Author Question: Which would be the priority nursing diagnosis during the acute phase of burn injury for a child who ... (Read 37 times)

altibaby · **on:** Jun 28, 2018

Which would be the priority nursing diagnosis during the acute phase of burn injury for a child who has a third-degree circumferential burn of the right arm?

1. Altered tissue perfusion, risk for
2. Infection, risk for
3. Impaired physical mobility
4. Altered nutrition: less than body requirements, risk for

Question 2

A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which of the following nursing interventions would the nurse omit from the plan of care for this child?

1. Frequent assessment of the surgical site
2. N.p.o. status until bowel sounds return
3. Monitor rectal temperature every hour.
4. Allow parents at the bedside as soon as possible.

ASDFGJLO · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

1
Rationale 1: Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered tissue perfusion to the extremity is the greatest risk and therefore the priority diagnosis.
Rationale 2: When the burn is circumferential, blood flow can become restricted due to edema and can result in tissue hypoxia; therefore, the priority diagnosis is altered tissue perfusion, risk for to the extremity. Risk of infection would be a secondary priority in this case.
Rationale 3: Impaired physical mobility is a secondary priority for the child with a circumferential burn. Edema to the area can result in restricted blood flow and tissue hypoxia, making the priority diagnosis altered tissue perfusion, risk for.
Rationale 4: Infection, nutrition, and mobility would have secondary priority in this case.
Global Rationale:

Answer to Question 2

3
Rationale:
1. The surgical site must be visualized frequently for bleeding.
2. This is standard postop care.
3. Rectal temperature is not indicated, and should never be done as frequently as q1h.
4. This describes family-centered care; parents should be involved as much as possible and should be present before the child wakes up.