Priority Nursing Diagnosis
The priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm is risk for airway compromise.
Why is Airway Compromise a Priority Concern in Clients with Full-Thickness Chemical Burns?
Full-thickness chemical burns can damage the airway, leading to airway compromise. This is because chemical burns can cause inflammation, swelling, and necrosis (death of tissue) of the airway. Airway compromise can be fatal, so it is important to assess the airway and intervene early if necessary.
Other Nursing Diagnoses to Consider
In addition to risk for airway compromise, other nursing diagnoses to consider for a client with full-thickness chemical burns include:
- Risk for fluid volume deficit: Full-thickness chemical burns can cause fluid loss through evaporation and increased capillary permeability. Fluid loss can lead to dehydration and shock.
- Risk for infection: Full-thickness chemical burns can create an open wound that is susceptible to infection.
- Pain: Full-thickness chemical burns can be very painful.
- Anxiety: Clients with full-thickness chemical burns may experience anxiety due to the pain, disfigurement, and potential for complications.
Nursing interventions for a client with full-thickness chemical burns will focus on preventing and managing complications. Nursing interventions include:
- Airway assessment: Nurses should assess the client’s airway closely for signs of airway compromise, such as stridor, wheezing, and dyspnea. If airway compromise is detected, nurses should take steps to open the airway, such as intubation.
- Fluid resuscitation: Nurses should administer fluids to the client to prevent dehydration and shock. The amount of fluid administered will depend on the severity of the burn injury and the client’s individual needs.
- Infection prevention: Nurses should implement infection prevention measures, such as wound care and isolation.
- Pain management: Nurses should provide pain management to the client to improve comfort and quality of life. Pain management may include medications, non-pharmacological interventions, or a combination of both.
- Anxiety reduction: Nurses should provide emotional support to the client and their family to help reduce anxiety.
The priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm is risk for airway compromise. Nurses should assess the client’s airway closely and take steps to open the airway if necessary. Nurses should also implement other nursing interventions, such as fluid resuscitation, infection prevention, pain management, and anxiety reduction.
It is important to note that the burn recovery process is unique to each individual. The timing and severity of complications can vary depending on the severity of the burn injury and the client’s underlying medical conditions. Nurses should work with the healthcare team to develop a personalized treatment plan for each burn patient.