CHAPTER II

DISCUSSION
A. MEDICAL CONCEPT
1. Definition
Burn are damage to the skin and body caused by flames, heat, cold,
friction, radiation (sunburn), chemicals or electrycity. Burns are generally
divided into three categories, depending on the damage. First-degree burns are
those with injury to the outer layer of skin called the epidermis. They will be
red and painful, with some swelling, a second-degree burn is when the
epidermis is burned, as well as the next layer, the dermis. Severe pain, white
and reddened areas, swelling, blisters, and perhaps drainage will be see. A
third-degree burn goes through all the layers of the skin and could involve
underlying tissue. It is often painless due to destruction of the nerves in the
area. The area will look black ( terned eschar) and/or reddened. ( Mary
DiGiulio, 2007)
Burn are caused by a transfer of energy from a heat source to the body.
The depth of the injury depends on the temperature of the burning agent and
the duration of contact with it. Burs are categorized as thermal ( including
electrical burns), radiation, or chemicals burns. They disrupt the skin, which
lead to increased fluid loss, infection, hypothermia, carring, compromised
immunity, and changes in function, appearance, and body image. ( Cecily Lynn
B, 2008 )
2. Classification
There are several ways of classifying burns. The following are three
commonly used typologies, based respectively on the cause, extent and severity
of the burn.
1. Classification by mechanism or cause
a. Thermal burns involve the skin and may present as:
- Scalds : caused by hot liquid or steam;
- Contact burns : caused by hot solids or items such as hot pressing irons and
cooking utensils, as well as lighted cigarettes;
- Flame burns : caused by flames or incandescent fires, such as those started by
lighted cigarettes, candles, lamps or stoves;

- Chemical burns : caused by exposure to reactive chemical substances such as

strong acids or alkalis;
- Electrical burns : caused by an electrical current passing from an electrical
outlet, cord or appliance through the body.
b. Inhalation burns, are the result of breathing in superheated gases,
steam, hot liquids or noxious products of incomplete combustion. They
cause thermal or chemical injury to the airways and lungs and
accompany a skin burn in approximately 20% to 35% of cases.
Inhalational burns are the most common cause of death among people
suff ering fi re-related burn
2. Classification by the degree and depth of a burn
1. First-degree or superficial burns are defined as burns to the epidermis
that result in a simple inflammatory response. They are typically caused
by exposure of the unprotected skin to solar radiation (sunburn) or to
brief contact with hot substances, liquids or flash flames (scalds). Firstdegree burns heal within a week with no permanent changes in skin
colour, texture, or thickness
2. Second-degree or partial-thickness burns result when damage to the skin
extends beneath the epidermis into the dermis. The damage does not,
however, lead to the destruction of all elements of the skin.
- Superficial second-degree burns are those that take less than three
-

weeks to heal.
Deep second-degree burns take more than three weeks to close and

are likely to form hypertrophic scars

3. Third-degree or full-thickness burns are those where there is damage to
all epidermal elements including epidermis, dermis, subcutaneous
tissue layer and deep hair follicles. As a result of the extensive
destruction of the skin layers, third-degree burn wounds cannot
regenerate themselves without grafting.
In adults, a full-thickness burn will occur within 60 seconds if the skin is
exposed to hot water at a temperature of 53 C. If, though, the temperature
is increased to 61 C, then only 5 seconds are needed for such a burn. In
children, burns occur in around a quarter to a half of the time needed for an
adult to burn.

3. Classification by extend of burn

The extent of burn, clinically referred to as the total body surface
area burned, is defined as the proportion of the body burned. Several.
Methods are used to determine this measurement, the most common being
the so-called rule of nines. This method assigns 9% to the head and neck
region, 9% to each arm (including the hand), 18% to each leg (including the
foot) and 18% to each side of the trunk (back, chest and abdomen). The
rule of nines is used for adults and children older than 10 years, while the
Lund and Browder Chart is used for children younger than 10 years. The
calculation assumes that the size of a childs palm is roughly 1% of the total
body surface area .
3. Burned Surface Area
The Rule of 9s is commonly used to estimate the burned surface area
in adults. The body is divided into anatomical regions that represent 9% (or
multiples of 9%) of the total body surface. The outstretched palm and fingers
approximates to 1% of the body surface area. If the burned area is small, assess
how many times your hand covers the area. Morbidity and mortality rises with
increasing burned surface area. It also rises with increasing age so that even
small burns may be fatal in elderly people.
The Rule of 9s method is too imprecise for estimating the burned
surface area in children because the infant or young childs head and lower
extremities represent different proportions of surface area than in an adult.
Burns greater than 15% in an adult, greater than 10% in a child, or any burn
occurring in the very young or elderly are serious.

