Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain?
A. Decreased Tissue Perfusion
B. Disturbed Body Image
C. Risk for Disuse Syndrome
D. Risk for Ineffective Breathing Pattern
Correct Answer: A. Decreased Tissue Perfusion
During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy.
Option B: Disturbed body image can develop. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.
Option C: Disuse syndrome can develop. Risk for disuse syndrome may be related to the physiological changes brought about by physical inactivity. These changes may include a decrease in muscle strength, limited joint movement, and loss of bone density. However, this is not a priority diagnosis at this time.
Option D: Chemical burns do not cause inhalation injury and a disrupted breathing pattern. The most common findings represent structural changes to the tissue directly affected, for example, the eye, oral mucosa, skin, esophagus, and lower intestinal system, especially the stomach and pylorus, respiratory system, among others.
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