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A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?

Admission Notes: 36 y/o female with bilateral leg burns. NKFDA. Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather Like appearance. No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0 to 1 0

Full thickness

Superficial

Partial-thickness superficial

Partial-thickness deep

Answer and Explanation

The Correct Answer is A

A. Full thickness:

Full-thickness burns involve damage to the entire thickness of the skin, including the epidermis and dermis. They often result in a white, charred, or leather-like appearance and are typically painless due to nerve damage. In the context of the patient's data, the description of "bilateral leg burns present with a white and leather-like appearance" indicates that the burns have penetrated deeply into the skin, suggesting full-thickness burns. The absence of blisters or bleeding is also consistent with full-thickness burns, as these burns often destroy the structures that would form blisters.

B. Superficial:

Superficial burns, also known as first-degree burns, only affect the outer layer of the skin (epidermis).They are characterized by redness, pain, and swelling but do not typically result in blisters or significant skin damage. The patient's description of "white and leather-like appearance" and the absence of blisters or bleeding are not indicative of superficial burns. Therefore, superficial burns are not an appropriate categorization based on the provided data.

C. Partial-thickness superficial:

Partial-thickness superficial burns, also known as second-degree superficial burns, affect the epidermis and part of the dermis. They are characterized by redness, blister formation, and pain. However, the description of "white and leather-like appearance" does not align with partial-thickness superficial burns, as these burns typically do not result in a white or charred appearance. Additionally, the absence of blisters or bleeding is not consistent with partial-thickness superficial burns.

D. Partial-thickness deep:

Partial-thickness deep burns, also known as second-degree deep burns, extend deeper into the dermis compared to partial-thickness superficial burns but do not penetrate through the entire dermis. They are characterized by redness, blister formation, and moderate to severe pain. The absence of blisters or bleeding and the description of "white and leather-like appearance" are more indicative of full-thickness burns rather than partial-thickness deep burns.

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Correct Answer is D

Explanation

A. Body mass index (BMI) of 19:

A BMI of 19 falls within the normal weight range. While obesity (high BMI) is a known risk factor for surgical complications, including SSIs, having a lower BMI (underweight) like 19 may not directly increase the risk of SSIs. However, extreme malnutrition or low BMI due to underlying health conditions could potentially impact wound healing and immune function, indirectly contributing to infection risk.

B. History of deep vein thrombosis (DVT):

A history of deep vein thrombosis is a risk factor for surgical complications, including SSIs. Patients with a history of DVT may have impaired circulation or underlying vascular issues, which can affect tissue perfusion, wound healing, and increase the risk of infections.

C. Aged 55 years old:

Age is a risk factor for surgical complications, including SSIs. Older adults, typically defined as those aged 65 and above, may have reduced immune function, slower wound healing, and underlying health conditions that contribute to infection risk. While 55 years old is not considered advanced age in terms of surgical risk, older age in general is associated with a higher risk of complications.

D. Type 2 diabetes mellitus:

Type 2 diabetes mellitus is a significant risk factor for SSIs. Diabetes can impair immune function, delay wound healing, and increase susceptibility to infections. Poorly controlled blood sugar levels in diabetic patients can further exacerbate the risk of SSIs post-surgery.

A. Change the dressing when it is saturated. B. Assess the wound bed once a day. C. Contact the provider when the dressing leaks. D. Change the dressing every 6 hours.

Correct Answer is A

Explanation

A. Change the dressing when it is saturated:

This intervention is the most appropriate for managing a deep wound with a wet to-damp dressing. Wet to-damp dressings are designed to maintain a moist environment conducive to wound healing. Changing the dressing when it becomes saturated with wound exudate helps prevent excessive moisture accumulation, which can lead to skin maceration and potential infection. It ensures that the wound bed remains in an optimal healing environment and reduces the risk of complications.

B. Assess the wound bed once a day:

Assessing the wound bed is an essential part of wound care, as it allows the nurse to monitor healing progress, assess for signs of infection, and evaluate the effectiveness of the chosen dressing. However, the frequency of wound bed assessment may vary depending on the specific patient's needs and the type of dressing being used. While daily assessment is generally recommended, it does not directly dictate the timing of dressing changes for wet to-damp dressings, which are primarily changed based on saturation levels.

C. Contact the provider when the dressing leaks:

Contacting the provider when the dressing leaks or when there are concerns or complications is an important step in patient care. Leaking dressings can indicate issues with the dressing application, excessive wound exudate, or potential complications such as infection. It's crucial to inform the provider promptly so that appropriate interventions can be implemented, but this instruction is more reactive and does not specifically address the timing of dressing changes.

D. Change the dressing every 6 hours:

Changing the dressing every 6 hours is not typically recommended for wet to-damp dressings unless specifically indicated based on the patient's condition and the amount of wound exudate. Frequent dressing changes can disrupt the healing process, cause unnecessary trauma to the wound bed, and increase the risk of infection. Dressing change frequency should be based on the assessment of wound exudate and the dressing's ability to maintain a moist environment.

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A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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