4. Etiology
Burns are the tissue damage that results from contact with thermal,
chemical, electrical, or radiation agens. Thermal burns are the most common
type of injury. A thermal burn occurs when the skin is damaged by heat. Tissue
under the skin may also damaged. Chemical burns occur upon contact with
acid, alkali, or organic compounds. Electrical burns occur upon contact with
high- or low-voltage electricity. In children, this contact is most often with
electrical cords. Radiation burns are least common and are infrequent in
children. Burn severity is detemined by (1) the depth of burn injury, (2)
percentage of body surface are affected , (3) involvement of specific body
parts.
5. Pathophysiology
Burns are caused by a transfer of energy from a heat source to the body.
Heat may be transfered through conduction or elecromagnetic radiation. Burns
can be categorized as thermal, radioation, electrical, or chemical. Tissue
destruction results from coagulation, protein, denaturation, or ionixation of
cellular contents. The skin and the mucosa of the upper airways are the sites of

tissue destruction. Deep tissue, including he viscera, can be damaged by

electrical burns or through prolonged contact with the burning agent.
The depth of the injury depends on the tenperature of the burning agent
and the duration of contact with the agent. For example, in the case of scald
burns, hot tap water at the a temperature of 68. 9 C ( 156 F) may in the
course of second result in a burs that destroys both epidermis and dermis
( full-thikness injury ). Fifteen second of exposure to hot water at 56.1 C
( 133 F ) results in a similar full-thikness injury.

6. Clinical Manifestations
First-degree burn. This minor burn affects only the outer layer of the
skin (epidermis). It may cause redness, swelling and pain. It usually heals with
first-aid measures within several days to a week. Sunburn is a classic example.
Second-degree burn. This type of burn affects both the epidermis and the
second layer of skin (dermis). It may cause red, white or splotchy skin, pain,
and swelling. And the wound often looks wet or moist. Blisters may develop,
and pain can be severe. Deep second-degree burns can cause scarring.
Third-degree burn. This burn reaches into the fat layer beneath the skin.
Burned areas may be charred black or white. The skin may look waxy or
leathery. Third-degree burns can destroy nerves, causing numbness. A person
with this type of burn may also have difficulty breathing or experience smoke
inhalation or carbon monoxide poisoning.
Symptoms of an airways burn: charred mouth; burned lips, burns on the
head, face, or neck, wheezing, change in voice, difficulty breathing; coughing,
singed nose hairs or eyebrows, dark, carbon-stained mucus.
7. Laboratory And Diagnostic Test
1. Complete blood cound decreased

2. Arterial blood gas values metabolic acidosis ( decreased pH, increased

partial pressure of carbon dioxide [ Pco2], and decreased partial pressure of
oxygen [ Po2])
3. Serum electrolyce levels decreased because of loss to traumatized areas
and interstital spaces.
4. Serum glucose level increased because of stress-invoked glycogen
breakdown or glyconeogenesis
5. Blood urea nitrogen level increased because of tissue breakdown and
oliguria
6. Creatinine clearance increased because of tissue breakdown and oliguria
7. Serum protein levels decreased becaused of protein breakdown for
massive energy needs
8. Chest radiographic study
8. Treatment
The objective of burn treatment is to prevent infection, decrease
inflammation and pain, and promote healing of the areas. Treatment choices
depend on the degree of burn and the amount of body surface area that was
burned. Any second-dgree burn greater than 5 to 10 percent of surface area and
all third-degree burns belong in a hospital, preferably within a specialized burn
unit. All electrical burns are and burns of the ears, eyes, face, hand, feed and
perineum require hispital care, as do chemical burns and burns in infants to the
elderly.
a. Check the area for any exposed electrical wires, if you are present on the
scene.
b. Use cold water to decreased the temperature of the area for a first-degree
c.
d.
e.
f.

burn or a small second-degree burn and to stop the burning.

