Burn Injury Nursing Care Plans

A major burn hits every system at once. You are managing airway, fluid shifts, an open wound the size of the patient, a hypermetabolic engine, and a person who just watched their body change. This guide covers the assessment, diagnoses, goals, and interventions you actually use at the bedside.

What is Burn Injury?

A burn is tissue damage from heat, chemicals, electricity, sunlight, or radiation. Scalds from hot liquids and steam, building fires, and flammable liquids and gases cause most of them. A major burn is catastrophic: painful treatment, long rehab, and a real chance of death, disfigurement, or lasting physical and emotional disability.

Classification of Burns

Burns are classified by depth and extent.

A first-degree burn (partial thickness) destroys the epidermis and produces localized pain and redness. It heals completely in 5 to 10 days. A superficial second-degree burn destroys the epidermis and the upper third of the dermis, with pain and blister formation; it heals completely but takes longer. A deep second-degree burn destroys the epidermis and dermis, leaving only the epidermal appendages in the hair follicles. The skin looks waxy white and may need grafting or prolonged recovery. A third-degree burn (full-thickness) destroys the entire epidermis and dermis and usually involves fat and muscle; the skin looks white, charred, or leathery. It requires skin grafting and prolonged recovery.

Phases of Burn Injury

Burn care moves through three phases, each with its own priorities.

The emergent phase runs from the onset of injury until fluid resuscitation is complete, roughly the first 24 hours. The priorities are an adequate airway and treating burn shock.

The intermediate phase starts about 48 to 72 hours after the burn. Capillary permeability normalizes and osmotic pressure returns, driving diuresis. If renal and cardiac function lag behind, the fluid that prevented hypovolemic shock can now tip the patient into congestive heart failure. Central venous pressure tells you where their fluid status stands.

The rehabilitative phase begins when the burn is closed and ends when the patient reaches their optimal level of function. The work here is getting them back to a normal life and helping them adjust to what the injury changed.

Nursing Care Plans and Management

The planning goals cover pain management, infection prevention, wound care, nutritional support, psychological support, and mobility. The point is comprehensive care that addresses physical, emotional, and psychological needs to promote healing, prevent complications, and drive recovery.

Nursing Problem Priorities

1. Maintain a clear airway and adequate breathing.
2. Deliver fluid resuscitation to prevent dehydration and shock.
3. Manage pain.
4. Control infection at the wound and systemically.
5. Assess and manage burn wounds to promote healing.
6. Meet the increased metabolic demand with nutritional support.

Nursing Assessment

Assess for the following subjective and objective data:

• Redness or discoloration at the burn site
• Pain or tenderness at the burn site
• Swelling or blister formation
• Peeling or shedding skin
• Open wounds or raw skin
• Charred or blackened skin in severe burns
• Difficulty breathing or coughing if the airway is involved
• Nausea or vomiting
• Weakness or dizziness
• Increased heart rate
• Decreased urine output
• Signs of infection: increased redness, swelling, or pus
• Changes in mental status or confusion
• Smoke inhalation symptoms: hoarseness, cough, or difficulty swallowing

Assess for factors related to the cause of injury:

• Neuromuscular impairment, pain or discomfort, decreased strength and endurance
• Restrictive therapies, limb immobilization, contractures
• Disruption of the skin surface with destruction of skin layers (partial- or full-thickness burn) requiring grafting
• Traumatic event, dependent patient role, disfigurement, pain
• Tracheobronchial obstruction: mucosal edema and loss of ciliary action (smoke inhalation); circumferential full-thickness burns of the neck, thorax, and chest, with airway compression or limited chest excursion
• Direct upper-airway injury from flame, steam, hot air, and chemicals or gases
• Situational crises: hospitalization, isolation, the memory of the trauma, threat of death or disfigurement
• Hypermetabolic state, which can run 50% to 60% higher than normal in proportion to the severity of injury
• Protein catabolism
• Destruction of skin and tissues, edema formation
• Manipulation of injured tissues, such as wound debridement
• Inadequate primary defenses: a destroyed skin barrier and traumatized tissue
• Inadequate secondary defenses: decreased Hb, suppressed inflammatory response

Nursing Diagnosis

After the assessment, you form a nursing diagnosis that fits the patient in front of you. Diagnostic labels organize care, but their usefulness varies by situation, and on the floor they matter less than your clinical judgment. Let the patient's actual priorities shape the plan.

