What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?
A. Acute Pain
B. Impaired Adjustment
C. Deficient Diversional Activity
D. Imbalanced Nutrition: Less than Body Requirements
Correct Answer: B. Impaired Adjustment
Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client.
Option A: By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
Option C: Diversional activity for pain is applicable during the intermediate phase of the burn injury. Provide diversional activities appropriate for age and condition. This helps lessen concentration on pain experience and refocus attention.
Option D: Imbalanced nutrition is more appropriate during the emergent and intermediate phases of the burn injury. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
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