A nurse is formulating a plan of care focusing on basic care and comfort for an older adult client who sustained deep partial-thickness burns to the anterior neck, chest, and bilateral axillae 48 hours ago. Which of the following interventions should the nurse include? Select all that apply.
- Position the client's head without pillows and place a small rolled towel under the shoulders.Answer
- BMaintain the client's arms in an adducted position resting on the abdomen to minimize pain and tension on the axillary burns.
- Maintain the ambient room temperature between 85°F and 90°F (29.4°C to 32.2°C) to prevent hypothermia.Answer
- DDelegate the evaluation of the client's unburned dependent skin surfaces to the unlicensed assistive personnel (UAP) during routine bathing.
- Provide a high-protein, high-calorie diet with oral nutritional supplements to support wound healing.Answer
- FAttribute sudden episodes of restlessness and disorientation to expected sleep deprivation and advanced age.
Answer
The correct interventions are positioning the head without pillows to promote neck extension, maintaining a warm ambient room temperature, and providing a high-protein, high-calorie diet.
The appropriate plan of care for a client with extensive burns must prioritize interventions that prevent joint contractures, maintain core body temperature, and meet hypermetabolic nutritional needs. Removing pillows promotes neck extension to prevent anterior neck contractures. Maintaining a warm room temperature (85°F to 90°F) is essential because clients with significant burns lose their ability to regulate body temperature and are at high risk for hypothermia. Providing a high-protein, high-calorie diet supports the intense metabolic demands of tissue repair and prevents severe weight loss.
Step-by-Step Solution
Key Concept
Basic care for major burns requires anti-contracture positioning, thermoregulation support, hypermetabolic nutrition, and vigilant assessment for complications like hypoxia.