nursing management of burns

Nursing management of Burns

Nursing assessment

1. Assess ABCDE (airway, breathing, circulation, disability, exposure; prevent hypothermia) and need for fluid resuscitation.

2. Assess severity of burn and conscious level.

3. Establish tha cause 

4. Assess associated factor; injury, fracture and internal injury.

5. Asses the possible inhalation injury.

6. Assess any pre-existing illness, any drug therapy, allergy and drug sensitivities.

7. Establish patient tetanus immunization.

8. Body surface area; rule of nine

9. Palmer surface of patient's hand including finger.

10. Depth of burn (first degree burn, second degree burn, third degree burn)

11. Assess pain, redness of area, absence or presence of blister, swelling, capillary refill time, reduced or absence sensation according to degree of burn.

12. Circumferential extremity burn

Assess circulation, checking for cyanosis, impaired capillary refilling.

13. Assessment of peripheral pulses.

14. Assess Neurological signs

Nursing Diagnose

1. Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation and upper airway obstruction.

2. Ineffective airway clearance related to edema and effect of smoke inhalation.

3. Fluid volume deficit related to increased capillary permeability and evaporation losses from burn wound.

4. Hypothermia related to loss of skin and open wounds.

5. Pain related to tissue injury

6. Risk of infection related to loss of skin barrier and altered immune response.

7. Impaired nutrition; less than body requirement related to hypermetabolic response to burn injury.

8. Impaired skin integrity related to open burn wounds and surgical interventions.

9. Impaired physical mobility related to edema, pain, skin and joint contractures.

10. Anxiety related to fear and emotional impact of burn injury.

Role of nurse in burn Management

1. Restoring normal fluid balance

IV therapy, oral intake, infusion pump

Monitor changes in fluid status 

2. Preventing infection

Burn wound care

Aseptic technique used for wound care procedures.

Protect patient from source of infection or contamination.

3. Maintaining adequate nutrition

Dietician plan; protein and colorie rich diet

Home made food

NG feeding tube inserted; continuous or bolus feeding of specific formula.

Patient weight

4. Promoting skin integrity

Wound care and dressing changes

Wound Management

Teach the patient and family by instruction, encourage to active part in dressing changes and wound care.

5. Relieving pain and discomfort

Assessment of pain (scale and intensity)

Analgesics and antianxiety medication

Dressing changes to reduce pain and discomfort

Teach patient and family; wound care relaxation technique

6. Promoting physical mobility

a. Prevent complication resulting from immobility.

b. Deep breathing, turning, changing position

Prevent; atelectasis, pneumonia

Control edema

Prevent pressure ulcer and contractures 

c. Initiate both active and passive ROM within prescribed limitation.

7. Strengthening coping strategies

Effective coping strategy

Self care, self feeding, assistance with wound care procedures, excercise, relaxation techniques.

Assess tha ability of patient, cope with information.

8. Educate the patient and family