The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s initial action?
A. Administer oxygen.
B. Loosen the dressing.
C. Notify the emergency team.
D. Document the observation as the only action.
Correct Answer: B. Loosen the dressing
Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status. Generally, it is recommended that pressure should be maintained between 20 and 30 mm Hg, which is above capillary pressure but less than what would diminish peripheral blood circulation.
Option A: It is unnecessary to administer oxygen. Wearing pressure garments is uncomfortable and challenging; problems with movement, appearance, fit, comfort, swelling of extremities, rashes, and blistering are common; consequently, low compliance with PGT is to be expected.
Option C: The nurse may intervene first. However, monitoring of pressure exerted by pressure garments is currently difficult and time-consuming, and not routinely done and currently, the optimal pressure magnitude for PGT remains unsolved.
Option D: The nurse may loosen the dressing to help the client breathe. Recent evidence suggests that pressure garment therapy is effective for the prevention and/or treatment of abnormal scarring after burn injury but that the clinical benefit is restricted to those patients with moderate or severe scarring.
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