For chemical burns, ensure that all the cehemical has been flushed away
For electrical burns, look for entance and exit wound
Cover the area with dry gauze.
If the skin is broken ( second-degree burn), use a topical antibiotic ointment
such as silvanede to prevent a secondary bacterial infection before applying

the gauze.
g. Administer pain medications ( ibuprofen, acetaminophen ) as needed.
h. For third-degree burns, the ecshar needs to be debrided ( cut away ) to allow
new tissue to grow.

i. These wound are often covered in moust sterile saline gauze, as new tissue
grows best in this environment. When the gauze dries, it adheres to the dead
tissue. The area is mechanically debrided when the gauze is removed.
j. Oral antibiotics may be necessary.
k. Administer pain medications ( oxycodone, morphine) as needed, especially
before dressing changs that may be painful.
l. Prevent heat loss due to larges areas of tisssue exposed from lack of skin
coverage.
m. Maintain fluid levels since fluid loss is common from evavoration and
wound drainage.
9. Complications
1. Renal failure
2. Metabolic acidosis
3. Hyperkalemia
4. Hypinatremia
5. Hypocalcemia
6. Pulmonary problems
a. Pulmonary edema
b. Pulmonary insufficiency
c. Bacterial pnenumonia
d. Pulmonary embolus
7. Infection
8. Scarring and joint contractures.

B. BASIC CONCEPT OF NURSING

1. Assesment
a. Activity/ rest
May Exhibit : Decreased strength, endurance
Limited range of motion (ROM) of involved areas
Impaired muscle mass, altered tone
b. Circulation
May Exhibit : Hypotension (shock)
Peripheral pulses diminished distal to extremity injury;
generalized peripheral vasoconstriction with loss of
pulses, mottling of skin, and coolness (electrical shock).
Tachycardia

(shock/anxiety/pain).

Dysrhythmias

(electrical shock). Tissue edema formation (all burns)

c. Ego Integrity
May Report :

Feeling

scared, self-conscious,

conspicuous, angry,

embarrassed, different
Concerns about family, job, finances, disfigurement
May Exhibit : Anxiety,crying, dependency, denial withdrawal, hostility,
aggressive behavior
d. Elimination
May Exhibit :

Urinary output decreased/absent during emergent phase;

color may be pink (hemochromogens from damaged red
blood cells [RBCs]) or reddish black if myoglobin
present, indicating deep-muscle damage
Diuresis (after capillary leak sealed and fluids mobilized
back into circulation)
Bowel sounds decreased/absent, especially in cutaneous
burns of more than 20%, because stress reduces gastric
motility/peristalsis

e. Food/ fluid
May Exhibit:

Generalized tissue edema (swelling is rapid and may be

extreme in early hours after injury). Anorexia,
nausea/vomiting

f. Neurosensory
May report:

May Exhibit:

Mixed areas of numbness, tingling, burning pain

Changes in vision, decreased visual acuity (electrical
shock)
Decreased deep tendon reflexes (DTRs), reflexes and
sensation in injured extremities. Seizure activity (electrical

10

shock). Corneal lacerations, retinal damage (electrical

shock). Rupture of tympanic membrane (electrical shock).
Paralysis (electrical injury to nerve pathways)
g. Pain/discomfort
May Report:
Pain varies, e.g., first-degree burns are extremely sensitive
to touch, pressure, air movement, and temperature
changes; second-degree moderate-thickness burns are
very painful, whereas pain response in second-degree
deep-thickness burns depends on intactness of nerve
endings; third-degree burns are painless
h. Respiration
May Report:

Confinement in a closed space, prolonged exposure

May Exhibit:

(possibility of inhalation injury)

Hoarseness, wheezy cough, carbonaceous particles on
face/in sputum, drooling/inability to swallow oral
secretions, and cyanosis (indicative of inhalation injury)
Thoracic excursion may be limited in presence of
circumferential chest burns. Upper airway stridor/wheezes
(obstruction due to laryngospasm, laryngeal edema).
Breath sounds: Crackles (pulmonary edema), stridor
(laryngeal edema), profuse airway secretions/ wheezing
(rhonchi)

i. Safety
May Exhibit:

