When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
A. Ineffective airway clearance related to edema of the respiratory passages
B. Impaired physical mobility related to the disease process
C. Disturbed sleep pattern related to facility environment
D. Risk for infection related to breaks in the skin
Correct Answer: A. Ineffective airway clearance related to edema of the respiratory passages
When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum.
Option B: This nursing diagnosis isn’t appropriate because burns aren’t a disease. Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and the development of contractures.
Option C: Disturbed sleep pattern may be appropriate, but don’t command a higher priority than the ineffective airway clearance because they don’t reflect immediately life-threatening problems. Initially, the patient may use denial and repression to reduce and filter information that might be overwhelming. Some patients display a calm manner and alert mental status, representing a dissociation from reality, which is also a protective mechanism.
Option D: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Note: Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.
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