The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?
A. Applies silver sulfadiazine (Silvadene) ointment
B. Covers the area with an elastic wrap
C. Places a synthetic dressing over the area
D. Removes loose nonviable tissue
Correct Answer: D. Removes loose nonviable tissue
The first step in this process is removing exudates and necrotic tissue. Burn patients are at high risk for infection, especially drug-resistant infection, which often results in significantly longer hospital stays, delayed wound healing, higher costs, and higher mortality
Option A: Since the adoption of topical antibiotics, such as mafenide in the 1960s and silver sulfadiazine in the 1970s, and of early excision and grafting in the 1970s and thereafter, systemic infections and mortality have consistently decreased. However, Gram-positive and Gram-negative bacterial infections still remain one of the most common causes of mortality following burn injury.
Option B: While many factors must be considered in dressing selection, the goals in selecting the most appropriate dressing should include providing protection from contamination (bacterial or otherwise) and from physical damage, allowing gas exchange and moisture retention, and providing comfort to enhance functional recovery.
Option C: The selection of an appropriate dressing depends on several factors, including depth of burn, condition of the wound bed, wound location, desired moisture retention and drainage, required frequency of dressing changes, and cost.
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