Nursing Goals

Goals and expected outcomes may include:

• The client maintains a position of function with no contractures.
• The client maintains or increases strength and function of the affected and compensatory body parts.
• The client demonstrates techniques and behaviors that let them resume activities.
• The client incorporates changes into self-concept without losing self-esteem.
• The client talks with family and SO about the situation and the changes that have occurred.
• The client develops realistic goals and plans for the future.
• The client shows clear breath sounds, a respiratory rate within normal range, and no dyspnea or cyanosis.
• The client verbalizes awareness of feelings and healthy ways to handle them.
• The client reports anxiety and fear reduced to a manageable level.
• The client demonstrates problem-solving skills and effective use of resources.
• The client demonstrates tissue regeneration.
• The client achieves timely healing of burned areas.
• The client meets metabolic needs with adequate nutritional intake, shown by stable weight and muscle mass, positive nitrogen balance, and tissue regeneration.
• The client reports relief or control of pain.
• The client shows relaxed facial expression and body posture.
• The client participates in activities and sleeps and rests appropriately.
• The client achieves timely wound healing, free of purulent exudate and afebrile.
• The client verbalizes understanding of the condition, prognosis, and potential complications.
• The client verbalizes understanding of therapeutic needs.
• The client performs necessary procedures correctly and explains the reasons for them.

Nursing Interventions and Actions

1. Improving Physical Mobility

Burns wreck mobility from several directions at once: neuromuscular impairment, pain, weakness, plus the restrictive therapies, immobilization, and contractures that come with treatment. Lost range of motion and muscle atrophy make daily activities hard, stall rehab, and raise the risk of long-term complications.

Note circulation, motion, and sensation of digits frequently. Edema compromises circulation to the extremities and can lead to necrosis and contractures. Frequent checks catch compromised circulation early and prevent loss of digits or limbs.

Maintain proper body alignment with supports or splints, especially over joints. Functional positioning prevents contractures, which cause permanent damage. Monitor and adjust as the patient changes.

Perform ROM exercises consistently, passive first, then active. Prevents tightening scar tissue and contractures, maintains muscle and joint function, and reduces calcium loss from bone.

Encourage patient participation in all activities as able. Builds independence, self-esteem, and recovery.

Involve family and SO in ROM exercises. Keeps them active in care and makes therapy more consistent.

Medicate for pain before activity or exercise. Loosens muscle and tissue stiffness so the patient can move and participate.

Schedule treatments and care to allow uninterrupted rest. Builds strength and tolerance for activity.

Combine ADLs with physical therapy, hydrotherapy, and nursing care. Stacking activities improves results by reinforcing each one.

Start the rehabilitative phase on admission. Patients participate more readily once they understand what recovery can look like.

2. Improving Body Image and Self-Esteem

Visible scarring, disfigurement, and functional loss hit self-image hard. Expect emotional distress, grief, and damaged confidence. Support and counseling help the patient face an altered body and adapt to a new physical reality.

Assess what the loss or change means to the patient and SO, including future expectations and cultural or religious beliefs. Sudden, unanticipated change creates grief over real or perceived loss. The patient needs support to work toward resolution.

Acknowledge and accept frustration, dependency, anger, grief, and hostility. Note withdrawal and denial. Treating these as normal responses helps resolution. You cannot push a patient before they are ready, and denial may be a prolonged but adaptive mechanism.

Set limits on maladaptive behavior. Stay nonjudgmental while giving care, and help the patient identify positive behaviors that aid recovery. Patients and SO handle this crisis the way they have handled past problems. Disruptive behavior is usually aimed at the situation, not the caregiver.

Be realistic and positive during treatments, teaching, and goal-setting. Builds trust and rapport.

Encourage the patient and SO to view wounds and help with care when appropriate. Promotes acceptance of the injury and the changed body.

Offer hope within the real parameters of the situation, but no false reassurance. Supports a positive attitude and realistic planning.

Help the patient identify the actual extent of change in appearance and body function. Starts the work of looking ahead to a different life.

Reinforce progress and encourage effort toward rehabilitation goals. Encouragement supports positive coping.

Show pictures or videos of burn care and other patient outcomes, selecting what fits the situation. Encourage the patient to discuss what they saw. Keeps expectations realistic and shows why certain devices and procedures matter.

Encourage family interaction with each other and with the rehab team. Opens communication and provides ongoing support.

Provide a support group for SO and tell them how they can help. Lets them vent feelings and respond to the patient more usefully.

Role-play social situations the patient is worried about. Prepares them for the reactions of others.

Provide thorough teaching and complete aftercare instructions. Stress keeping the dressing dry and clean. Supports self-care.