Skin :
General: Exact depth of tissue destruction may not be
evident for 35 days because of the process of
microvascular thrombosis in some wounds; unburned skin
areas may be cool/clammy, pale, with slow capillary refill
in the presence of decreased cardiac output as a result of
fluid loss/ shock state
Flame Injury : There may be areas of mixed depth of
injury because of varied intensity of heat produced by
burning clothing; singed nasal hairs; dry, red mucosa of
nose and mouth; blisters on posterior pharynx, circumoral
and/or circumnasal edema

11

Chemical Injury : Wound appearance varies according to

causative agent; skin may be yellowish brown with soft
leather-like texture; blisters, ulcers, necrosis, or thick
eschar. (Injuries are generally deeper than they appear
cutaneously, and tissue destruction can continue for up to
72 hr after injury.)
Electrical Injury : The external cutaneous injury is usually
much less than the underlying necrosis; appearance of
wounds varies and may include entry/exit (explosive)
wounds of current, arc burns from current moving in close
proximity to body, and thermal burns due to ignition of
clothing
Other : Presence of fractures/dislocations (concurrent
falls, motor vehicle accident; tetanic muscle contractions
due to electrical shock)
j. Teaching/learning
Discharge Plan: DRG projected mean length of inpatient stay: dependent
on burn percentage and specific surgical procedure
required
Considerations: May require assistance with treatments, wound care/
supplies, self-care activities, homemaker maintenance
tasks, transportation, finances, vocational counseling
Changes in physical layout of home or living facility other
than home during prolonged rehabilitation.
2. Diagnosis
a. Care of the Patient During the Emergent/Immediate Phase of Burn
1. Alteration in gas exchange and airway clearance
2. Alteration in fluid and electrolyte balance
3. High risk for infection
4. Altered body temperature; hypothermia/hyperthermia
5. Altered nutritional status: less than body requirements related to
increased nutritional requirements and altered gastrointestinal function
6. Pain and anxiety
b. Care of Patient During the Acure/Intermediate Phase of Burn
1. High risk for infection of burn wound and burn wound sepsis
2. Impaired skin integrity related to open burn wounds
3. Pain and discomfort related to painful burn wound, treatments,
debridement, and surgical interventions
12

4. Altered nutrition : less than body requirements

5. Body image disturbances related to burn wound and changes in role
and life-style
6. Immobility related to possible development of flexion contractures
and muscle atrophy
3. Nursing Interventions
A. Care of the Patient During the Emergent / Immediate Phase of Burn
1. Alteration in gas exchange and airway clearance
Goal : Asssure patent airway and adequate respiratory function
Expected Outcome :
Breathes spontaneusly
Is free dyspnea or shortness of breath
Exhibits respiratory rate between 12 and 20 breaths/min
Has pulmonary function parameters within normal limits
Shiows lung clear on auscultation
Is free of cerebral effects of hypoxia
Has arterial blood gases within normal limits
Exhibits respiratory secretions that are minimal, colorless and thin
Interventions :
Nursing Interventions
1. Maintain patent airway through proper

Rasionale
1. Ensure patent airway

positioning, removal of secretions, and

artificial airway indicated
2. Provide humidified oxygen through

2. Provides humidity to injured tissues

appropriate mode
3. Assess breath sounds and respiratory

and adequate oxygen supply

3. Provides baseline for

rate,

rhythm,

and

depth,

chest

excursion, and signs of hypoxia

4. Observe for the following :
a. Erythema or blistering of lips or
b.
c.
d.
e.

assessment

and

further

evidence

of

increasing respiratory compromise

4. Indicate injury to respiratory tree and
/ or risk of respiratory dysfunction

bucal mucosa
Singed nares
Burns of face, neck, or chest
Increasing hoarness
Soot in sputum or tracheal tissue in

respiratory secretions
5. Monitor arterial blood gases

5. Increasing Pco2 and decreasing Po2

may indicate need for mechanical

13

ventilation
2. Alteration in fluid and electrolyte balance
Goal : Restore optimal fluid and electrolyte balance; maintain perfusion of
vital organs and adequate circulation to extremities
Expected outcomes :
Exhibits intake, output and body weightthat correlate with pattern of

psysiologic pathology and expected results of therapy

Has serum electrolyte within normal limits
Exhibits urine output between 0.5 anf 1.0 ml/kg/hr
Has blood pressure higher than 90/60
Shows heart rate less than 110/min
Exhibits clear sensorium
Is free of excessive thirst
Shows normal reflexes and muscle tone indicative of electrolyte
balance

