Question

The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:

Imbalanced nutrition less than body requirements related to hypermetabolic state
Risk for infection related to altered skin integrity
Risk for fluid volume imbalance related to intracompartmental fluid shift
Acute pain related to burn injury

Answer 1

The primary nursing diagnosis for a patient with full thickness burns in the emergent phase focuses on the risk for fluid volume imbalance due to the body's loss of fluids and the resulting shock that can occur.

Step-by-step explanation:

In the emergent phase of burn injury, particularly with full thickness burns to a significant portion of the body such as the lower half of the torso and lower extremities, the primary nursing diagnosis would focus on the risk for fluid volume imbalance related to intracompartmental fluid shift. This is because burns, especially full thickness burns or third-degree burns, damage skin cells leading to fluid loss, dehydration, electrolyte imbalance, and potential renal and circulatory failure.

Treatment for burn patients typically includes the administration of intravenous fluids to counteract dehydration, and intravenous nutrients to support tissue repair and protein replacement. Due to the extensive damage that full thickness burns cause, including the destruction of nerve endings and sensory function, addressing fluid volume balance is critical in preventing hypovolemic shock, which is characterized by rapid heart rate, weak pulse, and other symptoms related to restricted blood flow.

While other concerns such as infection risk, imbalanced nutrition, and acute pain are also important and must be addressed, the immediate life-threatening concern is the fluid volume imbalance that arises from the body's response to a significant burn injury.