Refer to physical and occupational therapy, vocational counseling, psychiatric counseling, the clinical specialist psychiatric nurse, social services, and psychology as needed. Helps the patient regain independence and work through persistent emotional problems.

Refer the patient disfigured by burns to a reconstructive surgeon. Reconstructive surgery can rebuild self-esteem and confidence.

3. Improving Airway Clearance

Assess airway, breathing, and circulation. Watch for smoke inhalation and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Burning materials cause inhalation injury.

Get a history of the injury. Note preexisting respiratory conditions and smoking history. The burning agent, duration of exposure, and whether it happened in a closed or open space predict inhalation injury. The material burned (wood, plastic, wool) points to the type of toxic gas. Preexisting conditions raise the risk of complications.

Assess gag and swallow reflexes; note drooling, inability to swallow, hoarseness, and a wheezy cough. Suggests inhalation injury.

Monitor respiratory rate, rhythm, and depth; note pallor, cyanosis, and carbonaceous or pink-tinged sputum. Tachypnea, accessory muscle use, cyanosis, and sputum changes signal developing respiratory distress or pulmonary edema and the need for intervention.

Auscultate lungs for stridor, wheezing, crackles, diminished breath sounds, and a brassy cough. Airway obstruction or respiratory distress can come on fast or be delayed up to 48 hours after the burn.

Note pallor or a cherry-red color of unburned skin. Suggests hypoxemia or carbon monoxide.

Investigate restlessness, agitation, and altered LOC. Often related to pain, but changes in consciousness may reflect worsening hypoxia.

Monitor 24-hour fluid balance, noting variations. Fluid shifts or excess replacement raise the risk of pulmonary edema. Inhalation injury increases fluid demands by as much as 35% or more from obligatory edema.

Draw blood for CBC, type and crossmatch, electrolytes, glucose, BUN, creatinine, and ABGs. Baseline data that guides the next steps of treatment.

Monitor and graph serial ABGs or pulse oximetry. See Laboratory and Diagnostic Procedures.

Review serial chest x-rays. See Laboratory and Diagnostic Procedures.

Elevate the head of the bed. Avoid a pillow under the head when indicated. Promotes lung expansion. With head or neck burns, a pillow can inhibit respiration, cause necrosis of burned ear cartilage, and promote neck contractures.

Encourage coughing, deep breathing, and frequent position changes. Promotes lung expansion and drainage of secretions.

Suction with extreme care and sterile technique when needed. Keeps the airway clear, but do it cautiously because of mucosal edema and inflammation. Sterile technique reduces infection risk.

Promote voice rest, but periodically check the ability to speak and swallow secretions. Increasing hoarseness or a falling ability to swallow signals rising tracheal edema and possible need for intubation.

Administer humidified oxygen by the appropriate route (face mask). Oxygen corrects hypoxemia and acidosis. Humidity keeps the respiratory tract from drying and thins sputum.

Provide chest physiotherapy and incentive spirometry. Chest physiotherapy drains dependent lung areas; incentive spirometry improves lung expansion and reduces atelectasis.

Prepare for and assist with intubation or tracheostomy when indicated. Required when airway edema or circumferential burn interferes with respiration or oxygenation.

4. Minimizing Fear and Anxiety

Assess mental status: mood, affect, comprehension of events, and content of thoughts. Early on, patients use denial and repression to filter overwhelming information. A calm, alert manner can represent dissociation, another protective mechanism.

Investigate hypervigilance, hallucinations, sleep disturbance, nightmares, agitation, apathy, disorientation, and labile affect, which can shift moment to moment. Signs of extreme anxiety and a delirium state in a patient who is literally fighting for life. Rule out life-threatening physical causes even when the cause looks psychological.

Identify how the patient has coped with stress before. Past successful strategies help with the present.

Explain care procedures often and repeat as needed. Knowing what to expect reduces fear, clears up misconceptions, and promotes cooperation. After the shock of the trauma, many patients do not recall what they were told at the time.

Show willingness to listen and talk when the patient is free of painful procedures. Reassures the patient and SO that support is there and that you care about the person, not just the burn.

Involve the patient and SO in decisions when possible. Allow time for questions and repetition of proposed treatments. Builds a sense of control and reduces helplessness.

Provide constant, consistent orientation. Keeps the patient connected to their surroundings and reality.

Encourage the patient to talk about the burn when ready. Patients often need to retell what happened to make sense of a terrifying event. Trauma, grief, and disfigurement can lead to clinical depression, psychosis, and PTSD.

Explain what happened. Invite questions and answer honestly. Honest statements about the reality help the patient and SO begin to deal with it.

