Nursing diagnosis for burn pediatric
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nursing diagnosis pediatric burn patient NANDA priority interventions
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Nursing Diagnoses for Pediatric Burn Patients
Pediatric burn patients have unique physiologic and psychosocial vulnerabilities compared to adults - higher body surface area-to-weight ratio, thinner skin, immature thermoregulation, and greater psychological impact. The nursing diagnoses below are prioritized using an ABC + Safety framework.
Priority 1 - Airway & Breathing
1. Impaired Gas Exchange
Related to: Inhalation injury, carbon monoxide poisoning, airway edema, smoke inhalation
As evidenced by: Stridor, wheezing, carbonaceous sputum, decreased SpO2, cyanosis, hoarse voice
Key Interventions:
- Monitor respiratory rate, rhythm, depth; note use of accessory muscles
- Auscultate lungs for stridor, crackles, diminished breath sounds
- Note pallor or cherry-red skin (CO poisoning sign)
- Administer 100% O2 via non-rebreather mask; prepare for intubation if airway edema progresses
- Position HOB 30-45 degrees to optimize ventilation
- Suction if intubated; assess ability to ventilate frequently
2. Ineffective Airway Clearance
Related to: Mucosal edema, increased secretions from smoke/chemical inhalation
As evidenced by: Brassy cough, wheezing, inability to clear secretions
Priority 2 - Circulation & Fluid Balance
3. Deficient Fluid Volume (Hypovolemia / Burn Shock)
Related to: Capillary leak, third-spacing, fluid shifts from burn wound (esp. >10% TBSA)
As evidenced by: Decreased UO, tachycardia, hypotension, dry mucous membranes, increased hematocrit
Key Interventions:
- Obtain large-bore IV access (18G or larger)
- Administer IV fluid resuscitation using Parkland/Baxter formula (4 mL/kg/% TBSA burned in first 24 hrs) - note: pediatric patients may require modified formulas (Galveston formula adds maintenance fluid: 5000 mL/m² burn + 2000 mL/m² total BSA/day)
- Monitor urine output hourly - target 1 mL/kg/hr in children (vs. 0.5 mL/kg/hr in adults)
- Insert Foley catheter during resuscitation phase
- Monitor vital signs, CRT, and peripheral pulses frequently
- Watch for signs of overresuscitation ("fluid creep") - pulmonary edema, abdominal compartment syndrome
(Source: The Harriet Lane Handbook, 23rd ed.; Sabiston Textbook of Surgery)
Priority 3 - Skin Integrity & Infection Risk
4. Impaired Skin Integrity / Impaired Tissue Integrity
Related to: Thermal destruction of skin layers (partial/full thickness)
As evidenced by: Open wounds, eschar, blistering, exposed dermis or subcutaneous tissue
Key Interventions:
- Perform wound assessments each shift; document wound size, depth, color, drainage
- Maintain sterile/aseptic technique during dressing changes
- Apply prescribed topical antimicrobials (e.g., silver sulfadiazine, mafenide acetate)
- Elevate burned extremities to reduce edema
- Proper positioning and splinting, especially over joints - prevents contractures
5. Risk for Infection / Risk for Sepsis
Related to: Loss of skin barrier, impaired immune response, invasive lines, malnutrition
As evidenced by: Open burn wound, fever, elevated WBC, wound odor/purulence
Key Interventions:
- Monitor for signs of wound sepsis (Pseudomonas is a classic pathogen in burn wound sepsis)
- Maintain strict aseptic technique
- Monitor cultures and sensitivity results
- Assess IV/Foley sites for signs of infection
- Avoid prophylactic antibiotics (promotes resistance); treat confirmed infections only
- Change dressings as prescribed; use antimicrobial dressings as ordered
(Source: Mulholland & Greenfield's Surgery 7e; Harrison's Principles of Internal Medicine 22e)
Priority 4 - Pain & Comfort
6. Acute Pain / Chronic Pain
Related to: Tissue destruction, nerve exposure, dressing changes, procedures
As evidenced by: Verbal/behavioral pain expression, tachycardia, guarding, crying, refusal of care
Key Interventions:
- Use age-appropriate pain scales (FLACC for <4 yrs; Wong-Baker FACES; numeric scale for older children)
- Administer analgesics around the clock; give IV opioids before dressing changes
- Consider multimodal analgesia: opioids + NSAIDs + ketamine (procedural) + benzodiazepines for anxiety
- Use non-pharmacologic strategies: guided imagery, distraction, music therapy, hypnosis
- Adequate pain control is critical - undertreated pain increases PTSD risk and impairs wound healing
(Source: Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Medical and Psychiatric Treatment of Burned Children)
Priority 5 - Thermoregulation & Metabolism
7. Hypothermia / Risk for Hypothermia
Related to: Loss of skin barrier (primary thermoregulatory organ), large evaporative losses, wet dressings, IV fluids
As evidenced by: Core temperature <36°C, shivering, mottled skin, bradycardia
Key Interventions:
- Maintain warm room temperature (27-32°C in pediatric burn units)
- Use warming blankets, radiant warmers, warm IV fluids
- Cover non-burned areas
- Children are especially vulnerable due to high BSA-to-mass ratio
8. Imbalanced Nutrition: Less Than Body Requirements
Related to: Hypermetabolic state (up to 2x baseline), increased protein catabolism, poor oral intake
