A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

A. Cool the burn with ice water:

Not recommended: Cooling a burn with ice water directly is not recommended as it can lead to further tissue damage and complications. Instead, the burn should be cooled with cool (not cold) running water for a limited time and then covered with a clean, dry cloth.

B. Administer opioid analgesics:

Recommended: Severe burns can cause excruciating pain, and opioid analgesics are often necessary to manage this pain effectively. However, the specific opioid, dosage, and route of administration should be determined by the healthcare provider based on the client's condition and pain level.

C. Administer systemic antibiotics:

Not routinely recommended: Unless there are signs of infection or the burn involves deep tissue damage, systemic antibiotics are not typically administered prophylactically for burn injuries. However, if there are signs of infection, such as redness, swelling, warmth, or drainage from the burn site, antibiotic therapy may be initiated based on culture and sensitivity results.

D. Administer benzodiazepines for anxiety management:

Considered: Severe burns can cause significant psychological distress and anxiety in patients. Benzodiazepines may be considered to manage acute anxiety and agitation in these situations. However, the decision to administer benzodiazepines should be made based on the client's overall condition, vital signs, and response to non-pharmacological interventions for anxiety.

E. Lay the head of the bed flat:

Not recommended: In a client with severe burns who is experiencing increased work of breathing, anxiety, and rapid breathing, it is generally more beneficial to elevate the head of the bed slightly (semi-Fowler's position) to improve respiratory mechanics and reduce anxiety-related respiratory distress.

A. Decreased plasma volume:Burn injuries cause a significant inflammatory response, leading to fluid shifts from the intravascular space to the interstitial space. This results in hypovolemia and decreased plasma volume, especially during the acute phase of burns.

B. Diuresis:Diuresis typically occurs after fluid resuscitation and stabilization of the client (in the later phase of burn recovery). In the initial phase, oliguria is more common due to hypovolemia and reduced renal perfusion.

C. Hypermagnesemia:Hypermagnesemia is not typically associated with burn injuries. Instead, clients with burns often experience hypomagnesemia due to fluid shifts, protein loss, and increased renal losses.

D. Capillary leak:Burn injuries lead to a systemic inflammatory response, causing capillary leak syndrome. This increases vascular permeability, allowing fluid, electrolytes, and proteins to leak into the interstitial spaces, contributing to edema and hypovolemia.

E. Loss of protein:Proteins are lost through damaged capillaries and open burn wounds, contributing to decreased oncotic pressure, edema, and a need for aggressive nutritional support to promote healing and recovery.