Three days after a burn injury, the client develops a temperature of 100° F, a white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?
A. Acute phase of the injury
B. Autodigestion of collagen
C. Granulation of burned tissue
D. Wound infection
Correct Answer: D. Wound infection
Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.
Option A: These symptoms will not be seen in the acute phase of the injury. Assess and document size, color, depth of wound, noting necrotic tissue and condition of the surrounding skin.
Option B: Autodigestion of collagen will not increase the body temperature or cause foul-smelling wound discharge. Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
Option C: Granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge. Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.
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