Primary Nursing Diagnosis

Ineffective airway clearance related to airway edema

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level

INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suction-ing; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring


MINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection.

MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition. Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine or mafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered, through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Pharmacologic Highlights

Medication or

Drug Class Dosage



Topical antimicrobial Silver agents sulfadiazine

Cream that lowers bacterial counts, minimizes water evaporation, and decreases heat loss

Antimicrobial agent that is not irritating and has the fewest adverse effects

Mafenide acetate

Bacterial coverage for gramnegative and anaerobic coverage; deep eschar penetration

Painful but readily absorbed and can lead to metabolic acidosis

Other Pharmacologic Treatments: Tetanus prophylaxis, analgesia to manage the severe pain that accompanies thermal injury, other topical applications such as polymyxin B or Acticoat (dressings that release silver ions), H2 blockers.


The nursing care of the patient with a burn is complex and collaborative, with overlapping interventions among the nurse, the physician, and a variety of therapists. However, independent nursing interventions are also an important focus for the nurse. The highest priority for the burn patient is to maintain the airway, breathing, and circulation. The airway can be maintained in some patients by an oral or nasal airway, or by the jaw lift-chin thrust maneuver. Patency of the airway is maintained by endotracheal suctioning, whose frequency is dictated by the character and amount of secretions. If the patient is apneic, maintain breathing with a manual resuscitator bag before intubation and mechanical ventilation.

If the patient is bleeding from burn sites, apply pressure until the bleeding can be controlled surgically. Remove all constricting clothing and jewelry to allow for adequate circulation to the extremities. Implement fluid resuscitation protocols as appropriate to support the patient's circulation. If any clothing is still smoldering and adhering to the patient, soak the area with normal saline solution and remove the material. Wound care includes collaborative management and other strategies. Cover wounds with clean, dry, sterile sheets. Do not cover large burn wounds with saline-soaked dressings, which lower the patient's temperature. If the patient has ineffective thermoregulation, use warming or cooling blankets as needed and control the room temperature to support the patient's optimum temperature. If the patient is hypothermic, limit traffic into the room to decrease drafts and keep the patient covered with sterile sheets. Help the

170 Burns patient manage pain and distress by providing careful explanations and teaching distraction and relaxation techniques.

As the wounds heal, use strategies such as tubbing, débridement, and dressing changes to limit infection, promote wound healing, and limit physical impairment. If impaired physical mobility is a risk, place the patient in antideformity positions at all times. Implement active and passive range of motion as needed. Get the patient out of bed on a regular basis to limit physical debilitation and decrease the risk of infection. Implement strategies to limit stress and anxiety.

DOCUMENTATION GUIDELINES Emergent-Resuscitative Phase

• Flow sheet record of the critical physiological aspects of this time period; depending on the patient's condition, documentation times may be established for 15-minute intervals or less for vital signs and fluid balance

• Flow sheet record or information related to the condition of the wound, wound care, and psychosocial issues

Acute-Wound Coverage Phase

• The condition of the wound, healing progress, graft condition, signs of infection, scar formation, and antideformity positioning are important documentation parameters

• Psychosocial issues and the family's involvement in care are also important information

Rehabilitative Phase

• Status of healing and the appearance of scars, as well as the patient's functional abilities

• Ability of the patient and family to perform the complex care required during the months to come

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