comprehensive Nursing Care Plan for Third-Degree Burn

 **Nursing Care Plan for Third-Degree Burn**

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**Patient Profile:**

- Name: [Patient Name]

- Age: [Age]

- Gender: [Gender]

- Diagnosis: Third-degree burn

### **Assessment:**

1. **Subjective Data:**

   - Patient reports severe pain, described as deep, persistent, and throbbing.

   - Patient expresses fear of permanent scarring and functional impairment.

   - Anxiety related to the severity of the injury and the uncertain prognosis.

   

2. **Objective Data:**

   - Visible signs of third-degree burn: Full-thickness tissue damage affecting epidermis, dermis, and possibly subcutaneous tissue.

   - Charred appearance of the skin, with possible areas of white, leathery texture.

   - Loss of sensation in the affected area due to nerve destruction.

   - Presence of blisters in the surrounding areas (partial thickness burn).

   - Signs of systemic response: Increased heart rate, hypotension (if shock is present), and potential respiratory distress if inhalation injury is suspe

### **Nursing Diagnosis:**

1. **Impaired Skin Integrity** related to full-thickness tissue destruction and damage to dermal and subdermal layers as evidenced by burn wounds and blistering.

   

2. **Acute Pain** related to tissue injury, inflammation, and exposure of nerve endings.

   

3. **Risk for Infection** related to the disruption of the skin’s protective barrier and exposure to environmental pathogens.

4. **Impaired Physical Mobility** related to immobilisation and pain from the burn injury.

5. **Anxiety** related to the severity of the burn injury and uncertainty about recovery and rehabilitation.

### **Goals/Outcomes:**

1. The patient will demonstrate improved skin integrity by maintaining a clean and dry burn area, with no signs of infection, as evidenced by intact or healing tissue.

   

2. The patient will report a reduction in pain levels, achieving a pain score of 3/10 or less within 48 hours.

   

3. The patient will verbalise understanding of infection prevention and will adhere to prescribed wound care protocol.

4. The patient will demonstrate increased mobility within [specified timeframe], with the assistance of physical therapy or mobility aids.

5. The patient will exhibit reduced anxiety, demonstrating coping strategies, and engaging in discussions about their recovery process.

### **Interventions:**

1. **Wound Care:**

   - Assess burn site regularly for signs of infection (redness, purulent drainage, increased pain).

   - Clean the wound using sterile saline and apply a non-adherent dressing as per protocol.

   - Monitor for the development of new blisters and provide appropriate care to prevent rupture.

   - Apply prescribed topical antibiotics (if indicated) to prevent infection.

   - Elevate burned limbs (if applicable) to reduce swelling.

2. **Pain Management:**

   - Administer prescribed analgesics as needed (opioids, NSAIDs, or topical analgesics).

   - Monitor pain levels using a standard pain scale, reassessing regularly.

   - Provide psychological support to alleviate fear and discomfort, explaining the pain management plan.

3. **Infection Control:**

   - Educate the patient and family on proper wound care techniques, emphasising the importance of hand hygiene before dressing changes.

   - Use sterile techniques during all procedures involving the burn site.

   - Assess for systemic signs of infection (fever, increased white blood cell count).

4. **Mobility Assistance:**

   - Assist with positioning to promote comfort and prevent pressure ulcers.

   - Initiate physiotherapy consultation to assess and address any mobility issues.

   - Encourage active and passive range-of-motion exercises (if appropriate) to prevent contractures.

5. **Psychological Support:**

   - Offer a calm, supportive presence and listen to patient concerns.

   - Explain procedures and expected recovery stages in a clear and empathetic manner.

   - Involve family members in the care process to provide emotional support.

   - Offer referrals for counselling if anxiety becomes severe or persistent.

### **Evaluation:**

1. **Skin Integrity:** The burn area shows no signs of infection and is progressing towards healing, with minimal scarring.

   

2. **Pain Management:** The patient reports a reduction in pain levels, achieving a manageable state of comfort.

3. **Infection Control:** The patient demonstrates understanding of infection prevention techniques and adheres to care instructions without signs of infection.

4. **Mobility:** The patient is able to perform basic movements with minimal assistance and continues to make progress in physical therapy.

5. **Psychological Well-being:** The patient demonstrates reduced anxiety, verbalises understanding of the healing process, and reports feeling supported.

This care plan should be continuously updated and adjusted based on the patient’s progress, response to interventions, and any changes in clinical condition. Regular multidisciplinary team reviews, including the involvement of physiotherapists, psychologists, and wound care specialists, will enhance the patient’s overall recovery.