Burn Injury Nursing Care Plan
Thermal/chemical injury care across resuscitation, wound and rehab phases.
Quick answer
A Burn Injury nursing care plan centers on secure and protect the airway; anticipate rapid edema after inhalation injury; restore circulating volume with titrated crystalloid before shock becomes irreversible; control pain aggressively — iv route only during the emergent phase. Priority nursing diagnoses are Deficient fluid volume, Acute pain, Risk for infection, Impaired skin integrity. The plan below gives assessment cues, measurable goals, 10 intervention sets with rationales, and patient teaching.
Overview
A burn is tissue damage caused by heat, scalding liquid, flame, chemicals, electricity, radiation or friction. Beyond the visible wound, a major burn is a whole-body injury: capillaries leak plasma into the interstitium, metabolic rate can double, and the skin's barrier against infection and heat loss is gone. Because of that, burn care is judged less by the wound itself and more by airway status, circulating volume, infection control, nutrition and long-term function.
Depth drives treatment. A superficial (first-degree) burn injures only the epidermis and heals in about 5–10 days with redness and pain but no blisters. A superficial partial-thickness (second-degree) burn reaches the upper dermis and is painful, moist and blistered, healing without grafting. A deep partial-thickness burn destroys most of the dermis, looks waxy-white and often needs grafting. A full-thickness (third-degree) burn destroys epidermis and dermis and may extend into fat and muscle; it appears white, leathery or charred, is insensate at the center, and always requires excision and grafting.
Care also follows three phases. The emergent (resuscitative) phase runs from injury through roughly the first 24–48 hours and is dominated by airway protection and fluid resuscitation against burn shock. The intermediate (acute) phase begins around 48–72 hours as capillary integrity returns and fluid mobilizes back into circulation, producing diuresis and a real risk of fluid overload and heart failure — wound care, infection prevention and nutrition dominate here. The rehabilitative phase begins once wounds are closed and continues until the patient reaches maximal function, focusing on contracture prevention, scar management, body image and return to daily life.
Key numbers to know
TBSA estimate
Rule of Nines in adults; Lund–Browder chart is more accurate, especially in children whose head is proportionally larger.
Fluid resuscitation
Parkland-type formula: 4 mL lactated Ringer's × kg × %TBSA over 24 hours — half in the first 8 hours from the time of injury, the remainder over the next 16.
Best resuscitation endpoint
Urine output of about 0.5 mL/kg/hr in adults (roughly 30–50 mL/hr) with a clearing sensorium and stabilizing vital signs.
Inhalation red flags
Facial burns, singed nasal hair, soot in sputum, hoarseness, stridor, closed-space fire — intubate early, before edema closes the airway.
Calorie need
Roughly 25 kcal/kg plus 40 kcal per %TBSA burned per day in adults, with high protein for tissue regeneration.
Nursing priorities
- Secure and protect the airway; anticipate rapid edema after inhalation injury.
- Restore circulating volume with titrated crystalloid before shock becomes irreversible.
- Control pain aggressively — IV route only during the emergent phase.
- Prevent wound and systemic infection; burn sepsis is the leading cause of late death.
- Assess, debride and dress wounds to promote closure and prepare for grafting.
- Meet the hypermetabolic calorie and protein demand early.
- Maintain joints in a position of function to prevent contracture from day one.
- Support the patient and family through disfigurement, grief and post-traumatic stress.
Nursing assessment
Subjective data
- Pain, burning or tenderness at the wound, or unexpected numbness over a deep area
- Difficulty breathing, throat tightness, hoarseness or painful swallowing
- Thirst, nausea, dizziness or weakness
- Fear, guilt, flashbacks to the event, or worry about appearance and work
- Deep, throbbing ache or tingling in a circumferentially burned limb
Objective data
- Burn depth, color and extent (%TBSA) plus condition of surrounding skin
- Blisters, weeping, eschar, or charred, leathery, insensate tissue
- Singed facial or nasal hair, soot in sputum, stridor, cough, carbonaceous secretions
- Tachycardia, hypotension, delayed capillary refill, cool unburned skin
- Urine output below 30 mL/hr, dark or tea-colored urine (myoglobinuria)
- Rising edema, weight gain, or absent distal pulses in a circumferential burn
- Fever, purulent or green-tinged drainage, foul odor, graft separation
- Confusion or restlessness — often the first sign of hypoxia or hypovolemia
Related factors
- Destruction of skin layers with loss of the protective barrier
- Plasma shift into the interstitium from increased capillary permeability
- Tracheobronchial edema and loss of ciliary action from smoke inhalation
- Exposed nerve endings, dressing changes, debridement and grafting procedures
- Hypermetabolic state with increased calorie and protein requirements
- Pain, limb immobilization, splints and forming scar tissue
- Traumatic event, disfigurement and enforced dependence
Key nursing diagnoses
Goals and expected outcomes
- The client will maintain a patent airway with clear breath sounds, a respiratory rate within normal range, and no dyspnea or cyanosis.