Create a restful environment and use guided imagery and relaxation exercises. These soothe the severe anxiety that comes with burn trauma and treatment.

Help the family express grief and guilt. Family may fear the patient's death or feel guilty, believing they could have prevented it.

Stay empathic and nonjudgmental with patients and families. Disrupted relationships and financial, lifestyle, or role changes make this hard, and people react in many ways.

Encourage family and SO to visit and share family news. Remind the patient of past and future events. Maintains contact with familiar reality and a sense of continuity.

Involve the whole burn team from admission to discharge, including social work and psychiatric resources. Widens the support system and keeps care coordinated.

5. Providing Wound Care and Improving Skin Integrity

Lost skin means infection risk, impaired healing, and delayed recovery, plus fluid and electrolyte imbalance. Damaged tissue cuts blood flow to the area, which feeds more impaired healing and necrosis.

Assess and document the size, color, and depth of the wound, the necrotic tissue, and the surrounding skin. Baseline data on the need for grafting and the circulation available to support a graft.

Evaluate the color of grafted and donor sites; note healing or its absence. Shows whether circulation is adequate and flags developing complications.

Provide appropriate burn care and infection control. Prepares tissue for grafting and reduces the risk of infection and graft failure.

Maintain wound covering as indicated. See Pharmacologic Management.

Elevate the grafted area when possible. Maintain the desired position and immobility when indicated. Movement under a graft can dislodge it and interfere with healing.

Maintain dressings over a new graft or donor site as indicated: mesh, petroleum, nonadhesive. A translucent, nonreactive material between the graft and outer dressing eliminates shearing of new epithelium and protects healing tissue. The donor site is usually covered for 4 to 24 hours, then the bulky dressing comes off and fine mesh gauze is left in place.

Keep skin free from pressure. Promotes circulation and prevents ischemia, necrosis, and graft failure.

Once dressings are off and healing is established, wash sites with mild soap, rinse, and lubricate with cream several times a day. New graft and healed donor skin need this to stay flexible.

Aspirate blebs under sheet grafts with a sterile needle or roll them with a sterile swab. Fluid-filled blebs keep the graft from adhering and raise the risk of failure.

Prepare for and assist with surgical grafting or biological dressings:

• Homograft (allograft). Skin from living donors or cadavers, used as temporary cover for extensive burns until the patient's own skin is ready (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.
• Heterograft (xenograft, porcine). Animal skin used for the same purposes as a homograft, or to cover meshed autografts.
• Cultured epithelial autograft (CEA). Skin grown in a lab from an uninjured part of the patient's own skin; full- or partial-thickness. The process takes 20 to 30 days from harvest to application. The new sheets are 1 to 6 cell layers thick and very fragile.
• Artificial skin (Integra). FDA-approved for full-thickness and deep partial-thickness burns. Provides a permanent, immediate covering that reproduces normal skin function and stimulates regeneration of dermal tissue.

6. Maintaining Adequate Nutrition

Burns drive metabolic demand through the roof while the physical and emotional stress saps intake. The body needs more calories and protein to heal, so malnutrition sets in fast if you do not stay ahead of it. Decreased appetite, nausea, and difficulty swallowing make it harder.

Auscultate bowel sounds. Note hypoactive or absent sounds. Ileus is common after a burn but usually resolves within 36 to 48 hours, at which point you can start oral feedings.

Learn food likes and dislikes. Encourage SO to bring food from home when appropriate. Gives the patient a sense of control and can improve intake.

Monitor muscle mass and subcutaneous fat. Indirect calorimetry, when available, estimates body reserves or losses and the effectiveness of therapy.

Keep a strict calorie count. Weigh daily. Reassess open body surface area and wounds weekly. Caloric targets run 25 kcal/kg body weight plus 40 kcal per percentage of TBSA burn in the adult. As the wound heals, the burned percentage is reevaluated to recalculate dietary formulas.

Monitor serum albumin, prealbumin, Cr, transferrin, and urine urea nitrogen. See Laboratory and Diagnostic Procedures.

Perform fingerstick glucose and urine testing as indicated. See Laboratory and Diagnostic Procedures.

Provide small, frequent meals and snacks. Prevents gastric distension and may improve intake.

Frame diet as treatment and steer choices toward high-calorie, high-protein food. Calories and protein maintain weight, meet metabolic needs, and promote wound healing.

Have the patient sit up for meals and visit with others. Sitting prevents aspiration and aids digestion; socializing relaxes the patient and may improve intake.

