comprehensive Nursing Care Plan for Fourth-Degree Burns

 **Nursing Care Plan for Fourth-Degree Burns**

Ч4৷

**Patient Profile:**

- Name: [Patient Name]

- Age: [Age]

- Gender: [Gender]

- Diagnosis: Fourth-degree burn

### **Assessment:**

1. **Subjective Data:**

   - Patient expresses extreme pain, particularly around the edges of the burn area, but with areas of diminished sensation due to nerve damage.

   - The patient is anxious, expressing concerns about the long-term impact of the injury, including potential amputations and cosmetic disfigurement.

   - The patient reports difficulty in breathing if inhalation injury is suspected, along with feelings of helplessness and fear regarding recovery.

2. **Objective Data:**

   - Extensive tissue damage involving the epidermis, dermis, subcutaneous tissue, and extending into underlying structures such as muscles, tendons, and possibly bone.

   - Skin appears charred, leathery, or eschar-like, with areas of deep tissue necrosis.

   - Absence of sensation in the burned areas due to nerve destruction.

   - Potential for systemic shock, including hypotension, tachycardia, and respiratory distress if inhalation injury is present.

   - Signs of hypovolemia or electrolyte imbalance may be evident.

---

### **Nursing Diagnosis:**

1. **Impaired Skin Integrity** related to deep tissue destruction affecting multiple layers of the skin, muscle, and underlying structures as evidenced by full-thickness burn wounds.

   

2. **Acute Pain** related to severe tissue injury, nerve involvement, and inflammation, as evidenced by patient reports of pain in the surrounding areas.

   

3. **Risk for Infection** related to extensive skin damage and exposure of underlying tissues, compromising the body’s first line of defence.

4. **Ineffective Breathing Pattern** related to potential inhalation injury, compromised lung function, and the physiological stress response.

5. **Impaired Physical Mobility** related to immobilisation and severe pain due to injury to the skin, muscles, and other tissues.

6. **Anxiety** related to the severity of the injury, uncertainty of recovery, and concerns about the long-term effects such as loss of function or cosmetic disfigurement.

### **Goals/Outcomes:**

1. The patient will exhibit improved skin integrity, with wound areas progressing towards healing, as evidenced by the formation of granulation tissue and absence of infection.

   

2. The patient will report a reduction in pain to a manageable level, ideally scoring 3/10 or less within 48 hours, with appropriate analgesia and comfort measures.

3. The patient will demonstrate understanding and adherence to infection prevention protocols, showing no signs of systemic or local infection.

4. The patient will demonstrate effective breathing patterns with adequate oxygenation and respiratory function, as indicated by improved vital signs and oxygen saturation levels.

5. The patient will achieve a certain level of mobility with assistance, showing gradual improvement in range of motion and strength through physical therapy.

6. The patient will express reduced anxiety and engage in discussions about their treatment plan and expected recovery with emotional support.

### **Interventions:**

1. **Wound Care:**

   - Assess and document the burn areas regularly, checking for signs of infection, necrosis, or deterioration.

   - Apply sterile dressings and topical treatments as prescribed, including antimicrobial ointments if necessary.

   - In cases where eschar removal is required, coordinate with the surgical team for debridement procedures.

   - Prevent infection by using sterile techniques during dressing changes and ensuring appropriate wound care practices.

   - Elevate affected limbs (if appropriate) to reduce swelling and prevent compartment syndrome.

2. **Pain Management:**

   - Administer prescribed analgesics (opioids, NSAIDs, or specific local anaesthetics for burn pain) on a scheduled basis, with adjustments as necessary based on patient response.

   - Monitor pain levels continuously using a pain scale, adjusting pain management strategies as required.

   - Consider adjunctive therapies such as nerve blocks or regional anaesthesia for areas of extensive tissue damage.

   - Provide non-pharmacological interventions such as relaxation techniques, deep breathing exercises, and distraction to alleviate anxiety and support pain management.

3. **Infection Control:**

   - Educate the patient and their family on the importance of hand hygiene and proper wound care techniques.

   - Monitor for signs of infection, including redness, warmth, increased pain, or drainage from the wound sites.

   - Administer prophylactic antibiotics if indicated, and monitor for any adverse reactions.

   - Ensure all medical staff and visitors follow infection prevention protocols to minimise risk.

4. **Breathing Support:**

   - Assess the patient’s respiratory status, including rate, rhythm, and effort, and monitor oxygen saturation levels.

   - Administer supplemental oxygen if needed, particularly in cases of inhalation injury, and ensure a patent airway.

   - Monitor for signs of respiratory distress and collaborate with the respiratory therapy team for further interventions.

   - If indicated, provide mechanical ventilation or other advanced respiratory support based on the severity of the injury and the presence of pulmonary complications.

5. **Mobility Assistance:**

   - Work with physiotherapy to develop an appropriate mobility plan, focusing on early mobilisation to prevent contractures.

   - Assist with positioning to avoid placing stress on the burned areas and to promote comfort.

   - Encourage active and passive range of motion exercises to improve joint mobility and prevent stiffness.

   - Assess the need for assistive devices or rehabilitation services as part of the long-term recovery plan.

6. **Psychological Support:**

   - Offer empathetic support and listen to the patient’s concerns regarding the severity of the injury and potential long-term consequences.

   - Provide clear, detailed explanations about the recovery process, prognosis, and treatment options to reduce fear of the unknown.

   - Encourage the patient to express their feelings and provide referrals to mental health professionals or counsellors to address anxiety or post-traumatic stress.

   - Include family members in discussions to support the patient emotionally and provide a strong network for recovery.

### **Evaluation:**

1. **Skin Integrity:** The burn areas demonstrate appropriate wound healing, with granulation tissue formation and no signs of infection. The patient’s skin integrity is progressing towards recovery.

2. **Pain Management:** The patient reports significant pain relief, maintaining a manageable level of discomfort, with improved overall comfort.

3. **Infection Control:** The patient adheres to infection prevention protocols, and there are no signs of infection in the burn sites or systemic signs of sepsis.

4. **Breathing Patterns:** The patient exhibits effective and stable breathing patterns, with improved oxygenation and normal respiratory function.

5. **Mobility:** The patient shows gradual improvements in mobility, with increased range of motion and participation in physiotherapy sessions.

6. **Psychological Well-being:** The patient demonstrates reduced anxiety and engages positively in discussions about their care and long-term recovery, showing an increased sense of control over their situation.

This care plan should be regularly updated in response to the patient’s evolving needs and clinical condition. Multidisciplinary collaboration, including specialists in burn care, respiratory therapy, physical rehabilitation, and psychology, will be essential to the patient’s recovery and overall wellbeing.