- The client will demonstrate adequate fluid balance as evidenced by urine output of at least 30 mL/hr, stable vital signs and moist mucous membranes.
- The client will report pain controlled at or below an agreed level and will rest and participate in care.
- The client will show progressive wound healing and timely graft take, free of purulent drainage and fever.
- The client will maintain weight and positive nitrogen balance with intake meeting calculated calorie and protein needs.
- The client will maintain full range of motion and a position of function, with no contracture.
- The client will express feelings about appearance and incorporate body changes into self-concept without loss of self-esteem.
- The client and family will correctly perform wound care and explain the reason for each step before discharge.
Nursing interventions and rationales
1. Maintaining a patent airway and gas exchange
- Monitor rate, depth and effort of breathing and auscultate for stridor, wheezes or crackles — upper-airway edema peaks in the first 24 hours and can close the airway quickly.
- Watch for hoarseness, brassy cough, soot-streaked sputum or drooling; report immediately, since these predict impending obstruction and prompt early intubation while it is still elective.
- Elevate the head of bed and keep the neck extended if there are no spinal precautions, to limit edema and ease breathing.
- Give humidified high-flow oxygen; assume carbon monoxide poisoning after a closed-space fire, because pulse oximetry reads falsely normal.
- Encourage coughing, deep breathing and incentive spirometry every hour, and suction gently as needed to clear sloughed mucosa.
- Assist with escharotomy for a circumferential chest burn that restricts chest wall expansion.
2. Restoring fluid volume and tissue perfusion
- Start two large-bore IVs through unburned skin when possible and begin the calculated crystalloid rate timed from the moment of injury, not from arrival.
- Titrate fluids to urine output of 0.5 mL/kg/hr in adults and 1 mL/kg/hr in children rather than to a fixed rate; the formula is only a starting estimate.
- Record hourly intake and output, daily weight, and specific gravity; weigh on the same scale at the same time.
- Monitor for the fluid shift back into circulation at 48–72 hours — new crackles, jugular distention, dyspnea and rapid weight gain signal overload.
- Check electrolytes closely: early hyperkalemia from cell lysis, later hypokalemia and hyponatremia from diuresis and wound losses.
- Assess pulses, color, sensation, movement and capillary refill distal to any circumferential burn hourly; a deep throbbing ache or numbness suggests compartment syndrome.
- Take blood pressure on an unburned limb when possible and remove the cuff between readings to avoid worsening edema.
3. Managing pain and providing comfort
- Assess pain with a consistent scale before, during and after dressing changes; burn pain has a constant background component and a severe procedural spike.
- Give IV opioids in the emergent phase — intramuscular and subcutaneous absorption is unreliable when perfusion is poor and drug can dump into circulation later.
- Premedicate 20–30 minutes before debridement, hydrotherapy or physical therapy so the peak effect matches the procedure.
- Cover exposed wounds and keep the room warm and drafts away; moving air over a partial-thickness burn is intensely painful.
- Add non-drug measures — repositioning, elevation, music, guided imagery, distraction, cool compresses on small burns — as genuine adjuncts, not substitutes.
- Note that a full-thickness burn is numb at its center while surrounding partial-thickness skin is exquisitely painful; sudden new pain in a numb area is a warning sign.
4. Wound care and restoring skin integrity
- Document wound size, depth, color, drainage, odor and the condition of surrounding skin at every dressing change to track healing and detect infection early.
- Cleanse and debride as ordered, then apply the prescribed topical agent and dressing using strict aseptic technique.
- Inspect grafts and donor sites for color, adherence and healing; roll or aspirate fluid blebs under sheet grafts with a sterile technique so the graft can adhere.
- Immobilize and elevate a newly grafted area — shearing motion is the most common reason a graft fails.
- Keep pressure off healing areas and turn on schedule to protect circulation.
- Once wounds close, wash with mild soap, rinse and lubricate several times daily; new skin and healed donor sites stay dry, fragile and itchy for months.
