Nursing Care Plan – Providing arm and leg care for Burn patients

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Providing arm and leg care:

1. apply dressing from distal to proximal area to stimulate circulation and prevent constriction. wrap the burn gauze once around the arm or leg so the edges overlap slightly, until it cover the wound.

2. apply a dry roller gauze dressing to hold the bottom layers in place, secure with tape.

Providing hand and foot care

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1. wrap each finger separately with a sterile layer of 4×4 sterile gauze pad to allow the patient to use his hand and to prevent contractures.

2. place the hand in a functional position, and secure this position using a dressing, apply splint if ordered.

3. put gauze between each toes as appropriate.

Providing chest, abdomen And back care

1. apply the ordered medication to the wound in a thin layer. Then cover the entire burned area with sheets of burn gauze.

2. wrap the area with roller gauze or apply a specialty vest dressing to hold burn gauze in place.

3. secure the dressing with elastic netting or tape, make sure that dressing doesn’t restrict respiratory motion, especially in very young or elderly patients or in those with circumferential injuries.

Providing facial Nursing care

1. if the patient has scalp burns, clip or shave the hair around the burn as ordered, clip other hair until its about 5cm long to prevent contamination of burned scalp areas.

2. shave facial hair if it become in contact with burn areas.

3. facial burns managed with mild antibiotics ointment and lift open to air, if dressing required, don’t cover eyes, nostrils and mouth.

Providing Nursing ear care

1. clip or shave the hair around the affected ear.

2. remove exudate and crust with cotton- tipped applicators dipped in normal saline solution.

3. place 4×4 layer of gauze behind the auricle to prevent webbing.

4. apply the ordered medication to 4×4 gauze pads, and place pads over the burned area, before securing the dressing with roller bandage, position the patients ears normally to avoid damaging the auricular cartilage.

5. assess patient hearing ability.

Providing Nursing eye care

1. clean the area around the eye and eyelids with a cotton tipped applicator and normal saline solution every 4-6 hours or as needed, to remove crust and drainage.

2. administer ordered eye ointment or drops.

3. if the eyes cannot be closed apply lubricating ointments or drops as ordered.

4. be sure to close the patients eyes before applying eye pads to prevent corneal abrasion

Don’t apply any topical ointment near the eye without physician order.

Providing Nursing nasal care

Providing nasal care:

1. check the nostrils for inhalation injury, inflamed mucosa and soot.

2. clean the nostrils with cotton-tipped applicators dipped in normal saline solutions. Remove crusts.

3. apply ordered ointments.

4. if patient has nasogastric tube, use tracheostomy ties to secure the tube. Be sure to check the ties frequently for tightness resulting from swelling of facial tissue. Clean the area around the tubing every 4-6 hours.

Special consideration:

# thorough assessment and documentation of the wounds appearance is essential to detect infection or other complication:

– purulent wound with green exudate indicates infection.

– overly dry wound suggest dehydration.

– red edges suggest cellulitis.

– white powdery wound suggest cellulitis.

– healthy wound is clean, pinkish, shiny.

# because blisters protect underlying tissue, leave them intact, unless it interfere with joint motion, become infected or cause patient discomfort.

# burn patient need extra protein and carbohydrate for healing process.

Nursing Documentation for Burn Patient

– record date and time of care provided.

– describe wound condition.

– special dressing change technique.

– topical medication administration.

– positioning of the burned area.

– the patient tolerance of the procedure.

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Posted in Burn, Critical Care Nursing, Nursing Care Plans

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