Provide oral hygiene before meals. A clean mouth improves taste and appetite.

Insert a nasogastric tube as indicated. Decompresses the stomach and prevents aspiration.

Provide a high-calorie, high-protein diet with trace elements and vitamin supplements. Run 3000 to 5000 calories per day, with protein and vitamins, to meet metabolic needs, hold weight, and drive tissue regeneration. The oral route is preferred once GI function returns.

Insert and maintain a small feeding tube for enteral feedings and supplements if needed. Provides continuous feeding when the patient cannot take in their full daily calories orally. Continuous overnight tube feeding raises calorie intake without killing daytime appetite and oral intake.

Administer parenteral nutrition with vitamins and minerals as indicated. TPN meets metabolic needs when severe complications or esophageal or gastric injury rule out enteral feeding.

Administer insulin as indicated. Serum glucose may rise from the stress response, high caloric intake, and pancreatic fatigue.

Refer to a dietitian or nutrition support team. Sets individual nutritional needs based on weight and burn surface area and identifies the right routes.

Assess color, sensation, movement, peripheral pulses, and capillary refill on extremities with circumferential burns. Compare to the unaffected limb. Edema compresses vessels, impeding circulation and increasing venous stasis. Comparison helps separate a local problem from a systemic one such as hypovolemia or low cardiac output.

Take BP in unburned extremities when possible. Remove the cuff after each reading as indicated. Leaving a cuff on an injured limb can increase edema, reduce perfusion, and deepen a partial-thickness burn.

Check for irregular pulses. Dysrhythmias can come from electrolyte shifts, electrical injury, or release of myocardial depressant factor, cutting cardiac output.

Investigate reports of deep or throbbing ache and numbness. Signs of decreased perfusion or rising pressure in an enclosed space, as with a circumferential extremity burn (compartment syndrome).

Monitor electrolytes, especially sodium, potassium, and calcium. Replace as indicated. Losses or shifts alter cellular membrane potential and excitability, changing myocardial conductivity, raising the risk of dysrhythmias, and reducing cardiac output and tissue perfusion.

Measure intracompartmental pressures as indicated. Ischemic myositis can develop from decreased perfusion.

Elevate affected extremities. Remove jewelry and arm bands. Avoid taping around a burned area. Promotes circulation and venous return and reduces the harm of constricting edematous tissue. Prolonged elevation can impair arterial perfusion if BP falls or tissue pressure rises too far.

Encourage active ROM of unaffected body parts. Promotes local and systemic circulation.

Maintain fluid replacement per protocol. Maximizes circulating volume and tissue perfusion.

Avoid IM and SC injections. Altered perfusion and edema impair drug absorption. Injections into potential donor sites can ruin them through hematoma formation.

Assist and prepare for escharotomy or fasciotomy as indicated. Relieves the constriction of rigid eschar or edema and restores circulation.

7. Minimizing Pain and Providing Comfort

Burns expose nerve endings, and edema plus the manipulation of injured tissue during wound care drive the pain higher. Control it, or you invite anxiety, depression, and delayed healing.

Assess pain by location, character, and intensity (0-10 scale). Pain is almost always present and worst during dressing changes and debridement. Changes in location, character, or intensity may signal a complication such as limb ischemia, or herald the return of nerve function and sensation.

Cover wounds as soon as possible unless open-air exposure care is required. Temperature changes and moving air cause severe pain to exposed nerve endings.

Elevate burned extremities periodically. Reduces early edema; later, position changes and elevation reduce discomfort and the risk of joint contractures.

Provide a bed cradle as indicated. Keeping linens off the wounds reduces pain.

Wrap digits or extremities in the position of function, avoiding flexion of affected joints, using splints and footboards. Reduces deformity and contractures and promotes comfort. A flexed joint may feel better but leads to flexion contractures.

Change position frequently and assist with active and passive ROM. Movement reduces joint stiffness and muscle fatigue; the type of exercise depends on the location and extent of injury.

Maintain a comfortable room temperature; provide heat lamps and heat-retaining body coverings. Major burns can wipe out temperature regulation, so external heat may be needed to prevent chilling.

Medicate or place in hydrotherapy before dressing changes and debridement. Cuts the severe physical and emotional distress of these procedures.

Encourage the patient to express feelings about pain. Gives an outlet and may improve coping.

Involve the patient in scheduling activities, treatments, and medication. Builds a sense of control and strengthens coping.

Explain procedures and give frequent information, especially during debridement. Empathic support eases pain and promotes relaxation. Knowing what is coming lets the patient prepare and feel in control.

