Nursing Process
Care of the Patient during the Acute Phase
Assessment
Continued assessment of the patient during the early weeks after the burn injury
focuses on hemodynamic alterations, wound healing, pain and psychosocial responses,
and early detection of complications. Assessment of respiratory and fluid status
remains the highest priority for detection of potential complications.
The nurse assesses vital signs frequently. Continued assessment of peripheral pulses is
essential for the first few postburn days while edema continues to increase, potentially
damaging peripheral nerves and restricting blood flow. Observation of the
electrocardiogram may give clues to cardiac dysrhythmias resulting from potassium
imbalance, preexisting cardiac disease, or the effects of electrical injury or burn shock.
Assessment of residual gastric volumes and pH in the patient with a nasogastric tube is
also important. Blood in the gastric fluid or in the stools must also be noted and
reported.
Assessment of the burn wound requires an experienced eye, hand, and sense of smell.
Important wound assessment features include size, color, odor, eschar, exudate, abscess
formation under the eschar, epithelial buds (small pearl-like clusters of cells on the
wound surface), bleeding, granulation tissue appearance, status of grafts and donor
sites, and quality of surrounding skin. Any significant changes in the wound are
reported to the physician, because they usually indicate burn wound or systemic sepsis
and require immediate intervention.
Other significant and ongoing assessments focus on pain and psychosocial responses,
daily body weights, caloric intake, general hydration, and serum electrolyte,
hemoglobin, and hematocrit levels. Assessment for excessive bleeding from blood
vessels adjacent to areas of surgical exploration and débridement is necessary as well.
Gerontologic Considerations
In elderly patients, a careful history of preburn medications and preexisting illnesses is
essential. Nursing assessment of the elderly patient with burns should include particular
attention to pulmonary function, response to fluid resuscitation, and signs of mental
confusion or disorientation. Because of lowered resistance, burn wound sepsis and
lethal systemic septicemia are more likely in elderly patients. Furthermore, fever may
not be present in the elderly to signal such events. Therefore, surveillance for other
signs of infection becomes even more important. Nursing care of the elderly patient
with burn injuries promotes early mobilization, aggressive pulmonary care, and
attention to preventing complications.
Diagnosis
Nursing Diagnoses
Based on the assessment data, priority nursing diagnoses in the acute phase of burn care
may include the following:
Excessive fluid volume related to resumption of capillary integrity and fluid
shift from the interstitial to the intravascular compartment
Risk for infection related to loss of skin barrier and impaired immune response
Imbalanced nutrition, less than body requirements, related to hypermetabolism
and wound healing needs
Impaired skin integrity related to open burn wounds
Acute pain related to exposed nerves, wound healing, and treatments
Impaired physical mobility related to burn wound edema, pain, and joint