A nurse is caring for a client who is 24 hours post-thoracotomy with a chest tube connected to a closed drainage system set to -20 cm suction.
The nurse notes the following: Respiratory rate: 22/min, SpO2: 94 The client denies shortness of breath but reports mild incisional pain. Which action should the nurse take?

The scenario requires applying principles of wound management, pain control, and infection prevention for thermal burns. Knowledge of tissue integrity, pharmacological intervention, and sterile surgical asepsis is necessary to prevent complications like syndactyly, infection, and severe pain during treatment.

Choice A rationale

Placing gauze between digits prevents skin surfaces from touching during healing. This essential intervention stops webbing or contractures, known as syndactyly, by maintaining anatomical separation of the fingers while absorbing exudate from the injured thermal burn sites.

Choice B rationale

Topical lotions containing vitamin E are inappropriate for acute thermal burns. Lotions can trap heat or introduce contaminants into open wounds. Specialized antimicrobial agents are required instead of over the counter moisturizers to ensure proper healing and safety.

Choice C rationale

Silver sulfadiazine is a broad spectrum topical antimicrobial used to prevent and treat wound sepsis in second and third degree burns. It effectively penetrates the eschar to reduce bacterial colonization, which is critical for successful skin regeneration.

Choice D rationale

Intact blisters serve as a natural sterile barrier against environment pathogens. Piercing or debriding small blisters increases the risk of infection and tissue trauma. Blisters should remain intact unless they interfere with joint movement or are significantly large.

Choice E rationale

Burn care and debridement are excruciatingly painful procedures. Administering systemic analgesics like morphine sulfate prior to care ensures the client reaches a therapeutic peak, which facilitates cooperation, reduces physiological stress, and manages severe pain during dressing changes.

Choice F rationale

Thermal burns destroy the primary skin barrier, leaving the client highly susceptible to healthcare associated infections. Strict sterile technique during wound care and dressing changes is mandatory to prevent sepsis and promote uncomplicated healing of the damaged tissues.

Managing hepatic encephalopathy requires understanding the biochemical role of ammonia in brain toxicity. Knowledge of the enterohepatic circulation and the pharmacological action of osmotic laxatives is necessary to facilitate the excretion of nitrogenous wastes and improve neurological status.

Choice A rationale

Loop diuretics are used to treat ascites or edema but do not directly lower serum ammonia. Excessive diuresis can actually trigger hepatic encephalopathy by causing dehydration and electrolyte imbalances, such as hypokalemia, which increases renal ammonia production and toxicity.

Choice B rationale

Lactulose is a disaccharide that acidifies the colon, converting ammonia into non-absorbable ammonium ions. This osmotic effect also promotes bowel movements, facilitating the rapid excretion of these toxins from the gut, thereby reducing blood ammonia levels and confusion.

Choice C rationale

Restricting fluids does not lower ammonia and can worsen hepatic encephalopathy by causing dehydration and constipation. Adequate hydration and bowel motility are necessary to ensure that nitrogenous wastes are flushed from the gastrointestinal tract effectively to prevent systemic accumulation.

Choice D rationale

Protein breakdown in the gut by bacteria produces ammonia. Increasing protein intake in a client with end stage cirrhosis would likely worsen encephalopathy by providing more nitrogenous substrate for ammonia synthesis, further elevating toxic levels in the blood.