to the diet is needed. The initial burn edema must be taken into account when first weighing a patient and reassessing weight loss or gain. If the patient’s pre-burn weight is know it can be compared to their admission weight to estimate the impact of fluid and edema from the burn.

To make sure a patient is maintaining optimal nutritional status many burn units and dieticians recommend regularly checking the patient’s comprehensive metabolic panel (often includes electrolytes, albumin, magnesium and phosphorus) and a nutritional lab called pre-albumin that specifically looks at protein malnutrition. A 24-hour urine collection, least weekly, determines urea nitrogen levels and calculates nitrogen balance. It is important to ascertain nitrogen balance to determine if the patient is taking in enough protein for their body to use.
The quickest and easiest visual to determine in the patient is able to intake enough nutrition to maintain wound healing and recovery.

If wound healing and recovery is slow accompanied by weight loss, poor I+O, calorie counts and laboratory work the dietician and prescribing practitioner may consider supplemental nutrition in addition to any oral intake the patient might consume.

 

Long term goals:
Nursing Diagnosis: Alteration in Comfort r/t Burn Injury and Treatment
Special Consideration: Acute Burn Injury and Acute Pain vs. Rehabilitation Stage and Chronic Pain.


Outcome/Short Term Patient Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

Patient’s pain and anxiety and overall comfort level will be well managed using a combination of narcotic and non-narcotic interventions and adjunct alternative therapies (i.e. music therapy, reiki, relaxation, etc.).

Assess patient’s pain and comfort level frequently. Assess pain prior to procedures, during and after procedures and at intervals of rest. Use self-report scales as much as possible, or as able to considering patient’s age, acuity and level of consciousness.
.

Pre-mediate the patient for dressing changes and any type of burn therapy.

 

 

 

 

 

Consider anxiety as a component of comfort.

 

 

Consider alternative methods to control pain and anxiety. Some options are: distraction, relaxation, reiki massage, music therapy, etc. When appropriate and feasible have the burn patient participate in their own burn care and therapy, to allow a sense of control. Sometimes family presence and involvement can help the patient cope better with pain.

Consider that pain as a result of burn injuries will transition from acute to chronic pain. Consider both narcotic and non-narcotic medications, as well as adjunct therapies to help the patient.

 

 

 

Consider itch as a component of comfort management. Apply emollients as needed. Consider diphenhydramine or loratadine if itch interferes with sleep or causes the patient to re-open wound due to scratching.

If the patient’s pain cannot be adequately managed consider request a consult to a pain specialist.

Some studies suggest that burn nurses often underestimate burn patient’s pain. The only accurate method to determine a patient’s pain level and the effectiveness of interventions is by continuously assessing the patient’s pain. Self-report scales help the patient express their perception and level of pain.
Keep in mind that oral medications may take 30-45 minutes to take effect. Many intravenous narcotics have immediate onset, but a shorter duration. Continuous infusions of narcotics and sedatives (i.e. morphine or midazolam drips) may be needed in large burn injuries or burn patients requiring intubation (often as the result of inhalation injuries). Consider non-narcotic medications (acetaminophen or ibuprofen) for minor or healing burns. As the burn patient grows more tolerant of the prescribed medication, it may take a higher dose to maintain the same effect. Assessing the effectiveness of the pharmacological intervention each time it is given is paramount.

Many burn patients will have anticipatory anxiety prior to dressing changes and burn therapies. This may heighten the intensity of pain and perception of pain for the patient. Consider anxiolytics (i.e. lorazepam, midazolam) as a complement to the pain management regimen.

Many studies have shown that using non-pharmacologic interventions in combination with pain medications are more effective than the drug alone. Many burn patient’s report that having involvement in their care gives them back some control and alleviates some anxiety. Family involvement can be a comforting to some, consult with the patient first.

In a larger burn, it may take months for a patient to heal and wounds to close. Even in smaller burns, rehabilitation from the burn injury can be considerable. The pain experience can continue for weeks and months, at this point the patient goes from experiencing acute pain to chronic pain. Some studies have shown that chronic pain from burns can last for years. Consider peripheral neuropathies as a result of the burn injury or heterotrophic ossification as discussed in the chapter.
As the burn heals patients often experience itchiness, especially at donor sites or from burns that injured sebaceous and oil glands that can make healed burn tissue dry.

A pain specialist has advanced knowledge and understanding with clients experiencing pain. They may suggest other therapies or pharmacological interventions to better manage the patient’s pain.

 

Long-term goals:
Nursing Diagnosis: Body Image Disturbance and Role Strain r/t Burn Injury and Appearance


Outcome/Short Term Patient Centered Goals

Planning/Interventions
Implementation

Rationale for interventions

Evaluation

The patient will adjust to their new appearance and possible limitations to develop a positive self-image.

Discuss the roles the patient assumes in their life. Discuss how their roles may change due their injuries. Encourage the patient and their loved ones to share their feelings about these changes.

 

Encourage the patient, when psychologically ready, to look at their burns, healed skin and scars. Offer continual psychological and emotional response as the patient confronts their skin’s appearance.

 

 

Offer emotional and psychological support to patient’s family and loved ones to help them cope with the patient’s new appearance. Provide them with tips to help the patient adjust to home life and the outside world.

 

 

Encourage the patient to go on a therapeutic outing or a trip outside the hospital (while still a patient).

 

Encourage the patient upon discharge; to return to work, school, social/community obligations as soon as physically ready.

 

 

Offer continued psychological and emotional support to the patient by referring them to community services and support groups in their area.

 

 

Burn patients of all ages assume different roles in their lives. A burn injury can temporarily or permanently alter the patient’s ability to continue in these roles. The patient and the family must confront these changes and be allowed to express their feelings regarding them.
A patient’s first look into the mirror as they recover from a burn injury can be a traumatic and emotional one. Many burn units treat this as a major planned event. It is important to have social services and psychological support available to the patient if needed. Also family involvement is important to help the patient accept their new appearance.

Not only is this a momentous event for the patient but their loved ones as well. They can also experience feelings of loss as they cope with the patient’s new appearance. Their acceptance of the patient is the first step to the patient developing a positive body image. Loved ones will also play a crucial role in supporting the patient after discharge and their acceptance of their image to the outside world.
Many burn units have planned therapeutic outings with the patient or encourage the patient to go out with family and/or friends before discharge. This helps the patient experience the outside’s world’s reaction to their injury, while still having the support of the burn unit.

Many burn patients, although physically capable of participating in these activities, will avoid them for fear of others reactions to them or their own poor self image. Some burn patients become socially isolated due to their self-consciousness. Continued outpatient psychological support services may be needed to help the burn patient return to their pre-burn life.
The Phoenix Society (www.phoenix-society.org) is a national support group for burn survivors. They offer support to burn patients of all ages. Their program includes support groups, school re-entry programs, burn camps and online chats and blogs.

 






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