Medical Surgical Critical Care Burns #5

Question

A client was moved from the ED to the burn unit and is the acute phase of burn management. The client has full-thickness burns to the anterior trunk, perineum, and sacral areas of the body. The nurse is creating a care plan for the client. Which is the most appropriate priority diagnosis at this time?

Answers

  1. Risk for fluid volume overload
    • Rationale:

      This answer is not correct because in this phase, the client is diuresing, so fluid deficit, not overload may be managed.

  2. Risk for infection
    • Rationale:

      This answer is correct because wounds are healing and complications are managed, so the risk of infection is priority in this phase of burn management.

  3. Impaired skin integrity
    • Rationale:

      This answer is not correct because although impaired skin integrity is important, the risk of infection is priority in this phase of burn management.

  4. Impaired physical mobility
    • Rationale:

      This answer is not correct because although the client has impaired physical mobility, the risk of infection is priority in this phase of burn management. Impaired physical mobility may apply in the rehabilitative phase of burn management.

Overview

In the acute phase of burns, diuresis and wound healing occurs, so the client is at high risk for an infection.

Explanation

Learning Outcomes

The three stages of burn management include emergent, acute, and rehabilitative. In the emergent phase, the client’s airway is priority and body fluids are replaced. In the acute phase, diuresis, wound healing, and complications are managed, and in the rehabilitative phase, psychosocial support and rehab is provided to get the client back to their optimal functioning.

Test Taking Tip

Remember the three phases of burn management and the priority diagnosis in each stage.

Video Rationale