Provide basic comfort: massage of uninjured areas and frequent position changes. Promotes relaxation and reduces muscle tension and fatigue.

Encourage stress management: progressive relaxation, deep breathing, guided imagery, visualization. Refocuses attention and builds control, which can reduce reliance on medication.

Provide diversional activities appropriate to age and condition. Pulls focus off the pain.

Promote uninterrupted sleep. Sleep deprivation raises pain perception and weakens coping.

Administer analgesics (narcotic and non-narcotic) as indicated: morphine; fentanyl (Sublimaze, Ultiva); hydrocodone (Vicodin, Hycodan); oxycodone (OxyContin, Percocet). Burn patients often need around-the-clock dosing with titration. IV is used first to maximize effect. Concerns about addiction or doubts about the level of pain are not valid during the emergent and acute phases, but narcotics should be reduced as soon as feasible and replaced with alternative methods.

8. Preventing Infection

A burn strips the skin barrier that keeps pathogens out. Traumatized tissue, falling hemoglobin, and a suppressed inflammatory response make infection easier, and environmental exposure and invasive procedures add to the risk.

Examine wounds daily and document changes in appearance, odor, or drainage. Signs of sepsis, which often comes with full-thickness burns, demand prompt evaluation. Changes in sensorium, bowel habits, and respiratory rate usually precede fever and lab changes.

Examine unburned areas (groin, neck creases, mucous membranes) and vaginal discharge routinely. Eyes may swell shut or get infected by drainage from surrounding burns. If the lids are burned, eye covers may be needed to protect the cornea.

Monitor vital signs for fever and increased respiratory rate and depth, along with changes in sensorium, diarrhea, decreased platelet count, and hyperglycemia with glycosuria. These shifts flag systemic infection before the labs catch up.

Photograph the wound on admission and at intervals. Documents the baseline and the course of healing.

Obtain routine wound and drainage cultures and sensitivities. Allows early recognition and targeted treatment of wound infection.

Implement appropriate isolation as indicated. Depending on the wounds and the treatment choice (open versus closed), isolation can range from simple wound or skin precautions to complete or reverse isolation to cut cross-contamination and exposure to multiple bacterial flora.

Model good handwashing for everyone who contacts the patient. Prevents cross-contamination and reduces acquired infection.

Use gowns, gloves, masks, and strict aseptic technique during wound care, and provide sterile or freshly laundered linens and gowns. Keeps infectious organisms away.

Monitor or limit visitors as needed. Explain isolation to them and supervise adherence. Prevents cross-contamination while balancing the patient's need for family support.

Shave or clip hair around burned areas, including a 1-inch border (not eyebrows). Shave facial hair on men and shampoo the head daily. Reduces the opportunistic infections that follow immune depression and overgrowth of normal flora during systemic antibiotic therapy.

Provide special eye care: eye covers and tear formulas as appropriate. Protects healing and prevents adherence. Ear cartilage has limited circulation and is prone to pressure necrosis.

Prevent skin-to-skin contact: wrap each burned finger or toe separately, and keep a burned ear off the scalp. A strong, sweet, musty smell at a graft site points to Pseudomonas. Infection in a partial-thickness burn can convert it to full-thickness.

Remove dressings and clean burned areas in a hydrotherapy or whirlpool tub or a shower with a handheld head. Keep water at 100°F (37.8°C). Wash with a mild cleansing or surgical soap. Water softens and lifts dressings and eschar. Showering enhances wound inspection and avoids the cross-contamination that a tub can cause.

Debride necrotic or loose tissue, including ruptured blisters, with scissors and forceps. Leave intact blisters alone if they are smaller than 1 to 2 cm, do not interfere with joint function, and are not infected. Promotes healing and prevents autocontamination. Small intact blisters protect the skin and speed re-epithelialization, unless the burn is chemical, in which case fluid in the blister keeps destroying tissue.

Administer topical agents as indicated. See Pharmacologic Management.

Administer subeschar clysis or systemic antibiotics, and tetanus toxoid or clostridial antitoxin as appropriate. Tissue destruction and altered defenses raise the risk of tetanus and gas gangrene, especially in deep burns such as electrical injuries. See Pharmacologic Management.

Place IV and invasive lines in non-burned areas. Lowers the risk of insertion-site infection progressing to septicemia.

9. Initiating Patient Education and Health Teachings

Burn patients carry a lot of questions: most have never dealt with an injury like this, the experience is overwhelming, and the terminology is dense. That gap gets in the way of informed decisions, adherence, and preventing complications.

