Final answer:
For a patient with full thickness burns, the primary priority is assessing and ensuring a patent airway, followed by administering pain medication, avoiding cool compresses on the severe burns, and providing emotional support.
Step-by-step explanation:
Priority of Care for a Patient with Full Thickness Burns
When a nurse in an emergency department is caring for a client who has full thickness burns covering 20% of their body, the immediate priority is assessing the client's airway. Full thickness burns, also known as third-degree burns, extend through the entirety of the epidermis and dermis, and can damage nerve endings and sensory function. The risk of inhalation injury accompanying burns is significant, which could lead to airway compromise and respiratory distress. Therefore, assessment and management of the airway must take precedence to ensure the patient's ability to breathe.
After confirming a secure airway, attention should turn to administering pain medication. Despite the nerve endings being damaged in third and fourth-degree burns, the patient may still experience severe pain, especially in areas where there is a blend of burn severities. Because pain can cause significant stress and impact cardiovascular stability, it should be addressed promptly following airway stabilization.
The attention given to applying a cool compress to burns should be careful since cold temperatures can exacerbate the tissue damage and should not be used on full thickness burns. The mainstay of burn coverage involves sterile dressings and possibly specialized burn center care, depending on the extent of the injury.
It is also essential to provide emotional support as part of the holistic care approach, addressing the psychological and emotional needs of the patient who may be experiencing trauma.