- Understand the coverings used: allograft or xenograft as temporary biologic dressings, cultured epithelial autograft grown from the patient's own skin over about 3–4 weeks, and dermal regeneration templates for permanent coverage.
5. Preventing infection
- Use scrupulous hand hygiene and protective isolation per protocol; the burn wound is the largest open portal in the body.
- Watch for burn sepsis rather than only local signs — a falling temperature, ileus, confusion, glucose instability and unexplained tachycardia often precede a fever.
- Assess for change in wound color to green, brown or black, early separation of eschar, or rapid conversion of a partial-thickness burn to full thickness.
- Keep the patient's own body regions separated during care, shave hair around wound edges, and change gloves between wound sites to prevent cross-contamination.
- Obtain wound and blood cultures as ordered and give antimicrobials on time; verify tetanus prophylaxis status.
- Remove invasive lines as early as possible and rotate sites per policy.
6. Meeting hypermetabolic nutritional needs
- Auscultate bowel sounds; paralytic ileus is common for the first 36–48 hours, after which oral or enteral feeding should begin promptly.
- Provide a high-calorie, high-protein diet with vitamins A and C, zinc and iron, offered as small frequent meals plus supplements.
- Keep a strict calorie count, weigh daily, and recalculate needs weekly as the open surface area shrinks.
- Start early enteral tube feeding when oral intake cannot meet requirements; overnight feeds preserve daytime appetite. Reserve parenteral nutrition for a nonfunctional gut.
- Monitor prealbumin, albumin, transferrin, nitrogen balance and glucose; stress hyperglycemia is common and may need insulin.
- Involve the patient in food choices, offer oral care before meals, and sit them upright to eat — all measurably increase intake.
7. Preserving mobility and preventing contracture
- Position joints in extension and neutral alignment from admission; the comfortable flexed position is exactly the one that contracts.
- Perform active and passive range of motion at least twice daily, timed after analgesia, even while wounds are open.
- Apply splints and pressure garments as prescribed and check underlying skin at each removal.
- Encourage self-care activities as tolerated — brushing hair or feeding themselves is functional therapy and restores a sense of control.
- Collaborate with physical and occupational therapy from the first days, not at discharge.
8. Supporting body image, fear and coping
- Let the patient set the pace for looking at their wounds; stay present during the first dressing change they choose to watch.
- Acknowledge grief, anger and guilt as expected responses instead of correcting or minimizing them.
- Watch for withdrawal, flat affect, refusal of care, nightmares or hypervigilance and refer for psychological support and burn survivor peer groups.
- Involve family early in care and teaching so the patient does not feel like an object of care.
- Give honest, concrete information about scarring, timelines and reconstructive options — uncertainty fuels more anxiety than bad news does.
9. Pharmacologic and collaborative management
- Topicals: silver sulfadiazine (broad coverage, may cause transient leukopenia), mafenide acetate (penetrates eschar but is painful and can cause metabolic acidosis), silver-impregnated dressings and bacitracin for facial burns.
- IV opioids with adjuncts such as anxiolytics for procedures; scheduled dosing beats as-needed dosing for background pain.
- Tetanus prophylaxis, and systemic antibiotics only for documented infection rather than routine prophylaxis.
- Stress ulcer prophylaxis with an H2 blocker or proton-pump inhibitor to prevent Curling ulcer.
- VTE prophylaxis, and insulin for stress hyperglycemia.
- Assist with escharotomy or fasciotomy, hydrotherapy, excision and grafting.
10. Monitoring labs and diagnostics
- CBC: hemoconcentration early from plasma loss, then anemia as red cells are destroyed and diluted.
- Electrolytes, BUN and creatinine for shifts and evolving acute kidney injury.
- Arterial blood gases and carboxyhemoglobin after any enclosed-space fire.
- Urine myoglobin after electrical or deep burns; dark urine calls for higher fluid rates.
- Serum glucose, albumin, prealbumin and nitrogen balance to track the hypermetabolic response.
- Chest x-ray and bronchoscopy for suspected inhalation injury; wound and blood cultures for suspected sepsis.
Patient and family teaching
- Perform wound care and dressing changes step by step, with return demonstration by the patient and caregiver before discharge.
- Report fever, chills, increasing pain, foul odor, green or purulent drainage, or a wound that reopens.
- Continue range-of-motion exercises and wear splints and pressure garments for the full prescribed period — usually many months — to control scarring.
- Protect healed skin from sun for at least a year and use high-SPF sunscreen; new skin burns and pigments abnormally.
