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Difficulty: HardBasic Care and Comfort

A nurse is planning care for a client who sustained deep partial-thickness burns to the anterior neck, bilateral axillae, and chest 24 hours ago. The client is experiencing severe discomfort and persistently requests to rest in a curled, fetal position with multiple pillows placed under the head and knees. Which nursing action is the most appropriate to ensure physiological integrity while managing the client's basic care?

  1. A
    Provide a soft head pillow and elevate the knees 15 degrees to optimize immediate comfort and reduce metabolic stress.
  2. B
    Delegate the Unlicensed Assistive Personnel (UAP) to evaluate the axillary tissue for early signs of skin breakdown during repositioning.
  3. Omit pillows under the head, place a rolled towel beneath the shoulders to extend the neck, and support the arms in 90-degree abduction.Answer
  4. D
    Apply bilateral soft wrist restraints to prevent the client from pulling the arms inward and developing severe flexion contractures.

Answer

Omit pillows under the head, place a rolled towel beneath the shoulders to extend the neck, and support the arms in 90-degree abduction.
In burn management, the position of comfort is highly destructive because it is often the position of contracture. For burns involving the anterior neck and axillae, the nurse must actively prevent flexion and tissue webbing. Removing the head pillow and placing a rolled towel beneath the shoulders hyperextends the neck, preventing severe chin-to-chest contractures. Abducting the arms to 90 degrees prevents the axillary tissue from webbing. While this positioning may cause temporary discomfort, it is a critical, standard basic care intervention required to preserve joint function and mobility.

Step-by-Step Solution

1
Analyze the locations of the deep partial-thickness burns.
The injuries are located on the anterior neck, bilateral axillae, and chest.
Burn wounds naturally contract as they heal, pulling surrounding healthy tissue inward toward the center of the wound.
2
Evaluate the client's requested fetal position.
The requested position promotes flexion of the neck, hips, and knees.
In burn care management, a 'position of comfort' usually equates to a 'position of contracture', which must be avoided.
3
Determine the appropriate therapeutic positioning to counteract contractures.
The neck must be maintained in extension and the arms must be abducted.
Therapeutic positioning actively opposes the physiological direction of potential contractures, which is critical for preserving long-term functional mobility.

Key Concept

Therapeutic Positioning for Burn Clients (Anti-Contracture)
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Topics

Basic Care and Comfort

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