Nurse Jody formulates a nursing diagnosis of Impaired physical mobility for a client with third-degree burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?
A. Related to fat emboli.
B. Related to infection.
C. Related to femoral artery occlusion.
D. Related to circumferential eschar.
Correct Answer: D. Related to circumferential eschar.
As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. Note circulation, motion, and sensation of digits frequently. Edema may compromise circulation to extremities, potentiating tissue necrosis and development of contractures.
Option A: This client isn’t likely to develop fat emboli unless long bone or pelvic fractures are present.Maintain proper body alignment with supports or splints, especially for burns over joints. Promotes functional positioning of extremities and prevents contractures, which are more likely over joints.
Option B: Infection doesn’t alter physical mobility. Perform ROM exercises consistently, initially passive, then active. Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone.
Option C: A client with burns on the lower portions of both legs isn’t likely to have femoral artery occlusion. Medicate for pain before activity or exercise. Reduces muscle and tissue stiffness and tension, enabling the patient to be more active and facilitating participation.
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