- Moisturize daily and manage itching with prescribed measures rather than scratching.
- Keep eating a high-calorie, high-protein diet until wounds are fully closed and weight is stable.
- Expect emotional aftershocks and use burn support groups and counseling; ask about them early.
- Keep every follow-up appointment with the burn clinic, therapy and reconstructive surgery.
How to build this plan
- 1Assess the patient. Collect subjective and objective data through interview, physical assessment, labs and chart review. Complete, accurate data is the foundation of every later step.
- 2Analyze and cluster the data. Group related cues, compare them with normal findings, and identify patterns that point to actual or potential problems.
- 3Formulate nursing diagnoses. Write the problem statement using a recognized diagnostic label plus related factors and evidence (problem related to cause as evidenced by signs).
- 4Set priorities. Rank diagnoses as high, medium or low using ABCs, Maslow's hierarchy and the patient's own stated priorities. Life-threatening problems come first.
- 5Establish goals and outcomes. Write SMART, patient-centered outcomes: specific, measurable, attainable, realistic and time-bound (short-term and long-term).
- 6Select nursing interventions. Choose independent, dependent and collaborative actions that are safe, evidence-based and matched to the outcome.
- 7Provide rationales. State the scientific reason each intervention works. Rationales are what turn a task list into clinical reasoning.
- 8Evaluate the plan. Compare the patient's actual response with the expected outcome: met, partially met or not met — then continue, revise or discontinue.
- 9Document and communicate. Record the plan and the patient's response in the health record so the whole team works from the same information.
Summarized for study use. Always follow your school's or facility's approved care plan format and current clinical policy.
Practice Burn Injury questions
These concepts are tested on the ATI proctored exams below — every set has answers and rationales.
More Integumentary care plans
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Care plan writing guides
Common questions
What are the nursing diagnoses for Burn Injury?
Priority nursing diagnoses for Burn Injury: Deficient fluid volume; Acute pain; Risk for infection; Impaired skin integrity.
What are the nursing interventions for Burn Injury?
Monitor rate, depth and effort of breathing and auscultate for stridor, wheezes or crackles — upper-airway edema peaks in the first 24 hours and can close the airway quickly. Watch for hoarseness, brassy cough, soot-streaked sputum or drooling; report immediately, since these predict impending obstruction and prompt early intubation while it is still elective. Elevate the head of bed and keep the neck extended if there are no spinal precautions, to limit edema and ease breathing. Give humidified high-flow oxygen; assume carbon monoxide poisoning after a closed-space fire, because pulse oximetry reads falsely normal. Encourage coughing, deep breathing and incentive spirometry every hour, and suction gently as needed to clear sloughed mucosa. Assist with escharotomy for a circumferential chest burn that restricts chest wall expansion.
What are the nursing care goals for Burn Injury?
The client will maintain a patent airway with clear breath sounds, a respiratory rate within normal range, and no dyspnea or cyanosis. The client will demonstrate adequate fluid balance as evidenced by urine output of at least 30 mL/hr, stable vital signs and moist mucous membranes. The client will report pain controlled at or below an agreed level and will rest and participate in care. The client will show progressive wound healing and timely graft take, free of purulent drainage and fever. The client will maintain weight and positive nitrogen balance with intake meeting calculated calorie and protein needs. The client will maintain full range of motion and a position of function, with no contracture. The client will express feelings about appearance and incorporate body changes into self-concept without loss of self-esteem. The client and family will correctly perform wound care and explain the reason for each step before discharge.
What should you assess in a patient with Burn Injury?
Pain, burning or tenderness at the wound, or unexpected numbness over a deep area; Difficulty breathing, throat tightness, hoarseness or painful swallowing; Thirst, nausea, dizziness or weakness; Fear, guilt, flashbacks to the event, or worry about appearance and work; Deep, throbbing ache or tingling in a circumferentially burned limb; Burn depth, color and extent (%TBSA) plus condition of surrounding skin; Blisters, weeping, eschar, or charred, leathery, insensate tissue; Singed facial or nasal hair, soot in sputum, stridor, cough, carbonaceous secretions; Tachycardia, hypotension, delayed capillary refill, cool unburned skin; Urine output below 30 mL/hr, dark or tea-colored urine (myoglobinuria); Rising edema, weight gain, or absent distal pulses in a circumferential burn; Fever, purulent or green-tinged drainage, foul odor, graft separation; Confusion or restlessness — often the first sign of hypoxia or hypovolemia