Interventions :
Nursing Interventions
1. Observe vital signs ( including central

Rasionale
1. Hypovolemia is as

major

risk

venous pressure of pulmonary artery

immediately after the burn injury; as

pressure, if indicated), urine output,

mobilization of fluid occur, there is

and signs of hypovolemia or fluid

increased risk of fluid overload and

overload
congestive heart fali
2. Monitor urine output as least hourly 2. Provides information
and weigh patient daily

perfusion,

adequacy

about

renal

of

fluid

replacement, and fluid requirement and

3. Monitor mental status and sensorium

fluid status.
3. Provides infomation about adequacy of
cerebral perfusion and oxygenation

4. Maintain IV lines and regulate fluids 4. Adequate fluids are necessary to

at appropriate rates, as prescribed

maintain fluid and electrolyte status

and adequate perfusion of vital organs

14

5. Observe for symptoms of deficiency 5. Rapid shifts in fluid and electrolyte

or excess serum sodium, potassium,

status are possible in the postburn

calcium,

period

phosphorus,

bicarbonate.

Note

results

and
of

laboratory test and report abnormal

values to physician

3. High risk for infection

Goal : Absence of infection and sepsis
Expected Outcomes :
Is free of signs of local of systemic infection
Has negative vlood cultures
Has negative wound, sputum, and urine cultures
Interventions :
Nursing Interventions
1. Use sepsis in all aspects of patient care
:
a. Wash

1. Minimizes

Rasionale
risk

of

cross-

contamination ans spread of bacterial

hands

antibacterial

carefully
cleansing

with

contamination

agent

before and after patient care

b. Wear isolation gown or plastic
apron for patient contact
c. Cover hair and use mask whenn
patients wounds are exposed or
during sterile procedures
d. Use clean or sterile gloves in
patient care
e. Use aseptic technique for wound
care and invasive procedures
f. Changes IV lines and tubing and
ither equipment as recommended
2. Administer antibiotics and topical
antibacterial as prescribed

2. An adequate concetration pof the

agent in necessary to treat or perevent
infection effectively

15

3. Assess wound daily for local signs of

infection;swelling

and

redness,

purulent drainage, discoloration

4. Observe mental status, respiratory rate,
bowel sounds

3. Indicative of bacterial contamination

and infection
4. Decreased mentation and peristaltis
and increased respiratory rate are
early signs of septicemia

5. Assess for increased pulse, decreased

5. These are later signs of septicemia

BP, changes in urine output, facial

flushing, fever

4. Altered body temperature: hypotermia/hypertermia

Goal : maintenance of adequate body temperature
Expected Outcomes :
Body temperature in range of 36.1o to 38.3oC ( 97o to 101oF)
Exhibits no shivering
States room temperature is not too warm or too cool
Interventions :
Nursing Interventions
1. Provide a warm environment through

Rasionale
1. Minimized evaporative heat loss

use of heat shield, space blanket, heat

lights or blankets
2. when wounds must be exposed for 2. Minimizes heat loss through the burn
wound care, work quickly
3. Monitor rectal temperature

wound
3. Allows frequent assessment of body

temperature
4. Administer antipyretics for elevated 4. Reduces metabolic stress
body temperature as prescribed

5. Altered nutritional status: less than body requirement related to increased

nutritional requirement and altered gastrointestinal function
Goal : Improved nitritional status
Expected Outcomes :
Exhibits bowel sounds
Shows normal gastric aspirate; no bleeding
Tolerates oral or nasogastric feedings
Has negative stools for occult blood
16