Review the condition, prognosis, and what to expect. Gives the patient a base for informed choices.

Discuss expectations of returning home, to work, and to normal activities. Adjustment after discharge is hard and prolonged. Sleep disturbance, nightmares, reliving the accident, trouble resuming social and sexual life, and emotional lability all interfere with getting back to normal.

Review medications: purpose, dosage, route, and reportable side effects. Repetition lets the patient ask questions and confirms accurate understanding.

Identify signs that require medical evaluation: inflammation, increased or changed wound drainage, fever or chills, changes in pain, loss of mobility or function. Early detection of infection or delayed healing heads off more serious problems.

Teach skin care, including proper use of moisturizers, sunscreens, and anti-itch medications. Itching, blistering, and sensitivity of healing wounds and graft sites last a long time, and the fragile new tissue injures easily.

Have the patient and SO demonstrate burn, skin graft, and wound care. Identify sources for outpatient care and supplies. Builds competent self-care and independence after discharge.

Explain the scarring process and the proper use of pressure garments. Pressure garments support skin regrowth and reduce hypertrophic scarring and contractures. Consistent long-term use can reduce the need for reconstructive surgery.

Encourage continued exercise and scheduled rest periods. Maintains mobility, reduces complications, and prevents fatigue.

Identify specific activity limitations. Restrictions depend on the severity, location, and stage of healing.

Stress sustained intake of high-protein, high-calorie meals and snacks. Optimal nutrition drives tissue regeneration and well-being; the patient often needs to increase intake to meet healing demands.

Warn the patient and SO about exhaustion, boredom, emotional lability, and adjustment problems, and tell them counseling is available. Sets expectations and points to help when it is needed.

Stress the importance of followup care and rehabilitation. Long-term support, reevaluation, and changes in therapy are required for optimal recovery.

Provide the phone number of a contact person. Gives easy access to the team to reinforce teaching and head off complications.

Make sure immunizations are current, especially tetanus. Prevents further injury.

Identify community resources: skin and wound care professionals, crisis centers, recovery groups, mental health services, the Red Cross, visiting nurses, and homemaker services. Eases the transition home and supports independence.

10. Managing Fluid Volume

The inflammatory response raises capillary permeability and leaks fluid into surrounding tissue, driving fluid volume deficit.

Monitor vital signs and central venous pressure (CVP). Note capillary refill and the strength of peripheral pulses. Guides fluid replacement and gauges cardiovascular response. Invasive monitoring is indicated for major burns, smoke inhalation, or preexisting cardiac disease, with careful attention to the insertion site because of infection risk.

Monitor urine output and specific gravity. Observe color and Hematest as indicated. Titrate fluid replacement to an average urine output of 30-50 mL/hr in the adult. Urine can run red to black with massive muscle destruction from blood and myoglobin. With gross myoglobinuria, keep minimum output at 75-100 mL/hr to reduce the risk of tubular damage and renal failure.

Estimate wound drainage and insensible losses. Increased capillary permeability, protein shifts, inflammation, and evaporation hit circulating volume and urine output hard, especially in the first 24-72 hours.

Weigh daily. Replacement formulas depend partly on admission weight and subsequent changes. Expect a 15% to 20% weight gain in the first 72 hours during replacement, returning to pre-burn weight about 10 days after the burn.

Evaluate changes in mentation. A declining level of consciousness may signal inadequate circulating volume and reduced cerebral perfusion.

Measure the circumference of burned extremities as indicated. Helps estimate edema and fluid shifts affecting circulating volume and urine output.

Watch for gastric distension, hematemesis, and tarry stools. Hematest NG drainage and stools periodically. Curling's ulcer occurs in up to half of all severely burned patients, as early as the first week. Burns over 20% TBSA put the patient at risk for GI mucosal bleeding during the acute phase from decreased splanchnic blood flow and reflex paralytic ileus.

Monitor Hb/Hct, electrolytes, and random urine sodium. See Laboratory and Diagnostic Procedures.

Keep a cumulative record of the amount and types of fluid intake. Rapid replacement with different fluids and changing rates requires close tracking to prevent imbalance or overload.

Insert and maintain an indwelling urinary catheter. Allows close observation of renal function and prevents retention. Retained urine carrying tissue-cell breakdown products can lead to renal dysfunction and infection.

Insert and maintain large-bore IV catheters. Allows rapid infusion.

Administer calculated IV fluids, electrolytes, plasma, and albumin. Resuscitation replaces losses and helps prevent shock and acute tubular necrosis. Formulas vary by extent of injury, urine output, and weight. After initial resuscitation, a steady rate beats boluses, which can worsen interstitial fluid shifts and cardiopulmonary congestion.