As evidenced by: Weight loss, poor wound healing, decreased albumin/prealbumin
Key Interventions:
- High-protein, high-calorie, high-zinc/vitamin C diet
- Insert NGT for enteral feeds if child cannot meet oral intake - begin within 6-8 hours of injury
- Monitor daily weight, wound healing, albumin, prealbumin
- Consider TPN only if enteral route is not possible (e.g., severe facial/esophageal burns)
- Consult pediatric dietitian early
(Source: Royal Children's Hospital - Nursing Management of Burn Injuries CPG)
Priority 6 - Psychosocial & Developmental
9. Anxiety / Fear
Related to: Painful procedures, hospitalization, separation from caregivers, altered body image
As evidenced by: Crying, agitation, clinging, nightmares, refusal of procedures
Key Interventions:
- Allow parental presence during procedures whenever possible
- Use Child Life specialists for coping, play therapy, preparation
- Explain procedures in age-appropriate language
- Administer anxiolytics (benzodiazepines, SSRIs) as ordered
- Create a calm, consistent care environment
10. Risk for Post-Traumatic Stress Disorder (PTSD)
Related to: Traumatic burn event, painful hospitalization, inadequate pain control
As evidenced by: Re-experiencing, hypervigilance, avoidance behaviors, regression, nightmares
Key Interventions:
- Screen for Acute Stress Disorder (ASD) during hospitalization - 35% of burned children develop at least one psychological disorder
- Monitor for PTSD risk factors: large burn size, high pain levels, elevated heart rate, poor body image
- Treat caregivers/parents simultaneously - parental coping directly influences child recovery
- Refer to child psychiatry/psychology early; consider family-centered care approach
11. Disturbed Body Image
Related to: Scarring, disfigurement, loss of physical function
As evidenced by: Refusal to look at wounds, social withdrawal, negative self-statements
Key Interventions:
- Provide therapeutic communication; allow child to verbalize feelings
- Introduce mirror and body image discussions gradually (not forced)
- Peer support programs and burn survivor networks
- Refer to social work and psychiatry
12. Risk for Impaired Physical Mobility / Impaired Physical Mobility
Related to: Pain, scarring, contractures, splinting
As evidenced by: Limited ROM, unwillingness to move, scar banding over joints
Key Interventions:
- Begin passive ROM exercises early; progress to active ROM as tolerated
- Proper splinting and positioning - especially over joints (hand, neck, axilla, knee)
- Early referral to occupational and physical therapy
- Pressure garments as wounds mature to minimize hypertrophic scarring
Priority 7 - Safety & Family
13. Risk for Ineffective Thermoregulation (Hyperthermia)
Related to: Systemic inflammatory response, infection, hypermetabolic state
As evidenced by: Fever, tachycardia, diaphoresis
14. Caregiver Role Strain / Family Anxiety
Related to: Severity of child's injury, guilt, disruption of family life, prolonged hospitalization
As evidenced by: Parental guilt, anxiety, inability to cope, poor sleep
Key Interventions:
- Educate family about burn care, realistic expectations, and psychological sequelae
- Assess parental coping; refer to social work and family counseling
- Encourage parental participation in care (family-centered approach)
- Screen caregivers for depression and PTSD
Special Considerations: Child Abuse
Always assess for signs of abusive burn injuries (bilateral/stocking-glove distribution, contact burns in shape of objects, delay in seeking treatment). Abusive burns have higher mortality, longer hospitalization, and greater severity than accidental burns. Mandatory reporting is legally required.
(Source: Kaplan & Sadock's Comprehensive Textbook of Psychiatry)
Quick Reference: Nursing Diagnoses Summary Table
| Priority | NANDA Nursing Diagnosis | Core Goal |
|---|---|---|
| 1 | Impaired Gas Exchange | Maintain SpO2 >95%, patent airway |
| 2 | Ineffective Airway Clearance | Clear secretions, prevent obstruction |
| 3 | Deficient Fluid Volume | Restore circulating volume, UO 1 mL/kg/hr |
| 4 | Impaired Skin/Tissue Integrity | Wound healing, prevent infection |
| 5 | Risk for Infection / Sepsis | Prevent wound sepsis, aseptic care |
| 6 | Acute Pain | Adequate analgesia, reduce procedural pain |
| 7 | Risk for Hypothermia | Maintain normothermia |
| 8 | Imbalanced Nutrition (less than body req.) | Meet hypermetabolic demands |
| 9 | Anxiety / Fear | Reduce distress, support coping |
| 10 | Risk for PTSD | Early psych screening and intervention |
| 11 | Disturbed Body Image | Positive self-concept, gradual acceptance |
| 12 | Impaired Physical Mobility | Prevent contractures, restore function |
| 13 | Caregiver Role Strain | Support family unit |
Sources:
- Kaplan & Sadock's Comprehensive Textbook of Psychiatry - "Medical and Psychiatric Treatment of Burned Children"
- Sabiston Textbook of Surgery - Burn Resuscitation
- Harriet Lane Handbook 23rd ed. - Pediatric Burn Fluid Resuscitation
- Mulholland & Greenfield's Surgery 7e - Burn Wound Infections
- Royal Children's Hospital Clinical Guideline - Nursing Management of Burn Injuries
- NursesLabs - Burn Injury Nursing Care Plans
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