Interventions :
Nursing Interventions
1. Maintain nasogastric tube on low
intermittent

suction

until

bowel

sounds return

Rasionale
1. Burn injury often produces paralytic
ileus, which results in gastric and
abdominal

distention;

nasogastric

suction removes gastric secretions and

2. Auscultate for bowel sounds every
hours
3. Prior

prevents vomiting
2. Absebt bowel sounds and prevents
vomiting

to

tube

feedings,

aspirate

peristalis

may

indicate

paralytic ileus, obstruction, or sepsis

3. Large residual volume of gastric

stomach contents to check for residual

contents

amount and pH of gastric contents

absoptionlow pH indicates need for

4. Administer histamine blockers and

antacids as prescribed
5. Test

stools

and

indicates

inadequate

histamine blockers or antacids

4. Reduces risk of gastrics ulceration
common in burn patients

gastric

aspirate

contents for occult bleeding

5. May indicate presence of gastric or

duodenal ulcer

6. Pain and anxiety

Goal : reduction in pain and anxiety
Expected outcomes :
Shows that comfort level permits adequate rest and active
participation in required activities
Requires analgesics primarily prior to dressing change and potentially

painful treatments
Interventions :
Nursing Interventions
1. Assess patient for pain,

amd

differentiate from hypoxia

2. Administer

narcotic

intravena

nously

monitor

respiratory

narcotics

as

Rasionale
1. Assessment of pain provides baseline
for evaluating pain relief measures

analgesics
prescribed;
response

to

2. Intravenous
necessary

adminstration
because

of

is
altered

absoption and circulation resulting

from the burn
17

3. Introduce

relaxation

imagery,

or

other

analgesics
4. Provide emotional

technique,
adjuncts
supprot

to
and

reassurerance

3. Relaxation and imagery complement

analgesia and reduce anxiety
4. Emotional support and reassurerance
are essential to reduce extreme fear
and anxiety reduce fom burn injury,

5. Give honest information regarding

treatments and outcomes

5. Promotes trust needed for patients

status and medical care required for

emotional well-being and acceptance

optimal response

of painful treatments

B. Care of the Patient During the Acute/Intermediate phase of Burn Care

1. High risk for infection of burn wound and burn wound sepsis
Goal : Reduced risk of burn wound sepsis
Expected outcomes :
Exhibits clean, small, open wounds
Ehibits open wound areas that are pink reepithelializing, and free of

infection
Shows clean reephitelializing donor sites
Exhibit negative burn wound cultures

Interventions :
Nursing Interventions
1. Wash hands prior to all patients

Rasionale
1. Minimizes risk of cross-contamining

contacs
2. Prevent pressure on wounds

2. Enables detection of signs of shock,

so that treatment can be initiated

3. Prevent ressure on wounds

3. Minimizes

trauma

and

ensures

adequate perfusion to burn wounds

4. Apply

topical

antibacterials

prescribed
5. Prevent cross-contamination

as

4. Promotes

adequate

antibacterial

effects to topical agents

5. Reduces risk of bacterial colonization

2. Impaired skin integrity relate to open burn wounds

Goal : improved skin integrity and wounds healing

18

Expected Outcomes :
Demonstrates that most wounds are closed
Has completed or nearly completed skin grafting
Over 80% of body ciovered with intact skin
Interventions :
Nursing Interventions
1. Cleanse wound and rest of body,
including hair, daily

1. Reduces

Rasionale
potential

bacterial

contamination, a common cause

2. Apply topical antibacterial agents

of impaired wound healing

2. Reduces bacterial colonization

and dressing as prescibed

3. Prevent pressure, infection, and

and promotes healing

3. Avoids trauma of grafts necessary

mobilization of autografts
4. Provide donor site care

for wound closure

4. Promotes healing of donor site

5. Observe and report any signs of

5. Grafted or healed burn wounds

poor graft take of loss of skin

are susceptible to trauma

integrity after healing

3. Pain and discomfort related to painful burn wound, treatments,

debridement, and surgical interventions
Goal : Relief of pain and discomfort
Expected Outcomes :
Obtains relief of pain
Request analgesics only occasionally and specifically for muscle and

joint pain
Verbally reports minimal pain
Is free of physiologic and nonverbal indicators or moderate or severe
pain

Interventions :
Nursing Interventions
1. Assess patients pain carefully

Rasionale
1. Provides baseline for assessment of

2. Offer

pain relief measures

2. Provides multiple interventions that

analgesics

and

relaxation

breathing,

transcutaneous

stimulator,

or

other

nerve

appropriate

offer relief of pain and anxiety related

to fear of pain

19

measures

3. Assess

and

document

patients

3. Promotes use of effective pain relief

response to interventions
4. Assist patient with appropriate means

measure
4. Allows/ encourages patient to express

of expressing pain

extended pain and discomfort that

accompany

5. Educate patient about the usual pain

trajectory in burn recovery

repeated

painful

treatments
5. Reduces fear of the unknown, and
may provide some measure of control
to the patient