Administer diuretics, potassium, antacids, and histamine inhibitors as indicated. See Pharmacologic Management.

Add electrolytes to water used for wound debridement as indicated. A solution close to tissue fluid minimizes osmotic fluid shifts.

11. Administering Medications and Pharmacologic Support

Burn pharmacology covers analgesics (opioids and NSAIDs), antibiotics, topical antimicrobials to promote healing and prevent infection, and tetanus toxoid or clostridial antitoxin for significant injuries.

Wound Covering

• Biosynthetic dressing (Biobrane). Nylon fabric or silicon membrane with collagenous porcine peptides that adhere to the wound until removed or sloughed off by re-epithelialization. Useful for eschar-free partial-thickness burns awaiting autografts; it can stay in place for 2 to 3 weeks or longer and is permeable to topical antimicrobials.
• Synthetic dressing (DuoDerm). Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and interacts with exudate to form a soft gel that aids debridement.
• Opsite, Acuderm. Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) for clean partial-thickness wounds and donor sites. Reduces swelling and limits graft separation.

Insulin. Given because the stress response and metabolic changes after a burn cause insulin resistance and hyperglycemia. Insulin controls blood glucose, promotes wound healing, and lowers the risk of infection and delayed healing.

Topical Agents

• Silver sulfadiazine (Silvadene). Broad-spectrum, relatively painless, with intermediate and somewhat delayed eschar penetration. May cause rash or depression of WBCs.
• Mafenide acetate (Sulfamylon). Drug of choice for confirmed invasive burn-wound infection. Works against Gram-negative and Gram-positive organisms. Causes burning or pain on application and for 30 minutes after. Can cause rash, metabolic acidosis, and decreased Paco2.
• Silver nitrate. Effective against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa, but penetrates eschar poorly, is painful, and may cause electrolyte imbalance. Dressings must stay saturated. Stains skin and surfaces black.
• Bacitracin. Effective against Gram-positive organisms; used for superficial and facial burns.
• Povidone-iodine (Betadine). Broad-spectrum but painful on application; may cause metabolic acidosis, increased iodine absorption, and damage to fragile tissue.
• Hydrogels (Transorb, Burnfree). For partial- and full-thickness burns; fill dead space, rehydrate dry wound beds, and promote autolytic debridement. May be used when infection is present. Systemic antibiotics control general infections identified by culture and sensitivity. Subeschar clysis works against pathogens in granulated tissue at the line of demarcation, reducing sepsis risk.

Tetanus toxoid and clostridial antitoxin. Prevent or treat tetanus when the wound is contaminated. Tetanus toxoid provides long-term active immunity; clostridial antitoxin provides immediate passive immunity by neutralizing the toxin in known or suspected exposure.

Diuretics: mannitol (Osmitrol). May enhance urine output, clear tubules of debris, and prevent necrosis if acute renal failure is present.

Potassium. Hyperkalemia often occurs in the first 24-48 hours from tissue destruction, but later replacement may be needed because of large urinary losses.

Antacids: calcium carbonate (Titralac), magaldrate (Riopan). Reduce gastric acidity.

Histamine inhibitors: cimetidine (Tagamet), ranitidine (Zantac). Decrease hydrochloric acid production to reduce the risk of gastric irritation and bleeding.

12. Monitoring Diagnostic and Laboratory Results

Burn workup includes blood tests for hemoglobin, electrolytes, and organ function (liver and kidney), wound cultures for infection, and imaging such as x-rays to assess deep tissue involvement.

ABGs. A baseline is essential for ongoing respiratory assessment and treatment. Pao2 less than 50, Paco2 greater than 50, and a falling pH reflect smoke inhalation and developing pneumonia or ARDS.

Chest X-rays. Atelectasis or pulmonary edema may not show for 2 to 3 days after the burn.

Serum albumin, prealbumin, Cr, transferrin, urine urea nitrogen. Indicators of nutritional need and the adequacy of diet and therapy.

Hb/Hct, electrolytes, random urine sodium. Identifies blood loss or RBC destruction and fluid and electrolyte needs. Urine sodium less than 10 mEq/L suggests inadequate fluid resuscitation. In the first 24 hours, hemoconcentration is common as fluid shifts into the interstitial space.

Fingerstick glucose, urine testing. Monitors for hyperglycemia from hormonal changes, demand, or hyperalimentation.

Wound culture and sensitivity. Allows early recognition and targeted treatment of wound infection.