Nursing Care Plan for Burns

Nursing diagnosis: risk for Infection

Risk factors may include
Inadequate primary defenses—destruction of skin barrier, traumatized tissues
Inadequate secondary defenses—decreased Hgb, suppressed inflammatory response
Environmental exposure, invasive procedures

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Burn Healing
Achieve timely wound healing free of purulent exudate and be afebrile.

Nursing intervention with rationale:
1. Implement appropriate isolation techniques, as indicated.
Rationale: Dependent on type and extent of wounds, and the choice of wound treatment (e.g., open versus closed); isolation may range from simple wound and skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora.

2. Emphasize and model good hand-washing technique for all individuals coming in contact with client.
Rationale: Prevents cross-contamination and reduces risk of acquired infection.

3. Use gowns, gloves, masks, and strict aseptic technique during direct wound care and provide sterile or freshly laundered linens and gowns.
Rationale: Prevents exposure to infectious organisms.

4. Monitor and limit visitors, if necessary. Explain isolation procedure to visitors, if used. Supervise visitor adherence to protocol as indicated.
Rationale: Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against client’s need for family support and socialization.

5. Shave/clip all hair from around burned areas to include a 1-inch border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.
Rationale: Hair is a good medium for bacterial growth; however, eyebrows act as a protective barrier for the eyes. Regular shampooing decreases bacterial fallout into burned areas.

6. Examine unburned areas such as groin, neck creases, and mucous membranes; and vaginal discharge routinely.
Rationale: Opportunistic infections (e.g., yeast) frequently occur because of depression of the immune system and/or proliferation of normal body flora during systemic antibiotic therapy.

7. Provide special care for eyes, for example, use eye covers and tear formulas as appropriate.
Rationale: Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.

8. Prevent skin-to-skin surface contact—wrap each burned finger or toe separately; do not allow burned ear to touch scalp.
Rationale: Prevents adherence to the surface that it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.

9. Examine wounds daily; note and document changes in appearance, odor, or quantity of drainage.
Rationale: Identifies presence of granulation tissue indicating healing and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong, sweet, musty smell at a graft site is indicative of Pseudomonas.

10. Monitor vital signs for fever and increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
Rationale: Indicators of sepsis—often occurring with full-thickness burn—requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.