4. Altered nutrition: less than body requirements

Goal : Improved nutritional status
Expected Outcomes :
Demonstrate optimal nutritional status
Demonstrates daily weight gain
Is free of signs of protein, vitamin, or mineral deficiencies
Meets required nutritional needs by oral intake entirely
Exhibits normal serum protein levels
Interventions :
Nursing Interventions
1. Provide high-calorie, high-protein diet
by appropriate route

meet

2. Administer total patenteral nutritional

acording to protocol
3. Give

supplemental

Rasionale
1. Provides nutrients for healing and to
increased

metabolic

requirements for calories

2. May be necessary to provide adequate
nutrition to anorexic patient

vitamins

and

minerals as prescribed

3. Necessary for normal healing and

function

4. Weigh patient daily; record in graphic

4. Provides record of trends in weight

form
5. Report intoleranse manifested by

5. May

abdominal

distention,

osmitic diuresis, dehydration

diarrhea,

indicate

abnormal

gastrointestinal function or need for

alteration in dietary prescription

20

5. Body image disturbances related to burn wound and changes in role and
life-style
Goal : improved body image and acceptance of alcerations required as a
result of burn injury
Expected outcomes :
Has realitic concept of changes in body image and alterations required

in daily activities as a result of burn injury

Verbalizes ab accurate description of alterations in body image

postburn
Discusses changes in loife-style and daily activities that may required

postdischarge
Demostrates interest in resources that may be able to positively affect

cosmetic and functional results of injury

Is free of withdrawal and depression

Interventions :
Nursing Interventions
1. Assess patients readiness to express

1. Helps

Rasionale
to
determine

patients

feelings regarding alteration on body

awareness of effects of burn injury and

imge or life-style

ability to begin to deal with these

2. Provie opportunity for expression of

thoughts and feelings
3. Maintain

positive

changes
2. Allows patient

to

express

and

vercaloze feelings regarding burn

but

honest

approach in responding to questions

injury, ist effects, and outcomes

3. Encouranges patient to voice concerns
and ask questions in a trusting

4. Use significant resource persons to

atmosphere
4. Provides multiple sources of support

help patient cope

5. Support effective premorbid coping

5. Encourages patient to use familiar

mechanisms

coping mechanisms that have been

successful in the past

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6. Immobility related to possible developmentof flexion contactures and

muscle atrophy
Goal : Increased mobility and participation in activities of daily living
Expected Outcomes :
Demostrates range of joint motion that approaches preburn range
Shows joint motion that permits activities of daily living
Improves range of motion of conctacted joints daily
Is free periarticular calcification
Interventions :
Nursing Interventions
1. Position patient carefully to prevent

Rasionale
1. Reduces risk of flexion contractures

flexed position in burned areas

2. Implement range of motion exercises

2. Minimizes muscle artrophy

several times daily

3. Assist with ambulation

3. Encourages increased mobility and

4. Use splints and excercise devices

use of muscles
4. Encourages activity while maintaining

recommended

by

occupational

physical therapists
5. Encourages self-feeding and turning
and moving in bed

proper position of joints

5. Encourages independence and selfcare while encouraging activity and
exercise

4. Implementation
Implementation is a putting an instrument or plan into action.
Implementation as a phase of the nursing process involves putting the plan of
care (nursing interventions) into effect. The nurse coordinates her activities
with those of others responsible for contributing to patient care and delegates
responsibility to other professional and technical care-givers as appropriate.
During implementation the care plan is tested for effectiveness. Nursing
interventions may not have had the desired effect, or a change in the patient's
condition may present more critical problems that have a higher priority, thus
requiring revision of the plan and different interventions.
5. Evaluation

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Evaluation is a critical appraisal or assessment, a judgment of the value,

worth, character, or effectiveness of something; measurement of progress. A
broad view of evaluation in health care includes three approaches, directed
toward structure, process, and outcome, depending on the focus of evaluation
and the criteria or standards being used. The purpose of the evaluation is to
determine whether outcome criteria have been met and how care for the patient
might be improved. It is done for the purpose of improvement, by identifying
specific areas that need change for the better.

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