Nursing care after skin autotransplantation as a treatment method of second- and third-degree thermal burns – a case study based on the NANDA and ICNP ® classifications

Introduction:
Burns are the fourth most common cause of injury throughout the world. Thermal burns account for 86% of these. The basis of burn disease treatment is fluid resuscitation, pain management, antithrombotic treatment, and in severe cases, surgical intervention and skin transplantation. The aim of the study was to present selected nursing diagnoses of a patient with burn disease after partial skin autotransplantation as a thermal burn treatment method while using the NANDA and ICNP® classifications.

Material and methods:
The study applied the case study method of a 35-year-old woman with second-/third-degree thermal burns covering 40% of the body surface. Research techniques were used: observation, documentation analysis, and interview, using the American ABA burn depth assessment scale and the NRS pain scale research tools.

Results:
The main nursing diagnoses were severe pain on the injured tissue and in autografted areas, decreased myocardial oxygen demand due to the catabolic state of the body, the risk of oligovolemic shock, and the risk of graft site infection and infections on other burn wounds. The patient experienced increased anxiety and difficulties with accepting her health situation.

Conclusions:
The depth and extent of the trauma required skin autotransplantation in the patient. Treating the burn consisted, inter alia, of cor-recting fluid and electrolyte disorders, pain management, antithrombotic treatment, β-blocker administration, and transfusing blood products. Comprehensive care, requiring extended monitoring, epidemiological regime, and risk assessment of complications, was important in the nursing process. Both diagnosis classifications – NANDA and ICNP^® – proved useful in the patient’s care, com-plementing each other.